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coronary flow obstruction as a result of sinus sequestration if the ascending aorta is narrow and the neo-skirt reaches the sinotubular junction.456,457 The risk of coronary obstruction varies considerably depending on the index valve type, and is particularly increased if a stentless SAV or stented SAV with externally mounted leaflets is in place.457 The risk of sinus sequestration at the time of TAV-in-TAV implantation is particularly increased in supra-annular valves with a high neo-skirt.458,459 Even if coronary flow is preserved, coronary access may be difficult or impossible in a relevant proportion of patients after valve-in-valve implantation, especially after TAV-in-TAV.460–462 In patients who require a reintervention due to dysfunction of a surgical or transcatheter bioprosthesis, but are at increased risk of severe PPM or coronary obstruction, redo SAVR may be preferable despite the increased surgical risk. Fracture of surgical valves and leaflet modification techniques have been proposed for patients at high surgical risk and, if contemplated, should be performed in carefully selected patients at experienced centres (Table 6).463,464
The need for a meticulous CT-based anatomical analysis is paramount in patients with an estimated life expectancy exceeding the assumed valve durability to anticipate future risks at the time of the index valve intervention. Based on individual assessment, the following measures should be considered with respect to lifetime management: • Use of surgical and transcatheter valves with proven long-term durability to reduce the likelihood of reintervention.2,4,375,410,411,465–467 • SAVR with aortic root enlargement or implantation of a supra-annular transcatheter valve in patients with a small annulus at risk of severe PPM based on the predicted effective orifice area (EOA).436,438,468,469 • No implantation of stentless prostheses or prostheses with externally mounted leaflets in patients at risk of coronary obstruction during future TAV-in-SAV implantation.457
≥
Figure 9 Factors to be considered when selecting the mode of intervention for aortic stenosis. CAD, coronary artery disease; LV, left ventricular; LVOT, left ventricular outflow tract; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; THV, transcatheter heart valve; VHD, valvular heart disease. aLV thrombus and infective endocarditis are relative contraindications to TAVI and are therefore not listed. bParticularly relevant for patients in whom the anticipated life expectancy is thought to exceed valve durability.
ESC Guidelines 4669
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