Onishi Takayuki, Tang Gilbert H L
Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai.
Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA.
Curr Opin Cardiol. 2025 Sep 1;40(5):367-374. doi: 10.1097/HCO.0000000000001229. Epub 2025 Apr 24.
Predicting and preventing coronary obstruction in transcatheter aortic valve replacement (TAVR) is crucial due to its high mortality risk.
In native TAVR, predicting coronary obstruction requires assessing aortic cusp height, coronary artery height, valve-to-coronary distance, and leaflet calcium volume. The VIVID classification has been proposed for evaluating the risk of coronary obstruction in TAVR for failed bioprosthetic surgical valves. After TAVR with the Sapien 3 valve, the feasibility of redo TAVR and coronary access decreases with a shallower implantation of the initial Sapien 3. In redo TAVR of Sapien 3 within an Evolut valve, positioning the Sapien 3 outflow at node 4 improves redo TAVR feasibility and coronary accessibility compared to positioning at nodes 5 or 6. For valve sizing in redo TAVR with Sapien 3, in-vivo CT sizing results in smaller valve sizes than bench sizing, reducing coronary risk and improving redo TAVR feasibility. Leaflet modification and coronary stenting techniques and a dedicated leaflet-splitting device have been proposed to maintain coronary perfusion in high-risk cases.
Coronary preservation in high-risk TAVR remains a significant challenge, requiring further research into preprocedural planning and leaflet modification strategies.
由于经导管主动脉瓣置换术（TAVR）存在较高的死亡风险，预测并预防冠状动脉阻塞至关重要。
在原发性TAVR中，预测冠状动脉阻塞需要评估主动脉瓣叶高度、冠状动脉高度、瓣膜至冠状动脉距离以及瓣叶钙化体积。已提出VIVID分类法来评估生物人工心脏瓣膜置换术失败后TAVR中冠状动脉阻塞的风险。使用Sapien 3瓣膜进行TAVR后，初始Sapien 3瓣膜植入位置越浅，再次进行TAVR和冠状动脉通路的可行性越低。在Evolut瓣膜内对Sapien 3进行再次TAVR时，与将Sapien 3流出道置于节点5或6相比，将其置于节点4可提高再次TAVR的可行性和冠状动脉可及性。对于使用Sapien 3进行再次TAVR时的瓣膜尺寸选择，体内CT测量的瓣膜尺寸比体外测量的小，可降低冠状动脉风险并提高再次TAVR的可行性。已提出瓣叶改良和冠状动脉支架置入技术以及一种专用的瓣叶劈开装置，以在高危病例中维持冠状动脉灌注。
高危TAVR中的冠状动脉保护仍然是一项重大挑战，需要对术前规划和瓣叶改良策略进行进一步研究。
