Complex patient subgroups

24.1.5.1

Evolut-PRO CoreValve

Engagement depending on depth of valve implantation

If the Evolut-PRO CoreValve is positioned optimally (skirt below coronary ostia), it is feasible to engage the coronary artery in a coaxial manner, assuming the native aortic valve leaflets will not interfere with the path to the coronary ostium ( Fig. 24.2 , panel A).

If the valve is deployed high ( Fig. 24.2 , panel B) coronary obstruction would not occur due to the narrow waist of the valve and sufficient sinus of Valsalva width . However, selective coronary angiography would be difficult in this scenario and would have to occur from a diamond above the ostium, given that the supra-annular valve and its covered segment (e.g., sealing skirt) would be above the level of the ostium. A straighter catheter with a short tip, such as a Judkins right (JR) 4, could be used in this scenario, even for left main artery engagement .

Engagement depending on the position of the transcatheter valve commissures in relation to those of the native aortic valve

The circumferential sealing skirt of the Evolut-PRO CoreValve is 13 mm in height (14 mm in the 34-mm Evolut-R), however it rises up to 26 mm at the commissural insertion point ( Fig. 24.3 ). If a commissure ends up being positioned directly in front of the coronary ostium coaxial engagement of the coronary ostia would be challenging, if not impossible . Engagement also depends on the width of the sinus of Valsalva that determines the space between the valve frame and the coronary ostia; the wider the sinus the more room there is to manipulate a catheter toward the coronary ostia. A narrow sinus would require a very acute angle for the catheter to be pointing toward the ostia for a nonselective coronary angiogram. If selective engagement is required, a coronary wire would have to be manipulated into the coronary artery, and the guide, or a guide catheter extension, would then have to be railed into the ostium. This represents the most difficult scenario: a valve commissure overlying a low coronary ostium in a patient with a narrow sinus of Valsalva. The aforementioned description does not account for the native aortic leaflet height and severity of calcification facing the left and right sinuses. A tall and bulky leaflet may extend beyond the 13- or 14-mm sealing skirt of the repositionable Evolut-PRO self-expanding valve and would likely further add to the challenge of coronary reaccess .

Catheter selection

Left coronary artery : Smaller catheters, such as a JL3.5 or JL3, are frequently used to engage the left main. On the contrary, engagement of the RCA can usually be managed with a JR4 catheter. There are reports of XB guide catheter kinking and entrapment through the valve diamonds ( Fig. 24.4 ) . The following measures may minimize the risk of catheter entrapment:

• 1.

  Crossing the stent frame perpendicularly through a diamond at the same level with the coronary ostium.

• 2.

  Using catheters with favorable geometry (e.g., left Judkins for left and right Amplatz for the right coronary artery).

• 3.

  Using a balloon and/or a guidewire to back the catheter out of the coronary ostium.

Right coronary artery : JR4 or Ikari Right catheters are usually used. A JR4.5, JR5, or Amplatz right (AR) 2 catheter may be preferable if the sinus width is large, creating a larger distance from the valve frame to the ostium .

24.1.5.2

Sapien 3

Coronary engagement is often easier in patients who have a Sapien valve compared with a self-expanding valve.

Engagement depending on depth of valve implantation ( Fig. 24.5 )