Coronary access after repeat transcatheter aortic valve replacement in patients of small body size: A simulation study

Background: Coronary artery access after repeat transcatheter aortic valve replacement (TAV-in-TAV) is reportedly more dif fi cult because lea fl et displacement of the fi rst transcatheter heart valve (THV) impairs coronary cannulation; however, its effects in small patients are unknown. This study aimed to simulate coronary accessibility after TAV-in-TAV in patients of small body size. Methods: We retrospectively analyzed computed tomography scans after initial THV implantation and classi fi ed patients by THV and coronary artery location, valve -to -aorta distance, and valve -to -coronary distance. Risks were compared between the SAPIEN and CoreValve/Evolut series, among THV generations, and between bicuspid and tricuspid aortic valves in the CoreValve/Evolut series. Results: A total of 254 patients (SAPIEN series, n = 164; CoreValve/Evolut series, n = 90) were enrolled. The average body surface area of the patients was 1.44 m(2) . Patients were classi fi ed as " feasible " (26 % ), " theoretically feasible with low risk " (19.7 % ), " theoretically feasible with high risk " (8.7 % ), or " unfeasible " (45.8 % ). The " unfeasible " rate was signi fi cantly higher in the CoreValve/Evolut series than in the SAPIEN series (78.9 % vs 26.2 % ; P < .001). A signi fi cantly higher " un- feasible " rate was identi fi ed in the current model of SAPIEN (SAPIEN, 8.3 % ; SAPIENXT, 1.8 % ; SAPIEN3, 48.2 % ; P < .001), but not in the CoreValve/Evolut series (CoreValve, 83.3 % ; Evolut R, 80.0 % ; Evolut PRO, 71.4 % ; P = .587). Patients with a bicuspid aortic valve had a lower " unfeasible " rate compared to those with a tricuspid aortic valve (60.0 % vs 86.2 % ; P = .014). Conclusions: Patients of small body size may have a high probability of " unfeasible " coronary access after TAV-in-TAV, especially when treated with current high -frame devices, suggesting the need for careful strategic planning for initial THV implantation.