In patients who underwent transcatheter aortic valve replacement (TAVR) with self-expanding transcatheter heart valves (THVs) using commissural alignment (CA) techniques, coronary artery cannulation was unsuccessful in 5.5%, new study results show. Of the seven cases of unsuccessful cannulation, six involved an Evolut THV, according to the study. Giuliano Costa, MD, of A.O.U. Policlinico “G. Rodolico-San Marco,” Catania, Italy, and colleagues reported these data in a manuscript published Wednesday online in JACC: Cardiovascular Interventions. Coronary reaccess post-TAVR has become an important component of TAVR therapy. CA techniques is supposed to help with THVs that are more prone to impaired coronary reacess. This subject is not well-studied, and only one trial to-date — ALIGN-ACCESS — has investigated this phenomenon. That study, which compared the the self-expanding, supra-annular Evolut R and Pro (Medtronic) and Accurate neo (Boston Scientific) THVs with the balloon-expandable, intra-annular SAPIEN 3 THV (Edwards Lifesciences), found that CA with supra-annular THVs improves the rate of coronary access after TAVR, but that these valves still pose a higher risk of unfeasible or nonselective coronary access compared with SAPIEN 3. The purpose of the RE-ACCESS 2 study was to understand unsuccessful coronary cannulation post-TAVR with CA techniques for implanting the self-expanding devices. The investigator-driven, single-center, prospective RE-ACCESS 2 (Retain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent 2) study enrolled consecutive TAVR patients who were to receive Evolut R, PRO and PRO+, and ACURATE neo2 (Boston Scientific) THVs with CA implantation techniques. Unsuccessful coronary cannulation post-TAVR was the primary endpoint for this study. The investigators noted the importance of the secondary endpoint as well: identification of postprocedural predictors of unfeasible, selective coronary ostia re-engagement on computed tomographic angiography after TAVR. A total of 127 patients were enrolled in the study between September 2021 and December 2022, and seven of those patients had unsuccessful coronary cannulation after TAVR, six of whom received the Evolut THV (7.5% versus 2.3%; p=0.26). Patients who received an Evolut THV had similar failure of left coronary artery cannulation to patients who received ACURATE neo2 (2.5% versus 2.1%; p=1.00). The Evolut group experienced a numerically, higher rate of cannulation failure in the right coronary artery, although this difference was not statistically significant (6.3% versus 0.0%; p=0.16). Coronary overlap was associated with failure to single out cannulation of the right coronary artery (odds ratio [OR]=5.6; 95% confidence interval [CI]=1.2-25.8; p=0.03) in the Evolut group, but not in the ACURATE group (p=0.39). When the Evolut THVs were misaligned, this was associated with failure to selectively cannulate both coronary arteries (OR=24.7; 95% CI=1.9-312.9; p=0.01). The authors noted that the study’s small sample size means the results should be interpreted with caution and considered only hypothesis-generating. They added the low number of absolute events might have left the study statistically underpowered and that larger studies are required to further evaluate its findings. Overall, 5.5% of patients who underwent TAVR and coronary cannulation post-TAVR using self-expanding THVs with CA techniques experienced unsuccessful coronary cannulation, and most of these patients (six out of seven) received the Evolut device. In an accompanying editorial, Didier Tchétché, MD, and Vincenzo Cesario, MD, of the Groupe CardioVasculaire Interventionnel, Toulouse, France, wrote that the RE-ACCESS 2 study clarifies the reproducibility of CA with contemporary self-expanding THVs, noting the study’s 6.9% to 11.1% rate of failure to achieve CA. Tchétché and Cesario, who is also affiliated with Sapienza University of Rome, added that the study shows the clinical impact of coronary overlap, which is the leading cause of failed coronary access after TAVR. The editorialists noted that both the RE-ACCESS 2 study and another study published Wednesday online in JACC: Cardiovascular Interventions point out the difficulty of cannulating the right coronary artery (RCA) after TAVR. “We shall keep commissural alignment as the default strategy and combine it with coronary alignment depending on the eccentricity of the RCA,” the commenters concluded. “Proper commissural alignment is alright and even more important for the RCA. Sources: Costa G, Sammartino S, Strazzieri O, et al. Coronary Cannulation Following TAVR Using Self-Expanding Devices With Commissural Alignment: The RE-ACCESS2 Study. JACC Cardiovasc Interv. 2024 Mar 6 (Article in Press). Tchétché D, Cesario V. Commissural and Coronary Alignment Techniques: It Is All Right! JACC Cardiovasc Interv. 2024 Mar 6 (Article in Press). Image Credit: iushakovsky – stock.adobe.com