Optimize your approach Post-TAVR coronary access considerations

See how the Evolut™ platform sets the stage for successful post-TAVR coronary access.
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Evolut and future coronary access

The design of the Evolut frame, together with minor procedural adjustments and catheter selection based on the patient’s anatomy, helps facilitate post-TAVR coronary access. Highlights of this unique frame design include:

  1. Frame support — The frame reduces the need for additional backup catheters with more aggressive shapes.
  2. Narrow waist — This allows more space between the frame and the coronary ostia.
  3. Frame cell size — Cells are sized to accommodate all standard coronary access tools up to 10 Fr.
Evolut transcatheter aortic valve with catheter accessing the coronary shown with three numbers as callouts

Tailoring the procedure

With a few essential considerations, you can access coronaries through the Evolut frame, optimize post-TAVR coronary access procedures, and approach these cases with confidence.

1. Perform aortogram

An X-ray image showing the TAVR process

Insert pigtail within Evolut frame choose an orthogonal view of desired coronary, and perform an aortogram.

2. Select catheter

An X-ray image showing the TAVR process

Exchange to catheter shape based on root size/shape and location of commissure; downsize by 0.5 cm.

3. Approach coaxially

An X-ray image showing the TAVR process

Approach coronary coaxially, remain perpendicular to frame. Do not approach from below.¹ Use J-wire for aid.

4. Engage and continue

An X-ray image showing the TAVR process

Image courtesy of James Harvey, M.D.

Perform nonselective angio/use guidewire and guide extension devices to reach ostium and perform diagnostic/PCI.

5. Disengage safely

An X-ray image showing the TAVR process

Image courtesy of Harold Dauerman, M.D.

Always disengage catheter/guide over a guidewire.

 

The considerations for post-TAVR coronary access were created through a detailed review of available data, including publications and proctor input. These methods (including the use of accessory devices) have not been verified through bench testing.

For more detailed information, get our interactive procedural guidance document for post-TAVR coronary access.

High success rate for unplanned PCI2

Unplanned post-TAVR PCI is a rare but serious situation. Fortunately, data from a 15,325-patient multicenter international registry showed that successful treatment and outcomes are likely regardless of the TAVR device.

  • Incidence of unplanned post-TAVR PCI was rare (0.9%, median follow-up 191 days)
  • Very high success rate (96.6%) for post-TAVR PCI
  • No statistical difference in success rates for balloon-expandable versus self-expanding
  • No statistical difference in the following factors among patients treated with two valve types
    • Number of diagnostic or guiding catheters used
    • Total fluoroscopy time
    • Vascular access route during PCI

Gaining coronary access through any TAVR device can create complexities. But procedural considerations, commissural alignment, and effective case planning make the process feasible.

TAVR risks may include, but are not limited to, death, stroke, damage to the arteries, bleeding, and need for permanent pacemaker.

Additional resources

Explore commissural alignment

Understand the impact on final valve orientation and coronary artery overlap in a paper published in JACC by Dr. Tang, Dr. Zaid, and Dr. Fuchs, et al.

Hear from the experts

Dr. Harvey and Dr. Dauerman on procedural considerations for low-risk patients — including post-TAVR coronary access and commissural alignment.

Global Grand Rounds

Dr. Spies and Dr. Stinis share their perspectives on post-TAVR coronary access. They discuss the incidence of CAD, a literature review on PCI, and case reviews.

Related pages

Explore our other procedural guidance and outcomes you can expect from the Evolut platform.
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Evolut transcatheter aortic valve being deployed using the cusp overlap technique shown within a circular outline

Cusp overlap technique

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Top-down view of the Evolut transcatheter aortic valve within a circular outline

Comprehensive clinical evidence

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References

1

Harhash A, Ansari J, Mandel L, Kipperman R. STEMI After TAVR: Procedural Challenge and Catastrophic Outcome. JACC Cardiovasc Interv. July 11, 2016;9(13):1412–1413.

2

Stefanini GG, Cerrato E, Pivato CA, et al. Unplanned Percutaneous Coronary Revascularization After TAVR. JACC Cardiovasc Interv. January 25, 2021;14(2):198–207.