“…Ochiai et al 41 carried out a study to assess the risk of coronary obstruction (Figure 5) during TAVR‐in‐TAVR. The authors identified that almost 50% of the patients included in the study had a high risk of sinus sequestration at one or both coronary arteries.…”
Section: Viv‐tavr As Tavr‐in‐tavr—risk Of Coronary Obstruction and Unsuccessful Coronary Cannulationmentioning
Transcatheter aortic valve replacement (TAVR) has already received the green light for high‐, intermediate‐ and low‐risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve‐in‐valve procedures (TAVR‐in‐surgical aortic valve replacement [SAVR] and TAVR‐in‐TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.
“…Ochiai et al 41 carried out a study to assess the risk of coronary obstruction (Figure 5) during TAVR‐in‐TAVR. The authors identified that almost 50% of the patients included in the study had a high risk of sinus sequestration at one or both coronary arteries.…”
Section: Viv‐tavr As Tavr‐in‐tavr—risk Of Coronary Obstruction and Unsuccessful Coronary Cannulationmentioning
Transcatheter aortic valve replacement (TAVR) has already received the green light for high‐, intermediate‐ and low‐risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve‐in‐valve procedures (TAVR‐in‐surgical aortic valve replacement [SAVR] and TAVR‐in‐TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.
“…is is also the reason why surgical bioprostheses with externally mounted leaflets or stentless valves have a higher risk of coronary occlusion. e sinuses can even be completely sealed off when the displaced leaflets extend to the sinotubular junction (sinus sequestration), which is more likely in the case of a narrow sinotubular junction or TAVI-in-TAVI [15]. e risk for coronary obstruction can be assessed by measuring the virtual transcatheter valve-tocoronary (VTC) ostium distance and the valve-to-sinotubular junction distance.…”
Bioprosthetic surgical aortic valve failure requiring reintervention is a frequent clinical problem with event rates up to 20% at 10 years after surgery. Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has become a valuable treatment option for these patients, although it requires careful procedural planning. We here describe and illustrate a stepwise approach to plan and perform ViV-TAVI and discuss preprocedural computerized tomography planning, transcatheter heart valve selection, and implantation techniques. Particular attention is paid to coronary artery protection and the possible need for bioprosthetic valve fracture since patients with small surgical aortic bioprostheses are at a risk of high residual gradients after ViV-TAVI. Considering updated clinical data on long-term outcomes following ViV-TAVI, this approach may become the default treatment strategy for patients with a failing surgical aortic bioprosthesis.
“…Because the patient’s clinical status was declining despite inotropic support, after 3 negative blood cultures a TAVR-in-TAVR was planned after discussion within the local heart team. Pre-TAVR computed tomography (CT) showed THV commissure level (area below which a pericardial cylinder is created when the leaflets are tilted up) above the STJ and a narrow valve to STJ distance posing a risk of coronary obstruction due to sinus of Valsalva sequestration ( Figures 1A and 1B ) ( 2 ). Figure 1 Procedural Planning and Post-Procedural Evaluation in Case 1 (A) Pre-TAVR CT scan showing TAV commissure level (red dashed line) above the STJ (yellow dashed line) in both the left coronary sinus (LCS) and right coronary sinus (RCS).…”
Section: Casementioning
confidence: 99%
“…After evaluation by the heart team, the patient was deemed at very high risk for surgery (Society of Thoracic Surgeons risk score: 9.4%), and TAVR-in-TAVR was planned. Pre-TAVR CT scan showed a valve to STJ distance in the right coronary sinus of 0.2 mm (safety cut-off >2.0 mm) and a neocommissure level above the STJ posing a risk of coronary obstruction by sinus of Valsalva sequestration ( Figures 2A and 2B ) ( 2 ). Figure 2 Procedural Planning and Post-Procedural Evaluation in Case 2 (A) Pre-TAVR CT scan showing a TAV commissure level (red dashed line) above the STJ (yellow dashed line) , particularly in the right coronary sinus (RCS).…”
Section: Casementioning
confidence: 99%
“…As indications for transcatheter aortic valve replacement (TAVR) are expanding to include younger patients with life expectancy exceeding transcatheter heart valve (THV) durability, TAVR-in-TAVR procedures are increasingly being performed ( 1 ). However, depending on the patient’s anatomy and the type of THV implanted, a “redo TAVR” may pose a high risk of coronary flow obstruction due to sinus of Valsalva sequestration, a complication characterized by impairment of blood flow to the sinus and, consequently, to the coronaries ( 2 ). Sinus sequestration may occur after redo TAVR if the degenerated THV leaflets are pushed against the sinotubular junction (STJ) and are maintained in an open position by the new THV, thus preventing perfusion of the sinuses of Valsalva ( 3 ).…”
Redo transcatheter aortic valve replacement (TAVR) may pose the risk of coronary flow obstruction. We report 2 cases of severe TAVR regurgitation due to different physiopathological mechanisms in which TAVR-in-TAVR could be at high risk for sinus sequestration. Both cases were successfully treated by in-series implantation of a second transcatheter heart valve, thus avoiding sinus sequestration. (
Level of Difficulty: Intermediate.
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