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Novel Humanized Biosimulator to Predict Coronary Obstruction in High-Risk Valve-in-Valve Procedures.

ABSTRACT: We developed humanized biosimulator to predict the risk of coronary obstruction among high-risk patients undergoing valve-in-valve (ViV) procedures. In this case, based on unchanged instantaneous wave-free ratio values measured during a ViV simulation session, the procedure was performed safely in the patient the day afterward, without coronary artery issues and with good hemodynamic results. (Level of Difficulty: Advanced.).

SUBMITTER: Perrin N

PROVIDER: S-EPMC9911917 | biostudies-literature | 2023 Feb

REPOSITORIES: biostudies-literature

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Novel Humanized Biosimulator to Predict Coronary Obstruction in High-Risk Valve-in-Valve Procedures.

Perrin Nils N Bonnet Guillaume G Ibrahim Réda R Bonan Raoul R Leroux Lionel L Granada Juan F JF Tardif Jean Claude JC Modine Thomas T Ben Ali Walid W

JACC. Case reports 20221224

We developed humanized biosimulator to predict the risk of coronary obstruction among high-risk patients undergoing valve-in-valve (ViV) procedures. In this case, based on unchanged instantaneous wave-free ratio values measured during a ViV simulation session, the procedure was performed safely in the patient the day afterward, without coronary artery issues and with good hemodynamic results. (<b>Level of Difficulty: Advanced.</b>). ...[more]

PMID: 36776792

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Simple 2-dimensional anatomic model to predict the risk of coronary obstruction during transcatheter aortic valve replacement.

Project description:ObjectiveIn this study, a 2-dimensional (2D) index relying on preprocedural computed tomography (CT) data was developed to evaluate the risk of coronary obstruction during transcatheter aortic valve replacement (TAVR) procedures.MethodsAnatomic measurements from pre-TAVR CT scans were collected in 28 patients among 600 who were flagged as high risk (defined as meeting coronary artery height, h, <14 mm and/or sinus of Valsalva diameter, SOVd, <30 mm) for coronary obstruction. A geometric model derived from these anatomic measurements was used to predict the post-TAVR native cusp apposition relative to the coronary ostium. The distance from the cusp to the coronary ostium, DLC2D, was measured from the geometric model and indexed with the coronary artery diameter, d, to yield a fractional obstruction measure, DLC2D/d.ResultsTwenty-three of 28 high-risk patients successfully underwent TAVR without coronary obstruction, of whom 1 had coronary obstruction and 4 were deemed non-TAVR candidates. DLC2D/d differed significantly between the 2 groups (P < .0018), but neither h nor SOVd did (P > .32). The optimal sensitivity and specificity for DLC2D/d were 85% and occurred at a cutoff of 0.45. The optimal sensitivity and specificity of h and SOVd in this high-risk group were only 60% and 40%, respectively, for cutoffs of h = 10 mm and SOVd = 30.5 mm.ConclusionsThe 2D geometric model derived in this study shows promise for identifying patients with low-lying coronary ostium and/or small SOVd that may be safely treated with TAVR. DLC2D/d is more predictive of obstruction or poor TAVR candidacy compared with h and SOVd.

| S-EPMC7434688 | biostudies-literature

Modeling risk of coronary obstruction during transcatheter aortic valve replacement.

Project description:ObjectiveIn this study we aimed to evaluate risk of coronary obstruction during transcatheter aortic valve replacement and develop improved criteria based on computational modeling.MethodsPatient specific 3-dimensional models were constructed and validated for 28 patients out of 600 patients who were flagged as high risk for coronary obstruction (defined as meeting coronary ostium height < 14 mm and/or sinus of Valsalva diameter [SOVd] < 30 mm). The models consisted finite element analysis to predict the post- transcatheter aortic valve replacement native cusp apposition relative to the coronary ostium and were validated in vitro. The distance from cusp to coronary ostium (DLC) was derived from the 3-dimensional models and indexed with the coronary artery diameter to yield a fractional obstruction measure (DLC/d).ResultsTwenty-two out of 28 high-risk patients successfully underwent transcatheter aortic valve replacement without coronary obstruction and 6 did not. DLC/d between the 2 groups was significantly different (P < .00078), whereas neither coronary ostium height nor SOVd were significantly different (P > .32). A cutoff of DLC/d < 0.7 was predictive with 100% sensitivity and 95.7% specificity. The optimal sensitivity and specificity of coronary ostium height and SOVd in this high-risk group was only 60% and 40%, respectively, for cutoff coronary ostium height of 10 mm and SOVd of 30.5 mm.ConclusionsThree-dimensional modeling has the potential to enable more patients to be safely treated with transcatheter aortic valve replacement who have a low-lying coronary ostium or small SOVd. DLC/d is more predictive of obstruction than coronary ostium height and SOVd.

| S-EPMC6859205 | biostudies-literature

Valve-in-Valve Challenges: How to Avoid Coronary Obstruction.

