Post-TAVR Coronary Access - Transcatheter Aortic Valve Replacement

Evolut™ TAVR and future coronary access

The design of the Evolut™ frame, together with minor procedural adjustments and catheter selection based on the patient’s anatomy, helps facilitate post-TAVR coronary access. Highlights of this unique frame design include:

Larger windows — Three windows that are four times larger than standard cells to enable coronary access with the Evolut™ FX+ TAV.¹
Narrow waist — This allows more space between the frame and the coronary ostia.
Frame cell size — Standard cells are sized to accommodate all standard coronary access tools up to 10 Fr.
Frame support — The frame reduces the need for additional backup catheters with more aggressive shapes.

Window highlighted for emphasis.

Tailoring the procedure

A few essential considerations can help you access coronaries through the Evolut™ frame, optimize post-TAVR coronary access procedures, and approach these cases with confidence.

1. Align TAV.

Choose a C-arm angle with an orthogonal view of the coronary ostium of interest and adjust CAU/CRA to remove frame parallax and cell overlap.

2. Perform aortogram.

Insert pigtail catheter within the upper third of the Evolut™ frame and perform an aortogram or selective sinus injection to identify coronary ostium and TAV positions.

3. Select catheter.

Choose a catheter shape that allows perpendicular crossing of the frame and coaxial approach to the ostium.

4. Approach coaxially.

Image courtesy of James Harvey, MD

Use exchange-length J-wire to select neo-cusp of interest and exchange for selected catheter. Advance catheter to frame waist targeting the frame cell adjacent to ostium.

5. Disengage safely.

Image courtesy of Harold Dauerman, MD

To avoid entanglement with frame, remove catheter over the guidewire. For diagnostic and backup catheters (e.g., EBU or XB), remove catheter over the J-wire.

The considerations for post-TAVR coronary access were created through a detailed review of available data, including publications and proctor input. These methods (including the use of accessory devices) have not been verified through bench testing.

For more detailed information, get our interactive procedural guidance document for post-TAVR coronary access.

Download the guidance (open in new window)

High success rate for unplanned PCI²

Unplanned post-TAVR PCI is a rare but serious situation. Fortunately, data from a 15,325-patient multicenter international registry showed that successful treatment and outcomes are likely regardless of the TAVR device (36.1% balloon-expandable and 63.9% self-expandable).

Incidence of unplanned post-TAVR PCI was rare (0.9%, median follow-up 191 days)
Very high success rate (96.6%) for post-TAVR PCI

No statistical difference in success rates for balloon-expandable versus self-expanding
No statistical difference in the following factors among patients treated with two valve types:
- Number of diagnostic or guiding catheters used
- Total fluoroscopy time
- Vascular access route during PCI

Gaining coronary access through any TAVR device can create complexities. But procedural considerations, commissural alignment, and effective case planning make the process feasible.

TAVR risks may include, but are not limited to, death, stroke, damage to the arteries, bleeding, and need for permanent pacemaker.

Explore commissural alignment.

Understand the impact on final valve orientation and coronary artery overlap in a paper published in JACC Cardiovascular Interventions by Dr. Tang.

Read the paper (open in new window)

Medtronic Academy

Find valuable education resources designed to enhance your Evolut™ TAVR knowledge. The learning content consists of training modules, live cases, webinars, and more!

Explore Evolut™ TAVR procedure (open in new window)

Post-TAVR coronary access considerations

Evolut™ TAVR and future coronary access