Restriction in supra-annular transcatheter heart valve leaflet mobility during coronary access after valve-in-valve TAVI

Supported by the EuroIntervention Journal

Authors

Arif A Khokhar^1,2, Adriana Zlahoda-Huzior^2,3, Francesco Giannini⁴, Dariusz Dudek^4,5

Case summary

Coronary access after transcatheter aortic valve implantation (TAVI) can be challenging or unfeasible due to interactions between coronary catheters and elements of the transcatheter heart valve (THV) frames^1-3. Catheters may also interact with THV leaflets, which, in the extreme case of leaflet pinning, may lead to acute haemodynamic compromise. However, to date, the interaction between THV leaflets and catheters during coronary cannulation has not been visualized or evaluated.

We developed an ex vivo computed-tomography-derived patient-specific anatomical model to simulate coronary cannulation procedures. (Supplementary Figure 1A) The model was connected to a pulsatile flow simulator to replicate in vivo conditions. Two supra-annular valves, Evolut (Medtronic, Minneapolis MN, USA) and ACURATE neo2 (Boston Scientific, Marlborough, MA, USA) were selected for evaluation due to the higher placement of their leaflets, which may increase the likelihood for catheter-leaflet interactions.

A 26 mm Evolut and Size S ACURATE neo2 were implanted inside a Carpentier-Edwards Perimount 25 mm (Edwards Lifesciences, USA) surgical bioprosthesis to replicate coronary access after valve-in-valve TAVI. (Supplementary Figure 1B).

Expert operators cannulated the coronary ostia using different catheters under fluoroscopic guidance. Interactions between the catheters and THV leaflets were visualized using an internally mounted borescope camera. (Supplementary Figure 1C)

Our images demonstrate how coronary catheters can interact with the leaflets of both supra-annular THVs (Figure 1). The degree of restriction in leaflet mobility varied from mild systolic leaflet restriction to more significant leaflet pinning throughout the cardiac cycle. The degree of leaflet restriction was dependent on the choice of catheter and the cannulation technique. Leaflet pinning was more frequently observed with the use of the supportive Amplatz Left 1 catheter or if an Extra Backup catheter was pushed down to assume a more supportive position (Supplementary Videos 1-2). These interactions were observed with both commissural alignment and misalignment of the transcatheter heart valves.

The hemodynamic consequences of these restrictions in leaflet mobility are unknown. Mild leaflet interaction or restriction that affects only a single leaflet during systole would likely have no significant impact. In contrast, complete pinning of one or more leaflets could result in acute aortic insufficiency and subsequent haemodynamic compromise.

Operators should therefore be aware of this phenomenon, particularly when using supportive catheters during long complex PCI procedures in patients who underwent TAVI.

Changing the type or position of the guiding catheter or utilising an external cannulation technique which bypasses the valve frame can minimise or avoid interactions with THV leaflets (Supplementary Figure 2) (Supplementary Videos 3-4). 

These catheter-leaflet interactions were only evaluated for two specific self-expandable supra-annular THVs. However, it is likely that these interactions can occur with other THVs, particularly in patients with low-lying coronary arteries or following higher valve implantations.

Further testing in different anatomical settings using different THVs should be combined with hydrodynamic testing (transvalvular leakage, transvalvular gradients, and both effective and geometric orifice areas) to further evaluate the potential impact of these catheter-leaflet interactions.

Our work highlights how patient-specific ex vivo simulations offer physicians the opportunity to observe and evaluate the potential in vivo impact of different techniques particularly for complex structural heart interventions.

Supplementary Material

References

1. Barbanti M., Costa G., Picci A., et al. Coronary Cannulation After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2020;13(21):2542–55. Doi: 10.1016/j.jcin.2020.07.006.
2. Tarantini G., Nai Fovino L., Scotti A., et al. Coronary Access After Transcatheter Aortic Valve Replacement With Commissural Alignment: The ALIGN-ACCESS Study. Circ Cardiovasc Interv 2022;15(2):e011045. Doi: 10.1161/CIRCINTERVENTIONS.121.011045.
3. Valvo R., Costa G., Tamburino C., Barbanti M. Coronary artery cannulation after transcatheter aortic valve implantation. EuroIntervention 2021;17(10):835–47. Doi: 10.4244/eij-d-21-00158.

Affiliations

1. Imperial College Healthcare NHS Trust, London, UK
2. Digital Innovations & Robotics Hub, Krakow, Poland
3. Department of measurement and electronics, AGH University of Science and Technology, Krakow, Poland
4. Interventional cardiology unit, GVM Care & Research, Maria Cecilia Hospital, Cotignola, Italy
5. Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland