PDF(Pubmed)
Abstract：
BACKGROUND: Coronary access (CA) is a major concern in redo-transcatheter aortic valve implantation (TAVI) for failing supra-annular self-expanding transcatheter aortic valves (TAVs).
OBJECTIVE: This ex vivo study evaluated the benefit of leaflet splitting (LS) on subsequent CA after redo-TAVI in anatomies deemed at high risk of unfeasible CA.
METHODS: Ex vivo, patient-specific models were printed three-dimensionally. Index TAVI was performed using ACURATE neo2 or Evolut PRO (TAV-1) at the standard implant depth and with different degrees of commissural misalignment (CMA). Redo-TAVI was performed using the balloon-expandable SAPIEN 3 Ultra (TAV-2) at different implant depths with commissural alignment. Selective CA was attempted for each configuration before and after LS in a pulsatile flow simulator. The leaflet splay area was assessed on the bench.
RESULTS: In matched comparisons of 128 coronary cannulations across 64 redo-TAVI configurations, the overall feasibility of CA significantly increased after LS (60.9% vs 18.7%; p<0.001). The effect of LS varied according to the sinotubular junction height, TAV-1 design, TAV-1 CMA, and TAV-2 implant depth, given TAV-2 alignment. LS enabled CA for up to CMA 45° with the ACURATE neo2 TAV-1 and up to CMA 30° with the Evolut PRO TAV-1. The combination of LS and a low TAV-2 implant provided the highest feasibility of CA after redo-TAVI. The leaflet splay area ranged from 25.60 mm2 to 37.86 mm2 depending on the TAV-1 platform and TAV-2 implant depth.
CONCLUSIONS: In high-risk anatomies, LS significantly improves CA feasibility after redo-TAVI for degenerated supra-annular self-expanding platforms. Decisions on redo-TAVI feasibility should be carefully individualised, taking into account the expected benefit of LS on CA for each scenario.
OBJECTIVE: This ex vivo study evaluated the benefit of leaflet splitting (LS) on subsequent CA after redo-TAVI in anatomies deemed at high risk of unfeasible CA.
METHODS: Ex vivo, patient-specific models were printed three-dimensionally. Index TAVI was performed using ACURATE neo2 or Evolut PRO (TAV-1) at the standard implant depth and with different degrees of commissural misalignment (CMA). Redo-TAVI was performed using the balloon-expandable SAPIEN 3 Ultra (TAV-2) at different implant depths with commissural alignment. Selective CA was attempted for each configuration before and after LS in a pulsatile flow simulator. The leaflet splay area was assessed on the bench.
RESULTS: In matched comparisons of 128 coronary cannulations across 64 redo-TAVI configurations, the overall feasibility of CA significantly increased after LS (60.9% vs 18.7%; p<0.001). The effect of LS varied according to the sinotubular junction height, TAV-1 design, TAV-1 CMA, and TAV-2 implant depth, given TAV-2 alignment. LS enabled CA for up to CMA 45° with the ACURATE neo2 TAV-1 and up to CMA 30° with the Evolut PRO TAV-1. The combination of LS and a low TAV-2 implant provided the highest feasibility of CA after redo-TAVI. The leaflet splay area ranged from 25.60 mm2 to 37.86 mm2 depending on the TAV-1 platform and TAV-2 implant depth.
CONCLUSIONS: In high-risk anatomies, LS significantly improves CA feasibility after redo-TAVI for degenerated supra-annular self-expanding platforms. Decisions on redo-TAVI feasibility should be carefully individualised, taking into account the expected benefit of LS on CA for each scenario.
摘要：
背景：冠状动脉通路（CA）是重做经导管主动脉瓣植入术（TAVI）失败的主要问题。
目的：这项离体研究评估了在被认为具有不可行CA高风险的解剖结构中，redo-TAVI后小叶分裂（LS）对随后的CA的益处。
方法：离体，我们对患者特定模型进行了三维打印.使用ACURATEneo2或EvolutPRO（TAV-1）在标准植入深度和不同程度的连合错位（CMA）进行索引TAVI。使用球囊可扩张的SAPIEN3Ultra（TAV-2）在不同的植入物深度进行重做-TAVI，并进行连合对齐。在脉动流模拟器中，在LS之前和之后对每种配置尝试选择性CA。在长凳上评估了传单的张开区域。
结果：在64个redo-TAVI配置的128个冠状动脉插管的匹配比较中，LS后CA的总体可行性显着增加（60.9％vs18.7％；p<0.001）。LS的效果根据窦管连接高度而变化，TAV-1设计,TAV-1CMA,和TAV-2植入深度，给定TAV-2对齐。LS使用ACURATEneo2TAV-1启用了高达CMA45°的CA，使用EvolutPROTAV-1启用了高达CMA30°的CA。LS和低TAV-2植入物的组合在重做-TAVI后提供了CA的最高可行性。取决于TAV-1平台和TAV-2植入深度,小叶张开面积范围为25.60mm2至37.86mm2。
结论：在高风险解剖结构中，对于退化的超环形自膨式平台，在redo-TAVI之后，LS显着提高了CA的可行性。关于重做TAVI可行性的决定应该仔细个性化，考虑到每个方案的LSonCA的预期收益。
目的：这项离体研究评估了在被认为具有不可行CA高风险的解剖结构中，redo-TAVI后小叶分裂（LS）对随后的CA的益处。
方法：离体，我们对患者特定模型进行了三维打印.使用ACURATEneo2或EvolutPRO（TAV-1）在标准植入深度和不同程度的连合错位（CMA）进行索引TAVI。使用球囊可扩张的SAPIEN3Ultra（TAV-2）在不同的植入物深度进行重做-TAVI，并进行连合对齐。在脉动流模拟器中，在LS之前和之后对每种配置尝试选择性CA。在长凳上评估了传单的张开区域。
结果：在64个redo-TAVI配置的128个冠状动脉插管的匹配比较中，LS后CA的总体可行性显着增加（60.9％vs18.7％；p<0.001）。LS的效果根据窦管连接高度而变化，TAV-1设计,TAV-1CMA,和TAV-2植入深度，给定TAV-2对齐。LS使用ACURATEneo2TAV-1启用了高达CMA45°的CA，使用EvolutPROTAV-1启用了高达CMA30°的CA。LS和低TAV-2植入物的组合在重做-TAVI后提供了CA的最高可行性。取决于TAV-1平台和TAV-2植入深度,小叶张开面积范围为25.60mm2至37.86mm2。
结论：在高风险解剖结构中，对于退化的超环形自膨式平台，在redo-TAVI之后，LS显着提高了CA的可行性。关于重做TAVI可行性的决定应该仔细个性化，考虑到每个方案的LSonCA的预期收益。
