The increase in non-coronary cusp calcification is associated with the risk of coronary artery occlusion during future transcatheter aortic valve in valve procedures

Abstract Background Predicting the risk of coronary artery occlusion (CO) during Transcatheter Aortic Valve in Transcatheter Aortic Valve (TAV in TAV) is an important factor for selecting therapeutic strategy especially in patients with severe aortic stenosis considering lifetime management. Feasibility of TAV in TAV can be assessed by pre-procedural computed tomography (CT) measurement, but its accuracy is unclear, due to factors such as misalignment or eccentric deployment of the initial TAV. Methods We retrospectively evaluated 201 consecutive patients who underwent TAVR with Balloon expandable valve and pre- and post-procedural CT in our hospital from April 2020 to April 2024. Patients with bicuspid aortic valve and valve in valve procedures were excluded. Virtual valve to sinus (VTS) length and calcium volume of each coronary cusp in pre-procedural CT were measured using dedicated software (3mensio, Structural Heart). Low risk of CO was defined as virtual VTS 2.0mm in both right coronary cusp (RCC) and left coronary cusp (LCC). High risk of CO was defined as VTS ≤ 2.0mm in either RCC or LCC. Actual VTS length was measured on post-procedural CT and evaluated the accuracy of virtual CO risk during TAV in TAV. