Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
JACC Cardiovasc Interv. 2020 Mar 23;13(6):726-735. doi: 10.1016/j.jcin.2020.01.202.
The aim of this study was to evaluate the feasibility of coronary access and aortic valve reintervention in low-risk patients undergoing transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter heart valve (THV).
Younger, low-risk TAVR patients are more likely than older, higher risk patients to require coronary angiography, percutaneous coronary intervention, or aortic valve reintervention, but their THVs may impede coronary access and cause coronary obstruction during TAVR-in-TAVR.
The LRT (Low Risk TAVR) trial (NCT02628899) enrolled 200 subjects with symptomatic severe aortic stenosis to undergo TAVR using commercially available THVs. Subjects who received balloon-expandable THVs and who had 30-day cardiac computed tomographic scans were included in this study. In a subgroup, the feasibility of intentional THV crimping on the delivery catheter to pre-determine commissural alignment was tested.
In the LRT trial, 168 subjects received balloon-expandable THVs and had 30-day cardiac computed tomographic scans, of which 137 were of adequate image quality for analysis. The most challenging anatomy for coronary access (THV frame above and commissural suture post in front of a coronary ostium) was observed in 9% to 13% of subjects. Intentional THV crimping did not appear to meaningfully affect commissural alignment. The THV frame extended above the sinotubular junction in 21% of subjects, and in 13%, the distance between the THV and the sinotubular junction was <2 mm, signifying that TAVR-in-TAVR may not be feasible without causing coronary obstruction.
TAVR may present challenges to future coronary access and aortic valve reintervention in a substantial number of low-risk patients.
本研究旨在评估在接受经导管主动脉瓣置换术（TAVR）的低危患者中，使用球囊扩张式经导管心脏瓣膜（THV）进行冠状动脉入路和主动脉瓣再干预的可行性。
与年龄较大、风险较高的患者相比，年轻、低危的 TAVR 患者更有可能需要进行冠状动脉造影、经皮冠状动脉介入治疗或主动脉瓣再干预，但他们的 THV 可能会阻碍冠状动脉入路，并在 TAVR 中导致冠状动脉阻塞。
LRT（低危 TAVR）试验（NCT02628899）纳入了 200 例有症状的严重主动脉瓣狭窄患者，使用市售的 THV 进行 TAVR。本研究纳入了接受球囊扩张式 THV 治疗且在 30 天心脏计算机断层扫描的患者。在一个亚组中，测试了在输送导管上有意卷曲 THV 以预先确定瓣叶接合处对准的可行性。
在 LRT 试验中，168 例患者接受了球囊扩张式 THV 治疗，并进行了 30 天的心脏计算机断层扫描，其中 137 例的图像质量足以进行分析。在 9%至 13%的患者中观察到冠状动脉入路最具挑战性的解剖结构（THV 框架位于冠状动脉开口上方，瓣叶接合处缝线位于冠状动脉开口前方）。故意卷曲 THV 似乎并没有显著影响瓣叶接合处的对准。在 21%的患者中，THV 框架延伸至窦管交界上方，在 13%的患者中，THV 与窦管交界之间的距离<2mm，这表明如果不导致冠状动脉阻塞，TAVR 中可能无法进行 TAVR 再干预。
在相当数量的低危患者中，TAVR 可能会对未来的冠状动脉入路和主动脉瓣再干预造成挑战。
