Coronary Access After TAVR-in-TAVR as Evaluated by Multidetector Computed Tomography

Ole De Backer, Uri Landes, Andreas Fuchs, Sung Han Yoon, Ole Norling Mathiassen, Alexander Sedaghat, Won Keun Kim, Thomas Pilgrim, Nicola Buzzatti, Philipp Ruile, Abdallah El Sabbagh, Marco Barbanti, Claudia Fiorina, Luis Nombela-Franco, Arie Steinvil, Ariel Finkelstein, Matteo Montorfano, Pal Maurovich-Horvat, Klaus Fuglsang Kofoed, Philipp BlankeMatjaz Bunc, Franz Josef Neumann, Azeem Latib, Stephan Windecker, Jan Malte Sinning, Bjarne Linde Norgaard, Raj Makkar, John G. Webb, Lars Søndergaard

Research output: Contribution to journalArticlepeer-review


Objectives: The aim of this study was to assess coronary accessibility after transcatheter aortic valve replacement (TAVR)–in–TAVR using multidetector computed tomography. Background: Expanding TAVR to patients with longer life expectancy may involve more frequent bioprosthetic valve failure and need for redo TAVR. Coronary access after TAVR-in-TAVR may be challenging, particularly as the leaflets from the initial transcatheter heart valve (THV) will form a neo-skirt following TAVR-in-TAVR. Methods: In 45 patients treated with different combinations of CoreValve and Evolut (CV/EV) THVs with supra-annular leaflet position and SAPIEN THVs with intra-annular leaflet position, post-TAVR-in-TAVR multidetector computed tomographic scans were analyzed to examine coronary accessibility. Results: After TAVR-in-TAVR, the coronary arteries originated below the top of the neo-skirt in 90% of CV/EV-first cases compared with 67% of SAPIEN-first cases (p = 0.009). For these coronary arteries originating below the top of the neo-skirt, the distance between the THV and the aortic wall was <3 mm in 56% and 25% of CV/EV-first and SAPIEN-first cases, respectively (p = 0.035). Coronary access may be further complicated by THV-THV stent frame strut misalignment in 53% of CV/EV-in-CV/EV cases. The risk for technically impossible coronary access was 27% and 10% in CV/EV-first and SAPIEN-first cases, respectively (p = 0.121). Absence of THV interference with coronary accessibility can be expected in 8% and 33% of CV/EV-first and SAPIEN-first cases, respectively (p = 0.005). Conclusions: Coronary access after TAVR-in-TAVR may be challenging in a significant proportion of patients. THVs with intra-annular leaflet position or low commissural height and large open cells may be preferable in terms of coronary access after TAVR-in-TAVR.

Original languageEnglish
Pages (from-to)2528-2538
Number of pages11
JournalJACC: Cardiovascular Interventions
Issue number21
Publication statusPublished - Nov 9 2020


  • computed tomography
  • coronary access
  • transcatheter aortic valve

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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