A new study indicates that coronary angiography, with or without percutaneous coronary intervention (PCI), is feasible in patients who have undergone transcatheter aortic valve implantation (TAVI) with a self-expanding valve (CoreValve, Medtronic).
Authors Wah Wah Htun (Department of Cardiology, Detroit Medical Center/Wayne State University, Detroit, USA) and others report in Catheterization and Cardiovascular Interventions that “in the early era of TAVI”, engaging coronary arteries after a self-expanding valve had been implanted was difficult. They add that although interventional cardiologists have gained more experience with this approach, data for the feasibility of coronary angiography and PCI post TAVI “are not robust with mixed results from different small studies”. “Therefore, we aimed to analyse data from our centre that has been one of the first sites for the CoreValve US pivotal trial,” Htun et al comment.
After reviewing data from their centre, the authors identified 28 patients who had undergone 43 coronary angiographies after TAVI with a self-expanding valve. Of these patients, most required coronary angiography because of acute coronary syndromes. The mean duration between TAVI and the coronary procedure was 15 months.
Htun et al write that they were able to selectively engage 95% of the coronary arteries in the study but note that “additional catheters and manipulations were necessary” and that the fluoroscopy time “greatly exceeded” the US national average for diagnostic catheterisation—11.5 minutes vs. five minutes. Furthermore, they observe: “In our experience, JL catheters better engaged coronary arteries through the stent strut of the Medtronic self-expanding valve than EBU catheters because of the primary and secondary curves of the JL catheter.”
A recent US appropriate use criteria document advised that PCI should be performed prior to TAVI in patients with both obstructive coronary artery disease and severe aortic stenosis. However, according to Htun et al, “one would expect to do more coronary angiographies after TAVI in the future” given that the indication for TAVI is now expanding to include a younger generation. They comment that “although there are reportedly more challenges” in performing coronary angiography in patients with self-expanding valves compared with patients with balloon-expanding valves (ie. Sapien, Edwards Lifesciences), the choice of TAVI device should not be “solely based on this factor”. “With proper preparation, sound knowledge and enough experience, it is feasible and safe to perform coronary angiography and even complex PCI in these patients,” the authors conclude.
Htun told Cardiovascular News: “We do coronary angiogram or high quality cardiac computed tomography (CT) before implantation of TAVI in all patients. As we state in our paper, probably most interventional cardiologists tend to treat obstructive coronary artery disease—especially when it is in the proximal portion of the main vessels (left anterior descending, left circumflex and right coronary artery)—with PCI pre TAVI. Our recommendation regarding how to do coronary angiogram post TAVI successfully is to start with aortic root angiogram to understand the anatomical relation between transcatheter valve leaflet and coronary ostia that will help selective coronary angiogram.”