经导管主动脉瓣置换术联合瓣叶对齐后的冠状动脉通路：ALIGN-ACCESS研究
Coronary Access After Transcatheter Aortic Valve Replacement With Commissural Alignment: The ALIGN-ACCESS Study.
作者信息
Tarantini Giuseppe, Nai Fovino Luca, Scotti Andrea, Massussi Mauro, Cardaioli Francesco, Rodinò Giulio, Benedetti Alice, Boiago Mauro, Matsuda Yuji, Continisio Saverio, Montonati Carolina, Cacciavillani Luisa, Pavei Andrea, Masiero Giulia, Napodano Massimo, Fraccaro Chiara, Fabris Tommaso, Iliceto Sabino
机构信息
Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.).
Department of Cardiovascular Medicine, Graduate School of General Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan (Y.M.).
出版信息
Circ Cardiovasc Interv. 2022 Feb;15(2):e011045. doi: 10.1161/CIRCINTERVENTIONS.121.011045. Epub 2022 Feb 15.
BACKGROUND
Coronary access (CA) after transcatheter aortic valve replacement (TAVR) with supra-annular transcatheter heart valves (THV) can be challenging. Specific Evolut R/Pro and Acurate Neo THVs orientations are associated with reduced neo-commissure overlap with coronary ostia, while SAPIEN 3 THV cannot be oriented. With the ALIGN-ACCESS study (TAVR With Commissural Alignment Followed by Coronary Access), we investigated the impact of commissural alignment on the feasibility of CA after TAVR.
METHODS
We performed coronary angiography after TAVR with intra-annular SAPIEN 3, supra-annular Evolut R/Pro, and Acurate Neo THVs in 206 patients. Evolut THVs were implanted aiming for commissure alignment. Alignment of Acurate Neo was retrospectively assessed in 36, intentionally attempted in 26 cases. The primary end point was the rate of unfeasible and nonselective CA after TAVR.
RESULTS
Thirty-eight percent of patients received SAPIEN 3, 31.1% Evolut Pro/R, 30.1% Acurate Neo THV. Final valve orientation was favorable to commissural alignment in 85.9% of Evolut and 69.4% of Acurate Neo cases (with intentional alignment successful in 88.5%). Selective CA was higher for SAPIEN 3 than for aligned and misaligned supra-annular THVs (95% versus 71% versus 46%, <0.001). Cannulation of at least one coronary was unfeasible with 11% misaligned supra-annular, 3% aligned supra-annular, and 0% SAPIEN 3 THVs. Independent predictors of unfeasible/nonselective CA were implantation of a misaligned supra-annular THV (odds ratio, 4.59 [95% CI, 1.81-11.61]; <0.01), sinus of Valsalva height (odds ratio, 0.83 [95% CI, 0.7-0.98]; =0.03), and THV-sinus of Valsalva relation (odds ratio, 1.06 [95% CI, 1.02-1.1]; <0.01).
CONCLUSIONS
Commissural alignment improves the rate of selective CA after TAVR with supra-annular THVs. Nevertheless, aligned supra-annular THVs carry higher risk of unfeasible/nonselective CA than SAPIEN 3. Patients with a misaligned supra-annular THV, low sinus of Valsalva, and higher THV-sinus of Valsalva relation are at highest risk of impaired CA after TAVR.
背景
经导管主动脉瓣置换术（TAVR）中使用瓣上经导管心脏瓣膜（THV）后的冠状动脉通路（CA）可能具有挑战性。特定的Evolut R/Pro和Acurate Neo THV取向与新瓣叶交界与冠状动脉开口处重叠减少相关，而SAPIEN 3 THV无法进行取向。通过ALIGN-ACCESS研究（瓣叶交界对齐后行冠状动脉通路的TAVR），我们研究了瓣叶交界对齐对TAVR后CA可行性的影响。
方法
我们对206例患者在使用瓣内SAPIEN 3、瓣上Evolut R/Pro和Acurate Neo THV进行TAVR后进行了冠状动脉造影。植入Evolut THV时旨在实现瓣叶交界对齐。对36例患者的Acurate Neo对齐情况进行了回顾性评估，其中26例进行了有意尝试。主要终点是TAVR后不可行和非选择性CA的发生率。
结果
38%的患者接受了SAPIEN 3，31.1%接受了Evolut Pro/R，30.1%接受了Acurate Neo THV。在85.9%的Evolut病例和69.4%的Acurate Neo病例中，最终瓣膜取向有利于瓣叶交界对齐（有意对齐成功的比例为88.5%）。SAPIEN 3的选择性CA高于对齐和未对齐的瓣上THV（95%对71%对46%，<0.001）。11%未对齐的瓣上THV、3%对齐的瓣上THV和0%的SAPIEN 3 THV至少有一支冠状动脉插管不可行。不可行/非选择性CA的独立预测因素是未对齐的瓣上THV植入（比值比，4.59 [95% CI，1.81 - 11.61]；<0.01）、主动脉瓣窦高度（比值比，0.83 [95% CI，0.7 - 0.98]；=0.03）以及THV与主动脉瓣窦的关系（比值比，1.06 [95% CI，1.02 - 1.1]；<0.01）。
结论
瓣叶交界对齐可提高瓣上THV进行TAVR后选择性CA的发生率。然而，对齐的瓣上THV比SAPIEN 3具有更高的不可行/非选择性CA风险。瓣上THV未对齐、主动脉瓣窦低以及THV与主动脉瓣窦关系较高的患者在TAVR后CA受损的风险最高。
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