Abstract
Coronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement.
We retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not.
Among 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group (n = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 mm; P = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; P = .032), and longer left coronary cusp (15.1 vs 13.9 mm; P = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group (n = 6), 5 patients had a valve-to-coronary distance of less than 4 mm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 days. After a median follow-up of 351 days, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group.
LM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.
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•Coronary obstruction during TAVR is a rare, yet life-threatening, complication, and its management is challenging.•This is the largest single-center study investigating the outcomes and anatomic factors associated with stent placement for threatened LM obstruction during TAVR.•Certain anatomic factors on CT images may predict stent requirement (LCC length ≥16.5 mm, larger aortic annulus size [diameter ≥25 mm, perimeter ≥82 mm, area ≥5.0 cm2], and lower ratio of STJ diameter to prosthesis size [1.02 vs 1.11]) and may be effectively used for risk stratification, procedural planning, and identification of patients who may eventually require stenting for threatened LM obstruction.•This study found that only 25% of high-risk patients ultimately underwent LM stent deployment.•This study demonstrates that LM protection with a coronary wire, balloon, and/or unexpanded stent is a safe and effective strategy of preventing coronary obstruction during TAVR in high-risk patients, as 30-day and 1-year outcomes were favorable in both stent and nonstent groups.