Coronaries Behind Bars: Angiography & Intervention Following TAVR

Director Cardiac Catheterization Lab, VAMC

Associate Professor of Medicine

Governor, Oklahoma Chapter of ACC

Associate Program Director, CV Fellowship

University of Oklahoma

Faisal Latif MD, FSCAI, FACC

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 4B. EBU 3.75 guideC. JL 3.5D. JL 4.5E. Multipurpose

Lifetime ManagementEase 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.

Kleinman NS, et al. Coronary Intervention After Self-Expanding Transcatheter or Surgical Aortic Valve Replacement in the SURTAVI Trial. Presented at CRT 2019.

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* Ease of access data available for 42 of the 56 treated lesions. Patients with a SYNTAX score >22 were excluded.

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 374:1609–1620D'Ascenzo F, et al. Int J Cardiol 168:2528–2532.

Matias B. Yudi et al. JACC 2018;71:1360-1378

Factors Impacting Coronary 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

Diagnostic Angiography: Evolut

JL 3.5 or JR4

Ikari Rt 1.0/1.5

Guide + Coronary wire

Consider Aortogram

JR4

Ikari Rt or MP

Guide + Coronary wire

LCA RCA

Ascending Aortography

To identify the coronary take-off

Steps of Engaging the Coronary Ostium

Park J-wire to enter diamond in front of coronary ostium

Catheter engaged in the diamond Catheter across the diamond

Sub-selective Angiography First

Crossing the Stent Frame 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: Low Coronary Height (<10 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

FL 3.0/3.5

Ikari Rt 1.0/1.5

Rail guide in with:• Coronary wire +/-• Balloon support +/-• Guide Extension

JR4

Ikari Rt 1.5 or AR2 or MP

LCA RCA

Rail guide in with:• Coronary wire +/-• Balloon support +/-• Guide Extension

Guide Catheter Selection

Why is Extra Backup Guide not in the Algorithm?

Harhash A, et al. JACC CV Interv. 2016; 9(13): 1412-3

Why is Extra Backup Guide not in the Algorithm? Beware of Catheter Entrapment!

Harhash A, et al. JACC CV Interv. 2016; 9(13): 1412-3

Avoid cannulation of the ostia from below the coronary takeoff

Best Practices for PCI: Self-expanding ValvesAvoid 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

Matias B. Yudi et al. JACC 2018;71:1360-1378

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

Best Practices for PCI: CoreValveSteps in Dis-engaging the guide

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 an App for it!TAVR Cath Aid

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)