Coronaries Behind Bars: Angiography & Intervention ... · Coronaries Behind Bars: Angiography &...
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Coronaries Behind Bars: Angiography & Intervention Following TAVR
Director Cardiac Catheterization Lab, VAMC
Associate Professor of Medicine
Governor, Oklahoma Chapter of ACC
Associate Program Director, CV Fellowship
University of Oklahoma
Faisal Latif MD, FSCAI, FACC
Disclosures
Abbott Vascular, Inc (Speaker’s Bureau)
80 year old female s/p CoreValve 4 years ago. Which catheter will you use first to engage the left main?
A. JL 4B. EBU 3.75 guideC. JL 3.5D. JL 4.5E. Multipurpose
Lifetime ManagementEase of Coronary Access After TAVR
Among post-AVR percutaneous coronary interventions from the SURTAVI trial cohort, most lesions were deemed “easy” or “moderately difficult” to treat by the operator.
Kleinman NS, et al. Coronary Intervention After Self-Expanding Transcatheter or Surgical Aortic Valve Replacement in the SURTAVI Trial. Presented at CRT 2019.
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* Ease of access data available for 42 of the 56 treated lesions. Patients with a SYNTAX score >22 were excluded.
CAD post-TAVR
• >60% undergoing TAVR have coexisting CAD
• TAVR valves can reduce the elasticity of the aorta making access to coronary arteries more challenging
Leon MB, et al. PARTNER 2 Investigators. N Engl J Med 374:1609–1620D'Ascenzo F, et al. Int J Cardiol 168:2528–2532.
Matias B. Yudi et al. JACC 2018;71:1360-1378
Factors Impacting Coronary Access
• Width of SOV: Determines the space between the valve frame and the coronary ostia
• Wider Sinus →more room to manipulate a catheter toward the coronary ostium
• Narrow Sinus→ requires a very acute angle for catheter to point toward the ostia for a nonselective angiogram
Diagnostic Angiography: Evolut
JL 3.5 or JR4
Ikari Rt 1.0/1.5
Guide + Coronary wire
Consider Aortogram
JR4
Ikari Rt or MP
Guide + Coronary wire
LCA RCA
Ascending Aortography
To identify the coronary take-off
Steps of Engaging the Coronary Ostium
Park J-wire to enter diamond in front of coronary ostium
Catheter engaged in the diamond Catheter across the diamond
Sub-selective Angiography First
Crossing the Stent Frame Co-axially!
1. Crossing the stent frame perpendicularly through a diamond at the level of the coronary ostium
2. If there is difficulty with the frame cell directly coaxial to the ostium, use another cell
3. Avoid cannulation of the ostia from below the coronary takeoff
Selective Angiography
Edwards Sapien Valve: Standard Diagnostic Catheters
Sapien 3: Low Coronary Height (<10 mm)May have to contend with semi-selective angiography
Matias B. Yudi et al. JACC 2018;71:1360-1378
AUC pre-TAVR PCI
Higher mortality in patients with higher residual Syntax Score post-TAVR
FL 3.0/3.5
Ikari Rt 1.0/1.5
Rail guide in with:• Coronary wire +/-• Balloon support +/-• Guide Extension
JR4
Ikari Rt 1.5 or AR2 or MP
LCA RCA
Rail guide in with:• Coronary wire +/-• Balloon support +/-• Guide Extension
Guide Catheter Selection
Why is Extra Backup Guide not in the Algorithm?
Harhash A, et al. JACC CV Interv. 2016; 9(13): 1412-3
Why is Extra Backup Guide not in the Algorithm? Beware of Catheter Entrapment!
Harhash A, et al. JACC CV Interv. 2016; 9(13): 1412-3
Avoid cannulation of the ostia from below the coronary takeoff
Best Practices for PCI: Self-expanding ValvesAvoid Guide Kinking in Stent Frame
• Care should be taken when disengaging the guide, to avoid kinking:• More likely if the guide engaging from
below the level of coronary ostium
Matias B. Yudi et al. JACC 2018;71:1360-1378
How to Use an Extra Back-up Guide: Use a Guide Extension
• Use a coronary wire through the diamond of the valve
• Advance a guide extension and work through it
Best Practices for PCI: CoreValveSteps in Dis-engaging the guide
1. Disengage the guide catheter from ostium (while 0.014-inch wire in the coronary)
2. Withdraw guide catheter through the frame cell
3. If there is difficulty removing the guide catheter from the ostium, use a balloon to disengage prior to pulling.
Always remove the guide catheter over the coronary wire +/- balloon
Edwards Sapien Valve: PCI
• Standard catheters work majority of the time!
• If unable to engage coronaries, most likely the commissural tab is in the way – Solutions:
• Try the adjacent diamond to selective engage
• May have to contend with non-selective angiography
• May need to “fetch” the coronary with a wire and either:
• “rail-in” the guide or
• Use a guide extension
There is an App for it!TAVR Cath Aid
Take Home Message• Use Judkins catheters more frequently
• Exercise extreme care if using extra back-up guides – Best not to pass guide through the stent frame
• Use guide extension liberally
• Future: • Fluoroscopically identifiable commisures for TAVR valves
• Alignment of TAVR valve commisures to native valve (like SAVR)