Fusion Imaging Guidance for Coronary Reaccess After Valve-in-Valve Transcatheter Aortic Valve Replacement

Abstract

Coronary reaccess can be difficult after valve-in-valve transcatheter aortic valve replacement. We present a case whereby prior valve-in-valve transcatheter aortic valve replacement created difficulty with coronary reaccess. Computed tomography-fluoroscopy fusion imaging was used for guidance to successfully engage the coronary arteries and perform percutaneous coronary intervention.

Graphical abstract

An 84-year-old man with a history of coronary artery bypass grafting presented to our institution with unstable angina. His past medical history also included a surgical aortic valve replacement with a 23-mm tissue valve that required valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) 7 years prior with a 26-mm self-expandable transcatheter heart valve (THV) because of bioprosthetic dysfunction. Urgent cardiac catheterization revealed a patent bypass graft to the left anterior descending artery, and nonselective angiography revealed severe calcific disease of the distal left main and ostial circumflex arteries (Figure 1A, Video 1). Coronary cannulation was not possible, so the patient was taken off the table and placed on antianginals and intravenous heparin. He underwent a computed tomography (CT) for interventional planning. Although the commissures of the THV were aligned with the bioprosthetic valve commissures (Figure 1B), the neoskirt extended above the ostium of the left coronary artery into the sinotubular junction with a virtual valve-to-sinotubular junction distance (VT-STJ) <1 mm that explained the difficulty with coronary reaccess (Figures 1C and 1D).

Figure 1.

Fusion Imaging to Guide Coronary Reaccess

Nonselective angiography from above the neoskirt (A). Computed tomography demonstrating commissural alignment; the ”c-tab” (white arrowhead) of the self-expanding transcatheter heart valve is in line with its commissure (B). The neoskirt of the ViV TAVR is measured from where the base of the surgical valve begins to where the leaflets are “pinned” against the transcatheter heart valve frame (C). At the top of the neoskirt, the virtual valve to sinotubular junction (VT-STJ) is measured, which is <1 mm (D). Preoperative computed tomography identifies a location in which the prior bioprosthetic leaflet was obstructing access to the left sinus, and after coregistration with computed tomography-fluoroscopy fusion, a landmark was registered onto fluoroscopy view and the guide catheter (white star) was advanced toward the landmark (white arrow) (E). After the operator was able to position a guide catheter at the landmark and advance across the displaced leaflet to engage into the left sinus, successful percutaneous coronary intervention of the distal left main and ostial left circumflex was performed (F).

The procedure was performed under general anesthesia with transesophageal echocardiography guidance via transfemoral access. Preoperative CT was able to identify a cell within the THV in which the prior bioprosthetic leaflet was obstructing access to the left sinus. This point was identified with a landmark on CT, and coregistration using CT fluoroscopy fusion guidance was used for intraoperative guidance. Toggling between views, the operator was able to position a 7-F guide catheter at the landmark (Figure 1E, Video 2). Using forward momentum and a microcatheter for excess support, the catheter was able to force the prior surgical leaflet down and engage into the left sinus. The coronary lesion was then able to be treated with intravascular lithotripsy and percutaneous coronary intervention with excellent results (Figure 1F).

Discussion

After ViV TAVR, the leaflets of the degenerated surgical prosthesis will be displaced outward, creating a tube graft that is commonly referred to as the “neoskirt.” If the coronary ostium is below the neoskirt, coronary cannulation may not be feasible if the VT-STJ is small (<2 mm).¹ To our knowledge, there have been no techniques described to overcome this barrier. Nonselective angiography from above the neoskirt may allow visualization of the coronary arteries; however, percutaneous coronary intervention would not be feasible because the guide catheters would be too large to engage. Coronary artery bypass grafting could be one strategy for revascularization, but many TAVR patients are not candidates for surgery.

This is the first published application of utilizing intraprocedural fusion imaging to aid in coronary reaccess after ViV TAVR. CT fluoroscopy fusion coregistration allowed us to locate the exact THV cell and level we could traverse through the displaced bioprosthetic leaflet. This technique may not be feasible if the bioprosthetic leaflet is rigid.

Conclusions

Preprocedural planning and utilization of intraprocedural fusion imaging may help improve success rates for coronary cannulation after ViV TAVR.

Funding Support and Author Disclosures

Dr Kaple is a consultant for Abbott and Edwards Lifesciences. Dr Faraz is a consultant for Abiomed and Shockwave. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Unable to Selectively Engage the Left Coronary Artery

Nonselective angiography from above the neoskirt reveals a severe stenosis in the left-main coronary artery/left circumflex artery.

Video 2

Computed Tomography-Fluoroscopy Fusion Imaging Used to Landmark the Transcatheter Heart Valve Cell Adjacent to the Left Sinus

The guide catheter is then advanced after coregistration and directed at the cell.