Optimal Angiographic View for Implantation of Self-Expanding Transcatheter Aortic Valves

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Abstract

Background. Transcatheter aortic valve implantation is safe and effective alternative to surgical treatment of severe aortic valve stenosis among patients of all risk groups. Optimal implantation depth is key for successful hemodynamic and clinical

Results. Despite the improvement of prostheses design and increasing experience of operators cardiac conduction abnormalities and paravalvular leak continue to be a significant complication of this procedure, directly affecting the long-term prognosis. Self-expanding valves require special approaches for optimal angiographic projection to assess the implantation depth of the prosthesis.

Aims — in this study we compared coplanar view and cusp overlap technique during self-expanding aortic valves implantation.

Methods. We performed a retrospective analysis of 81 TAVI performed in Russian Research Center of Surgery. The patients were divided into two groups depending on the implantation projection: coplanar view (CV) and cusp overlap technique (COT). The incidence of cardiac conduction abnormalities (cumulative incidence of third degree AV block and left bundle branch block) depending on the implantation projection was analyzed. The procedural characteristics in the form of contrast agent volume, fluoroscopic time and operator comfort were also evaluated.

Results. After TAVI 16 (51.6%) and 13 (26.0%) patients had cardiac conduction disturbances (cumulative incidence of third degree AV block and left bundle branch block) in the CV and COT respectively (p = 0.019). In the CV group, 2 (6.5%) patients, and in the COT group, 3 (6%) patients had third degree AV block (p = 0.935) and 14 (45.2%) и 10 (20%) left bundle branch block (p = 0,016). In the COT group, there was a significant decrease contrast media (181 ± 66.4 mL vs. 158.9 ± 50.8 mL, p = 0.032). Fluoroscopic time also decreased (23.2 ± 7.7 min vs. 21.3 ± 6.8 min), but without a significant difference (p = 0.678). According to the results of the operator survey, the COT projection was more comfortable.

Conclusions. Optimal implantation depth is an important condition for achieving hemodynamic efficiency of the prosthesis and reducing the risk of conduction abnormalities. Operator comfort, better assessment of the implantation depth, safety and efficiency of the cusp overlap technique allow its use as the main implantation view for TAVI.

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About the authors

Gayk V. Mardanyan

Russian Research Center of Surgery

Author for correspondence.
Email: haikrurg@gmail.com
ORCID iD: 0000-0002-7442-520X
SPIN-code: 2707-0511

MD, PhD

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow

Shota G. Chargazia

Russian Research Center of Surgery

Email: shota.chg@gmail.com
ORCID iD: 0000-0002-8598-2933
SPIN-code: 5965-6158

Clinical Resident

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow

Kiazim A. Kur-ipa

Russian Research Center of Surgery

Email: kuripo90@gmail.com
ORCID iD: 0000-0002-2395-5999
SPIN-code: 1778-4140

Clinical Resident

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow

Roman S. Polyakov

Russian Research Center of Surgery; Russian Medical Academy of Continuing Professional Education

Email: roman.polyakov@gmail.com
ORCID iD: 0000-0002-9323-4003
SPIN-code: 9515-5680

MD, PhD, Professor

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow; 2/1, building 1, Barrikadnaya st., 123242, Moscow

Mikhail V. Puretskiy

Russian Medical Academy of Continuing Professional Education; Russian Research Center of Surgery

Email: 9672287797@mail.ru
ORCID iD: 0000-0003-4988-4102
SPIN-code: 8905-1410

MD, PhD, Professor

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow; 2/1, building 1, Barrikadnaya st., 123242, Moscow

Aleksandra A. Pirkova

Russian Research Center of Surgery

Email: 9672287797@mail.ru
ORCID iD: 0000-0002-5101-1004
SPIN-code: 4024-4326

MD, PhD

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow

Gordey S. Vlasko

Russian Research Center of Surgery

Email: vlasko13@yandex.ru
ORCID iD: 0000-0001-8521-7126
SPIN-code: 9687-2557

PhD, Student

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow

Sergey O. Popov

Russian Research Center of Surgery

Email: Dr.Popov_S@mail.ru
ORCID iD: 0000-0002-4488-1597

MD, PhD

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow

Sergey A. Abugov

Russian Research Center of Surgery; Russian Medical Academy of Continuing Professional Education

Email: sabugov@gmail.com
ORCID iD: 0000-0001-7636-4044
SPIN-code: 1126-8001

MD, PhD, Professor, Corresponding Member of the RAS

Russian Federation, 2 Abrikosovsky lane, 119991, Moscow; 2/1, building 1, Barrikadnaya st., 123242, Moscow

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Supplementary files

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2. Fig.1. Error bars for the incidence of cardiac conduction disturbances (A) in the form of 3rd degree AV block (B) and complete left bundle branch block (C) after TIA using 3CT and SOT

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3. Fig.2. Error bars for contrast agent used (A), scanning time (B) for TIAC using 3ST and SOT

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4. Fig.3. Anatomical features of the relative position of the conduction system of the heart and the aortic valve: 1 - non-coronary cusp; 2 - septal leaflet of the tricuspid valve; 3 - aorta; 4 — area of the removed membranous septum; 5 - left coronary cusp; 6 - aortic cusp of the mitral valve; 7 - opening of the tricuspid valve; bracket - location of the left ventricular outflow tract; asterisk - transverse sinus of the pericardium; the dotted line on the left side of the figure is the area separating the aortic root from the transverse sinus; a line of triangles is the site of penetration of the His bundle; the dotted line on the right side of the picture is the right fibrous triangle

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5. Fig.4. A – MSCT angiography of the aortic valve in the projection of the three leaflets; B — three-dimensional reconstruction of the aortic valve root in the projection of the three leaflets; red marker corresponds to the non-coronary cusp, purple to the right coronary cusp, yellow to the left coronary cusp

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6. Fig.5. A — MSCT angiography of the aortic valve in the projection of the overlapping leaflets; B — three-dimensional reconstruction of the aortic valve root in the projection of the overlapping leaflets; red marker corresponds to the non-coronary cusp, purple to the right coronary cusp, yellow to the left coronary cusp

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7. Fig.6. Implantation of the Corevalve Evolut R valve, angiography in the projection of the overlapping leaflets (A) and the projection of the three leaflets (B)

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