Expanding TAVI options: elective rotational atherectomy during trans-catheter aortic valve implantation




Summary


Aortic valve stenosis (AVS) in the elderly is frequently associated to coronary artery disease (CAD). In patients with significant coronary stenosis surgical valve replacement is associated to coronary bypass grafting, but whether coronary angioplasty is needed in patients receiving trans-catheter aortic valve implantation (TAVI) is unknown. Given the frequent complexity of CAD in the elderly with calcific AVS, rotational atherectomy (RA) may be needed in some cases. No data are available about feasibility and safety of RA during TAVI.


The need for myocardial revascularization in TAVI candidates is discussed, and a series of RA cases performed during TAVI is described.


1


Introduction


Significant coronary artery disease (CAD) has been reported in more than 60% of octogenarians undergoing surgical aortic valve replacement (SAVR) and in 40 to 75% of high-risk patients undergoing trans-catheter aortic valve implantation (TAVI) . The impact of CAD on prognosis among patients undergoing TAVI depends on the angiographic complexity as quantified by the SYNTAX score . In fact, among cases with confirmed significant CAD, those with high SYNTAX score had an increased risk of cardiovascular mortality, stroke, and myocardial infarction at 1 year follow-up compared to those with low SYNTAX score or no CAD (no CAD: 13%, low SYNTAX score: 16%, high SYNTAX score: 30%; p = 0.02) . Unlike coronary artery bypass grafting (CABG) at the time of SAVR, PCI among patients undergoing TAVI appears to confer no excess short-term risk of death, myocardial infarction, and stroke compared with isolated TAVI although there is no agreement about the real need for treating coronary stenosis before, or after TAVI in the absence of clear signs of ischemia. Such indication may be better addressed by assessing the clinical need dictated by symptoms during follow-up. Last, it is important to mention that completeness of revascularization did not impact clinical outcomes in 124 TAVI patients with significant CAD who underwent staged or concomitant PCI in 32% of cases according to a heart team decision .


Aged patients with severe calcific aortic valve stenosis (AVS) often present with severely calcified CAD, and its treatment poses technical challenges, with increased risk of intra-procedural complications and mid-term clinical events like recurrence of angina or infarction related to restenosis or stent thrombosis. Severe and diffuse calcifications often require the use of rotational atherectomy (RA) to permit stent implantation and expansion. However, there are no reports on the safety and feasibility of using electively RA in old patients with severe AVS and whether RA should be better performed before or after valve implantation.




2


Cases’ presentation


Out of our consecutive series of 148 trans-femoral TAVI procedures, 86 (58%) had significant CAD, and among these, 29 (33%) were indicated myocardial revascularization. During the first 2 years of our TAVI experience, CAD was treated always electively before TAVI, while in the last 2 years most PCI were performed either during the same procedure, or however, during the same hospital admission. In 3 cases (10%), RA was needed and performed with immediate success, without subsequent complications and with implantation of drug active stents. In one case RA was needed after failure to cross a lesion of the proximal RCA with balloons ( Fig. 1 ), and in two cases because of a diffuse and severe calcific disease of the LAD causing severe impairment of the coronary reserve ( Figs. 2 and 3 ).




Fig. 1


a) Left anterior oblique angiographic incidence of the right coronary artery; b) 1.25 mm balloon cannot cross a severe calcific lesion before TAVI; c) angiogram of the right coronary artery after TAVI; d) 1.75 mm bur through the lesion immediately after TAVI; e) result after implantation of a bio-active-stent (BAS) 4.0 × 19 mm.



Fig. 2


a) Cranial postero-anterior angiographic incidence of the left anterior descending artery with severe calcifications in a patient with a degenerated bioprosthesis in aortic position (Hancock 25 mm); b) adenosine-free iFR measurement showing severe reduction of the coronary reserve; c) 1.50 mm bur through the lesion immediately after valve in valve in the aortic position; d) result after implantation of a drug-eluting stent 3.0 × 23 mm.



Fig. 3


a) Cranial right-anterior angiographic incidence of the left anterior descending artery showing severe calcific stenosis of the mid segment; b) adenosine-free iFR measurement showing severe reduction of the coronary reserve after valve implantation; c) 1.75 mm bur through the lesion; d) result after implantation of a drug-eluting stent 3.5 × 12 mm.


All patients had preserved left ventricular (LV) function (ejection fraction 48, 64 and 52%), moderate-to severe impairment of the glomerular filtration rate (35, 44 and 50 ml/min) and high clinical risk as assessed by the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), 23, 18 and 24 (see Table 1 ). Although there are no clear recommendations, in all cases RA was performed after TAVI because it was assumed that any eventual ischemic complication related to the PCI procedure (slow flow or vessel occlusion) would have been better tolerated after the complete release of the LV pressure overload. Of note, no difficulty was encountered when catheterizing the coronary ostia after the valve implantation with a 6Fr guiding catheter. Furthermore, the assessment of the functional lesion severity may be physiologically more reliable after the correction of the AVS. On the other hand, the ischemia related to the rapid ventricular pacing during valve implantation is very short and unlikely to create irreversible hemodynamic impairment before myocardial revascularization.



Table 1

























































































Patients characteristics Patient 1 Patient 2 Patient 3
Gender M F M
Age (years) 83 81 85
Logistic EuroSCORE 23 18 24
NYHA class before TAVI IV III III
Degree of CAD 2VD 1VD 2VD
Symptomatic angina Yes No Yes
Peripheral artery disease Yes No Yes
eGFR (ml/min/m 2 ) 35 50 44
Cardiac rhythm Sinus Sinus Sinus
Treated vessel RCA Proximal LAD Mid-LAD
Previous heart surgery No Hancock aortic valve 25 mm No
LVEF (%) 52 48 64
AVA (cm 2 /m 2 ) 0.35 0.40 0.38
Mean aortic gradient (mmHg) 58 55 60
DAPT duration (months) 1 3 3
Type of stent NO-donor bio-active stent Everolimus-eluting stent Zotarolimus-eluting stent

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Nov 14, 2017 | Posted by in CARDIOLOGY | Comments Off on Expanding TAVI options: elective rotational atherectomy during trans-catheter aortic valve implantation

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