Management of difficult coronary anatomy during transcatheter aortic valve implantation: what are the key issues?

Objective: Predicting and preventing coronary obstruction in transcatheter aortic valve replacement (TAVR) is crucial due to its high mortality risk.

Results: In native TAVR, predicting coronary obstruction requires assessing aortic cusp height, coronary artery height, valve-to-coronary distance, and leaflet calcium volume. The VIVID classification has been proposed for evaluating the risk of coronary obstruction in TAVR for failed bioprosthetic surgical valves. After TAVR with the Sapien 3 valve, the feasibility of redo TAVR and coronary access decreases with a shallower implantation of the initial Sapien 3. In redo TAVR of Sapien 3 within an Evolut valve, positioning the Sapien 3 outflow at node 4 improves redo TAVR feasibility and coronary accessibility compared to positioning at nodes 5 or 6. For valve sizing in redo TAVR with Sapien 3, in-vivo CT sizing results in smaller valve sizes than bench sizing, reducing coronary risk and improving redo TAVR feasibility. Leaflet modification and coronary stenting techniques and a dedicated leaflet-splitting device have been proposed to maintain coronary perfusion in high-risk cases.

Conclusions: Coronary preservation in high-risk TAVR remains a significant challenge, requiring further research into preprocedural planning and leaflet modification strategies.