Hsiung Ingrid, Spilias Nikolaos, Bazarbashi Najdat, Ahuja Keerat R, Patel Jay, Kaur Simrat, Rossi Jeffrey, Gad Mohamed, Abdelfattah Omar, Saad Anas, Popovic Zoran, Miyasaka Rhonda, Yun James, Weiss Aaron, Unai Shinya, Puri Rishi, Reed Grant, Krishnaswamy Amar, Kapadia Samir R
Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio.
Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
J Soc Cardiovasc Angiogr Interv. 2022 May 4;1(4):100339. doi: 10.1016/j.jscai.2022.100339. eCollection 2022 Jul-Aug.
Coronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement.
We retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not.
Among 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group ( = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 mm; = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; = .032), and longer left coronary cusp (15.1 vs 13.9 mm; = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group ( = 6), 5 patients had a valve-to-coronary distance of less than 4 mm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 days. After a median follow-up of 351 days, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group.
LM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.
经导管主动脉瓣置换术（TAVR）期间冠状动脉阻塞是一种罕见但危及生命的并发症。在高危患者中常规使用或不使用支架置入的左主干（LM）保护措施仍存在争议。本研究的目的是评估TAVR期间LM保护的结果，并确定与支架置入需求相关的解剖学因素。
我们回顾性分析了2014年至2019年在我院进行的所有TAVR病例（初次置换和瓣中瓣置换），并确定了在手术过程中接受冠状动脉导丝、球囊和/或支架进行LM保护的患者。我们比较了最终接受LM支架置入和未接受LM支架置入患者的TAVR术前计算机断层扫描主动脉根部特征、手术数据、短期和长期结果。
在1925例TAVR患者中，41例（2.1%）接受了LM保护，其中10例（25%）在瓣膜置入后因有冠状动脉阻塞风险最终在LM置入了支架。在初次TAVR组（n = 35）中，8例患者接受了LM支架置入。较大的TAVR假体、较大的瓣环周长（83.8 vs 76.1 mm；P = 0.038）、窦管交界直径与假体尺寸的较低比值（1.02 vs 1.11；P = 0.032）以及较长的左冠状动脉瓣叶（15.1 vs 13.9 mm；P = 0.18）与LM支架置入的较高发生率相关。在瓣中瓣TAVR组（n = 6）中，5例患者的瓣膜至冠状动脉距离小于4 mm，其中2例接受了LM支架置入。支架组和非支架组在30天时均有良好的结果，无重大不良心血管事件或冠状动脉阻塞。中位随访351天后，4例患者死亡（9.7%）（支架组1例，非支架组3例），两组均无晚期冠状动脉阻塞或经皮冠状动脉介入治疗病例。
对于适当选择的高危患者，在TAVR期间使用冠状动脉导丝、球囊或支架进行LM保护是一种安全有效的冠状动脉保护方法。瓣环周长、假体尺寸、左冠状动脉瓣叶长度、LM开口高度以及窦管交界与假体尺寸的比值是支架置入的重要预测因素。
