In patients at high risk of coronary obstruction after transcatheter aortic-valve replacement (TAVR), stent implantation could offer advantages compared with wires alone, but the data are not clear, according to a new study. Although TAVR outcomes have been improving, coronary occlusion remains a threatening complication with high rates of morbidity and mortality, Dr. Tullio Palmerini of Policlinico S. Orsola, in Bologna, Italy, and colleagues note in JACC: Cardiovascular Interventions. One registry shows an incidence of 0.66% and a one-year mortality rate of 45.5%, highlighting, say the researchers, "the importance of anticipating and preventing this complication." The researchers examined data on more than 10,000 patients who underwent TAVR at 19 international centers and identified 236 with preventive coronary wiring. Of these, 143 ultimately received stents and 93 did not. At 3 years of follow-up, rates of cardiac death were lower in patients receiving stents (7.8%) compared to those with wiring alone (15.7%), but the difference fell short of statistical significance (P=0.13). There were two cases of definite stent thrombosis in patients receiving stents (0.9%) and four cases of delayed coronary occlusion in patients protected with wires only (4.3%). In the latter group there were three fatalities. One patient was rescued by rewiring and stenting across the jailed coronary ostium. The researchers call for further prospective studies, but conclude "that preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk of delayed coronary occlusion." In an accompanying editorial, Dr. Philippe Garot of Institut Cardiovasculaire Paris-Sud, in Massy, France, notes that several alternatives have been proposed to prevent TAVR-related coronary obstruction. These include the BASILICA technique (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction during TAVR). "Coronary obstruction after TAVR is rare but is associated with severe consequences," he told Reuters Health by email. Of protective options "preventive wiring seems useless, BASILICA and dedicated valves are under evaluation and preventive stenting appears the most efficient with acceptable mid-term outcomes." Dr. Palmerini and three of his coauthors report financial ties to device makers. The researcher did not respond to requests for comments. —David Douglas Source
