Modeling risk of coronary obstruction during transcatheter aortic valve replacement

J Thorac Cardiovasc Surg. 2020 Mar;159(3):829-838.e3. doi: 10.1016/j.jtcvs.2019.04.091. Epub 2019 May 18.


Objective: In this study we aimed to evaluate risk of coronary obstruction during transcatheter aortic valve replacement and develop improved criteria based on computational modeling.

Methods: Patient specific 3-dimensional models were constructed and validated for 28 patients out of 600 patients who were flagged as high risk for coronary obstruction (defined as meeting coronary ostium height < 14 mm and/or sinus of Valsalva diameter [SOVd] < 30 mm). The models consisted finite element analysis to predict the post- transcatheter aortic valve replacement native cusp apposition relative to the coronary ostium and were validated in vitro. The distance from cusp to coronary ostium (DLC) was derived from the 3-dimensional models and indexed with the coronary artery diameter to yield a fractional obstruction measure (DLC/d).

Results: Twenty-two out of 28 high-risk patients successfully underwent transcatheter aortic valve replacement without coronary obstruction and 6 did not. DLC/d between the 2 groups was significantly different (P < .00078), whereas neither coronary ostium height nor SOVd were significantly different (P > .32). A cutoff of DLC/d < 0.7 was predictive with 100% sensitivity and 95.7% specificity. The optimal sensitivity and specificity of coronary ostium height and SOVd in this high-risk group was only 60% and 40%, respectively, for cutoff coronary ostium height of 10 mm and SOVd of 30.5 mm.

Conclusions: Three-dimensional modeling has the potential to enable more patients to be safely treated with transcatheter aortic valve replacement who have a low-lying coronary ostium or small SOVd. DLC/d is more predictive of obstruction than coronary ostium height and SOVd.

Keywords: CFD; FEA; TAVR; calcification; coronary obstruction; patient-specific.

Publication types

  • Validation Study
  • Video-Audio Media

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve / diagnostic imaging
  • Aortic Valve / surgery*
  • Computed Tomography Angiography
  • Coronary Angiography / methods
  • Coronary Stenosis / diagnostic imaging
  • Coronary Stenosis / etiology*
  • Decision Support Techniques*
  • Female
  • Heart Valve Prosthesis
  • Humans
  • Male
  • Middle Aged
  • Models, Cardiovascular*
  • Patient-Specific Modeling*
  • Predictive Value of Tests
  • Prosthesis Design
  • Reproducibility of Results
  • Risk Assessment
  • Risk Factors
  • Transcatheter Aortic Valve Replacement / adverse effects*
  • Transcatheter Aortic Valve Replacement / instrumentation
  • Treatment Outcome