The study was prompted by a patient that Dr. Won-Keun Kim of Kerckhoff Heart Center in Bad Nauheim, Germany had to handle when he was on call. Achieving coronary engagement, which usually happened "in a few minutes," took more than an hour in this case, he said, and he decided to explore further.
As reported in JACC: Cardiovascular Interventions, Dr. Kim and colleagues analyzed international registry data from 441 patients with prior TAVR requiring urgent or emergent coronary angiography (CA). Most (89%) had acute coronary syndromes.
High success rates were achieved for CA of the right (98.3%) and left (99.3%) coronary arteries; however, rates were higher in patients with short SFPs than in those with long SFPs for CA of the right coronary artery (99.6% vs. 95.9%) but not for the left (99.7% vs. 98.7%).
PCI of native coronary arteries was successful in 91.4% of cases, regardless of valve type (short, 90.4% vs. long, 93.4%).
Guide engagement failed in six patients: three underwent emergent coronary artery bypass grafting and three died in the hospital.
Among patients requiring revascularization of native vessels, independent predictors of 30-day all-cause mortality were prior diabetes, cardiogenic shock, and failed PCI; however, valve type or success of coronary engagement were not predictive factors.
The authors conclude, "CA or PCI after TAVR in acute settings is usually successful, but selective coronary engagement may be more challenging in the presence of long SFPs. Among patients requiring PCI, prior diabetes, cardiogenic shock, and failed PCI were predictors of early mortality."
Dr. Kim said, "I would have expected worse outcomes for long SFP, but as discussed in the paper, there are multiple confounding factors that affect outcomes, and the sample size may have been too small to detect any differences."
More attention needs to be paid to the choice of prosthetic, he said, "and this decision is in the hands of the TAVR operator. The majority of patients can be treated with any kind of prosthesis, but if the anticipated result is similar, I would certainly prefer a short SFP."
"However," he added, "if for any reason I assume that the immediate outcome might be better when using a long SFP, I would not hesitate to use a long SFP, as coronary access still will be possible in most cases."
Dr. Neil Kleiman of Houston Methodist in Texas, author of a related editorial, commented in an email to Reuters Health, "Cardiologists often (assume) that intervention is not possible after a patient has undergone TAVR. However, as shown in the study, it is possible to do such interventions with a very high success rate."
"The requirement, of course, is that operators be patient and flexible in their approach and that they gain some understanding of the novel techniques that are sometimes required to perform such interventions," he said. "It also does make the point that it is incumbent upon valve manufacturers to incorporate features that facilitate coronary access as they develop new iterations of their valves."
SOURCE: https://bit.ly/3eRrkOd and https://bit.ly/3ePdSdO JACC: Cardiovascular Interventions, online July 19, 2021.
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