Pavitt Christopher, Arunothayaraj Sandeep, Broyd Christopher, Michail Michael, Cockburn James, Hildick-Smith David
Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England.
Int J Cardiovasc Imaging. 2024 Jul;40(7):1555-1564. doi: 10.1007/s10554-024-03142-7. Epub 2024 May 25.
Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.
采用瓣叶对合的经导管主动脉瓣植入术（TAVI）旨在降低冠状动脉阻塞风险并保持良好的冠状动脉通路。然而，由于冠状动脉瓣叶内冠状动脉起源偏心，冠状动脉 - 瓣叶重叠（CCO）仍可能发生。采用冠状动脉对合而非瓣叶对合的TAVI可能会进一步改善冠状动脉通路。为比较采用瓣叶对合与冠状动脉对合方法进行TAVI后的CCO发生率。分析了102例因TAVI而转诊的重度（三尖瓣）主动脉瓣狭窄患者的心脏CT扫描结果。定义了天然瓣叶不对称性和冠状动脉偏心性，并用于模拟采用瓣叶对合与冠状动脉对合的TAVI。比较了最佳冠状动脉对合（距瓣叶中心<10°）和严重不对合（距冠状动脉 - 瓣叶重叠<15°）的发生率。此外，评估了植入过程中瓣膜不对合的影响。天然右冠状动脉（RCA）起源比右冠状动脉瓣叶中心更靠近右冠状动脉瓣叶/无冠状动脉瓣叶（RCC - NCC）交界15.8°（9.5至24°）。天然左冠状动脉（LCA）起源比左冠状动脉瓣叶中心更靠近左冠状动脉瓣叶/无冠状动脉瓣叶（LCC - NCC）交界4.5°（0至11.5°）（p<0.01）。与瓣叶对合相比，冠状动脉对合使最佳对合的RCA比例增加了一倍（62/102 [60.8%]对31/102 [30.4%]；p<0.001），而最佳LCA对合无显著变化（62/102 [60.8%]对74/102 [72.6%]；p = 0.07）。两种策略均未出现严重不对合的情况。模拟15°的瓣膜不对合导致瓣叶对合病例中有7/102（6.9%）存在严重RCA受损风险，而冠状动脉对合则无此情况。两种方法的透视投影相似。与瓣叶对合相比，冠状动脉对合使相对于RCA开口的最佳TAVI定位增加了2倍，且不影响LCA。采用冠状动脉对合而非瓣叶对合可能会改善TAVI后的冠状动脉通路，并且对瓣膜旋转误差更不敏感，尤其是对于右冠状动脉。
