Strategies to improve reaccess not resolved
When performing TAVR, other factors that might influence subsequent PCI success includes commissural alignment and positioning, according to Dr. Kim. But he cautioned that there are a number of potential controversies when weighing how to improve chances of post-TAVR angiographic reaccess without compromising the success of valve replacement.
“Lower positioning facilitates coronary access, but unfortunately will increase rates of conduction disturbances,” he noted.
Overall, one of the main messages from this analysis is that “the fear of impaired coronary access [after TAVR] may well be disproportionate to the reality,” according to Neal S. Kleiman, MD, an interventional cardiologist at Houston Methodist DeBakey Heart and Vascular Center. Dr. Kleiman wrote an editorial on the registry findings in the same issue of JACC: Cardiovascular Interventions).
Yet, he agreed that the issue of angiographic reaccess after TAVR cannot be ignored. Although reaccess after TAVR has so far been “surprisingly rare,” Dr. Kleiman expects cases to increase as more younger patients undergo TAVR. He suggested that interventionalists will need consider this issue when performing TAVR, a point he reemphasized in an interview.
“It is still a concern when recommending TAVR to a patient and still poses challenges to device manufacturers,” said Dr. Kleiman, suggesting that “a new set of skills” will be required to perform TAVR that will optimize subsequent angiographic access and PCI.
Dr. Kim agreed. Ultimately, other challenges, such as PCI performed after TAVR-in-TAVR placement, are likely to further complicate this issue, but he, too, is looking to new devices to minimize the problems.
“It would be desirable to modify the design, especially of long SFPs, to improve access for PCI, and there are ongoing efforts of the manufacturers to achieve this,” Dr. Kim said.
Dr. Kim reported financial relationships with Abbot, Boston Scientific, Edwards Lifesciences, Medtronic, and Meril Lifesciences. Dr. Kleiman reported financial relationships with Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic.