Japan: High transcatheter heart valve (THV) implantation remarkably reduces conduction disturbances after TAVR (transcatheter aortic valve replacement), a recent study published in JACC: Cardiovascular Interventions has shown. However, CT after TAVR revealed a risk for unfavourable coronary access after TAVR and sinus sequestration in TAVR-in-TAVR.
The study showed that high THV implantation versus conventional implantation was associated with a remarkable reduction in pacemaker rates (0% versus 10.8% Evolut; no difference in SAPIEN 3).
Data are scarce regarding the impact of high THV implantation on coronary access after TAVR as evaluated by postimplantation CT (computed tomography). To fill this knowledge gap, Tomoki Ochiai, Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan, and colleagues sought to assess the impact of high THV implantation on coronary access after TAVR.
The study included 258 and 160 patients treated with SAPIEN 3 and Evolut R/PRO/PRO+ THVs, respectively. In the Evolut R/PRO/PRO+ group, the target implantation depth was 1 to 3 mm using the cusp overlap view with commissural alignment technique for the HIT (high implantation technique), whereas, for the conventional implantation technique (CIT), it was 3 to 5 mm using 3-cusp coplanar view. In the SAPIEN 3 group, the HIT employed the radiolucent line-guided implantation, whereas, for the CIT, central balloon marker-guided implantation was used. To analyze coronary accessibility, post-TAVR CT was performed.
The authors reported the following findings:
The high implantation technique reduced the incidence of new conduction disturbances after TAVR for both THVs.
In the Evolut R/PRO/PRO+ group, post-TAVR CT showed that the HIT group had a higher incidence of the interference of THV skirt (22.0% vs 9.1%) and a lower incidence of the interference of THV commissural posts (26.0% vs 42.7%) with access to 1 or both coronary ostia compared with the CIT group.
These incidences were similar between the HIT and CIT groups in the SAPIEN 3 group (THV skirt: 0.9% vs 0.7%; THV commissural tabs: 15.7% vs 15.3%).
In both THVs, CT-identified risk of sinus sequestration in TAVR-in-TAVR was significantly higher in the HIT group compared with the CIT group (Evolut R/PRO/PRO+ group: 64.0% vs 41.8%; SAPIEN 3 group: 17.6% vs 5.3%).
"The study's findings provide insight to help guide design optimization of future THV platforms and highlight the significance of considering coronary access and the need for redo TAVR," the researchers wrote. "Findings support tailoring implantation technique based on anatomical and clinical factors to facilitate lifetime management of aortic stenosis patients."
Reference:
The study "Impact of High Implantation of Transcatheter Aortic Valve on Subsequent Conduction Disturbances and Coronary Access" was published in JACC: Cardiovascular Interventions. DOI: https://www.jacc.org/doi/10.1016/j.jcin.2023.03.021