经 TAVR 后的冠状动脉通路。
Coronary Access After TAVR.
机构信息
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan. Electronic address: https://twitter.com/TomokiOchiai.
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
出版信息
JACC Cardiovasc Interv. 2020 Mar 23;13(6):693-705. doi: 10.1016/j.jcin.2020.01.216.
OBJECTIVES
The aim of this study was to assess the incidence of unfavorable coronary access after transcatheter aortic valve replacement (TAVR) using post-implantation computed tomography (CT).
BACKGROUND
Real-world data regarding coronary access after TAVR assessed using post-implantation CT are scarce.
METHODS
Post-TAVR CT of 66 patients treated with Evolut R or Evolut PRO valves and 345 patients treated with SAPIEN 3 valves were analyzed. The distance from inflow of the transcatheter heart valve (THV) to the coronary ostia and the overlap between THV commissures and the coronary ostia were assessed. Coronary access was defined as unfavorable if the coronary ostium was below the skirt or in front of the THV commissural posts above the skirt in each coronary artery.
RESULTS
CT-identified features of unfavorable coronary access were observed in 34.8% (n = 23) for the left coronary artery and 25.8% (n = 17) for the right coronary artery in the Evolut R/Evolut PRO group, while those percentages were 15.7% (n = 54) for the left coronary artery and 8.1% (n = 28) for the right coronary artery in the SAPIEN 3 group. In the Evolut R/Evolut PRO group, 16 coronary engagements were performed after TAVR, while 64 coronary engagements were performed in the SAPIEN 3 group after TAVR. In an engagement-level analysis, the success rates of selective coronary engagement were significantly lower in patients with CT-identified features of unfavorable coronary access compared with those with favorable coronary access in both the Evolut R/Evolut PRO (0.0% vs. 77.8%; p = 0.003) and SAPIEN 3 (33.3% vs. 91.4%; p = 0.003) groups.
CONCLUSIONS
Coronary access may be challenging in a significant proportion of patients after TAVR. THVs with low skirt or commissure height and large open cells that are designed to achieve commissure-to-commissure alignment with the native aortic valve may facilitate future coronary access. (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Thrombosis and Its Treatment With Anticoagulation [RESOLVE]; NCT02318342).
目的
本研究旨在通过经导管主动脉瓣置换术（TAVR）后的植入后计算机断层扫描（CT）评估不利的冠状动脉入路。
背景
使用植入后 CT 评估 TAVR 后冠状动脉入路的真实数据很少。
方法
对 66 例采用 Evolut R 或 Evolut PRO 瓣膜和 345 例采用 SAPIEN 3 瓣膜治疗的患者进行了 post-TAVR CT 分析。评估了经导管心脏瓣膜（THV）流入处到冠状动脉开口的距离以及 THV 交界与冠状动脉开口之间的重叠。如果每个冠状动脉的冠状动脉开口位于裙边下方或裙边上方的 THV 交界后，则定义为冠状动脉入路不良。
结果
在 Evolut R/Evolut PRO 组中，CT 识别的左冠状动脉不良冠状动脉入路特征为 34.8%（n=23），右冠状动脉为 25.8%（n=17），而 SAPIEN 3 组中左冠状动脉为 15.7%（n=54），右冠状动脉为 8.1%（n=28）。在 Evolut R/Evolut PRO 组中，TAVR 后进行了 16 次冠状动脉吻合，而在 SAPIEN 3 组中 TAVR 后进行了 64 次冠状动脉吻合。在吻合级别分析中，与 CT 识别的有利冠状动脉入路相比，在 Evolut R/Evolut PRO（0.0%对 77.8%；p=0.003）和 SAPIEN 3（33.3%对 91.4%；p=0.003）组中，具有 CT 识别的不利冠状动脉入路特征的患者选择性冠状动脉吻合的成功率明显较低。
结论
TAVR 后，相当一部分患者的冠状动脉入路可能具有挑战性。具有低裙边或交界高度和大开放细胞的 THV，旨在实现与原生主动脉瓣的交界对交界对准，可能有助于未来的冠状动脉入路。（经导管和外科主动脉生物瓣血栓形成及其抗凝治疗评估[RESOLVE]；NCT02318342）。
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