Project description:Coronary obstruction is a rare but life-threatening complication in patients undergoing transcatheter aortic valve replacement (TAVR). Aortic valve-in-valve (VIV) procedures to treat failed surgical bioprosthesis is associated with ~6-fold higher risk for coronary obstruction in certain situations. The primary mechanism consists in the occlusion of the coronary ostium by the dislodged leaflet from the bioprosthesis after deployment of the transcatheter heart valve (THV), which most commonly occurs during the index procedure, but in up to 1/3 of cases a delayed presentation ensues. The clinical presentation consists of severe hypotension and ECG changes in most of the patients, with very high mortality rates. Therefore, pre-procedural multi-slice computed tomography is crucial for identifying high-risk features, such as low coronary heights, shallow sinuses of Valsalva, and short virtual THV to coronary ostial distance (VTC). Also, some models of surgical bioprosthesis present an increased risk for this dreadful complication. Preemptive protective strategies with coronary wiring, with or without placement of an undeployed stent, could mitigate the risks associated with this complication in high-risk patients, even though studies are lacking. This review aims to take a clinical perspective on the challenges in avoiding this complication during VIV procedures.

| S-EPMC6716332 | biostudies-literature

Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up.

Project description:Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.

| S-EPMC10219453 | biostudies-literature

Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement.

Project description: Not available

| S-EPMC8288806 | biostudies-literature

How to Avoid Coronary Occlusion During TAVR Valve-in-Valve Procedures.

Project description:Transcatheter aortic valve-in-valve replacement has been recently reported as a less-invasive alternative to re-do surgery in patients with bioprosthetic valve failure. Although procedural success is achieved in the great majority of patients, this therapy is associated with several potential complications, and coronary occlusion is one of the most feared. This is a rare event, but it is associated with an extremely poor prognosis. In this review, the mechanisms, the identification of patients at high risk, the primary prevention strategies, and treatment of coronary occlusion will be discussed.

| S-EPMC6877473 | biostudies-literature

Acute left main coronary artery occlusion following transcatheter aortic valve replacement without obvious risk factors of coronary obstruction.

Project description: Not available

| S-EPMC7219302 | biostudies-literature

Transcatheter aortic valve-in-valve post-dilatation as an overlooked risk factor of delayed coronary obstruction: a case report.

Project description:BackgroundThe risk of coronary obstruction during transcatheter aortic valve-in-valve replacement (VIV-TAVR) in patients deemed at high risk for surgical re-intervention is still a concerning issue.Case summaryA 78-year-old woman with a past medical history of hypertension, chronic kidney disease, and rheumatoid arthritis was referred for a symptomatic and severely stenotic surgical Mitroflow n.21 bio-prosthesis and was subsequently recommended for a VIV procedure. Multiple anatomical risk factors for coronary occlusion required a pre-emptive coronary chimney stenting protection. The implantation of an Evolut-R 23 mm valve resulted in a gradient of 21 mmHg thus, a post-dilatation with an 18 mm balloon was performed. Both electrocardiographic and haemodynamic parameters remained excellent, however, a hazardous leaflet dislodgment became evident. Regardless, a prophylactic chimney stenting was performed because of the operator's perceived high risk of late coronary occlusion.DiscussionThe implantation of transcatheter valves inside failed surgically implanted aortic bio-prosthesis is broadly recognized as a safe and less-invasive alternative to repeated high-risk surgery. Although procedural success is achieved in the great majority of patients, this therapy may be jeopardized by rare but serious complications such as impending or established acute coronary occlusion. Several specific anatomical and procedural risk factors have been identified and primary coronary prevention strategies are often mandatory when they arise. Valve-in-valve post-dilation has been overlooked in its role as an additional risk factor of late coronary obstruction. Therefore, chimney stenting, performed after balloon post-dilation to prevent delayed coronary obstruction, even if the acute coronary event does not occur intra-procedurally, is strongly advisable.

| S-EPMC7649518 | biostudies-literature

Bail out lithotripsy to treat delayed valve-in-valve TAVR-related coronary obstruction.

Project description:Coronary access difficulty and stent compression by the juxtaposed aortic valve leaflet hamper percutaneous management of delayed coronary artery obstruction (CAO) after valve-in-valve (Edwards Sapien 3 in St. Jude Trifecta) transcatheter aortic valve replacement (TAVR). Here, we present a case of delayed post-TAVR CAO treated with intravascular lithotripsy and multistenting to overcome stent compression by the adjacent calcified leaflet.

| S-EPMC10099844 | biostudies-literature

High risk of coronary artery obstruction during TAVR, how to avoid it?

Project description:BackgroundCoronary artery obstruction after percutaneous aortic replacement is a complication with high short-term mortality secondary to the lack of timely treatment. There are various predictors of coronary obstruction prior to valve placement such as the distance from the ostia, the degree of calcification, the distance from the sinuses; In such a situation some measures must be taken to prevent and treat coronary obstruction.Case presentationAn 84-year-old male, with severe aortic stenosis and high surgical risk, who was treated with TAVR. However, during the deployment of the valve he presented hemodynamic instability secondary to LMCA obstruction. The intravascular image showed obstruction of the ostium secondary to the displacement of calcium that he was successfully treated with a chimney stent technique.ConclusionsThe high degree of calcification and the left ostium near the annulus are conditions for obstruction of the ostium at the time of valve release; In this context, provisional stenting prior to TAVR in patients at high risk of obstruction should be considered as a safe prevention strategy to achieve the success of the procedure.

| S-EPMC10949699 | biostudies-literature

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