Coronaries Behind Bars: Angiography & In Interv rvention Following TAVR Faisal Latif MD, FSCAI, FACC Director Cardiac Catheterization Lab, VAMC Associate Professor of Medicine Governor, Oklahoma Chapter of ACC Associate Program Director, CV Fellowship University of Oklahoma
Disclosures Abbott Vascular, Inc (Speaker ’ s Bureau)
80 year old female s/p CoreValve 4 years ago. Which catheter will you use first to engage the left main? A. JL 4 B. EBU 3.75 guide C. JL 3.5 D.JL 4.5 E. Multipurpose
Lifetime Management Ease of Coronary Access After TAVR Among post-AVR percutaneous coronary interventions from the SURTAVI trial cohort, most lesions were deemed “ easy ” or “ moderately difficult ” to treat by the operator. Proportion of Lesions* * Ease of access data available for 42 of the 56 treated lesions. Patients with a SYNTAX score >22 were excluded. Kleinman NS, et al. Coronary Intervention After Self-Expanding Transcatheter or Surgical Aortic Valve Replacement in the SURTAVI Trial. Presented at CRT 2019.
CAD post-TAVR • >60% undergoing TAVR have coexisting CAD • TAVR valves can reduce the elasticity of the aorta making access to coronary arteries more challenging Leon MB, et al. PARTNER 2 Investigators. N Engl J Med 374:1609 – 1620 D'Ascenzo F, et al. Int J Cardiol 168:2528 – 2532.
Factors Im Impacting Coronary ry Access • Width of SOV: Determines the space between the valve frame and the coronary ostia • Wider Sinus → more room to manipulate a catheter toward the coronary ostium • Narrow Sinus → requires a very acute angle for catheter to point toward the ostia for a nonselective angiogram Matias B. Yudi et al. JACC 2018;71:1360-1378
Dia iagnostic Angiography: Evolut LCA RCA JL 3.5 or JR4 JR4 Consider Aortogram Ikari Rt 1.0/1.5 Ikari Rt or MP Guide + Coronary wire Guide + Coronary wire
Ascending Aortography To identify the coronary take-off
Steps of f Engaging the Coronary ry Ostium Park J-wire to enter diamond in Catheter across the diamond Catheter engaged in the diamond front of coronary ostium
Sub-selective Angiography First
Crossing the Stent Frame Co Co-axially! 1. Crossing the stent frame perpendicularly through a diamond at the level of the coronary ostium 2. If there is difficulty with the frame cell directly coaxial to the ostium, use another cell 3. Avoid cannulation of the ostia from below the coronary takeoff
Selective Angiography
Edwards Sapien Valve: Standard Diagnostic Catheters
Sapien 3: Lo Low Coronary Height (< (<10 mm) mm) May have to contend with semi-selective angiography Matias B. Yudi et al. JACC 2018;71:1360-1378
AUC pre-TAVR PCI Higher mortality in patients with higher residual Syntax Score post-TAVR
LCA RCA Guide Catheter Selection FL 3.0/3.5 JR4 Ikari Rt 1.5 or AR2 or MP Ikari Rt 1.0/1.5 Rail guide in with: Rail guide in with: • Coronary wire +/- • Coronary wire +/- • Balloon support +/- • Balloon support +/- • Guide Extension • Guide Extension
Why is is Ext xtra Backup Guide not in in th the Alg lgorithm? Harhash A, et al. JACC CV Interv. 2016; 9(13): 1412-3
Why is is Ext xtra Backup Guide not in in th the Alg lgorithm? Beware of f Catheter Entrapment! Avoid cannulation of the ostia from below the coronary takeoff Harhash A, et al. JACC CV Interv. 2016; 9(13): 1412-3
Best Practices for PCI: Self-expanding Valves Avoid Guide Kinking in Stent Frame • Care should be taken when disengaging the guide, to avoid kinking: • More likely if the guide engaging from below the level of coronary ostium
How to Use an Extra Back-up Guide: Use a Guide Extension • Use a coronary wire through the diamond of the valve • Advance a guide extension and work through it Matias B. Yudi et al. JACC 2018;71:1360-1378
Best Practices for PCI: CoreValve Steps in Dis-engagin ing the guid ide 1. Disengage the guide catheter from ostium (while 0.014-inch wire in the coronary) 2. Withdraw guide catheter through the frame cell 3. If there is difficulty removing the guide catheter from the ostium, use a balloon to disengage prior to pulling. Always remove the guide catheter over the coronary wire +/- balloon
Edwards Sapien Valve: PCI • Standard catheters work majority of the time! • If unable to engage coronaries, most likely the commissural tab is in the way – Solutions: • Try the adjacent diamond to selective engage • May have to contend with non-selective angiography • May need to “ fetch ” the coronary with a wire and either: • “ rail-in ” the guide or • Use a guide extension
There is is an App for it it! TAVR Cath Aid id
Take Home Message • Use Judkins catheters more frequently • Exercise extreme care if using extra back-up guides – Best not to pass guide through the stent frame • Use guide extension liberally • Future: • Fluoroscopically identifiable commisures for TAVR valves • Alignment of TAVR valve commisures to native valve (like SAVR)
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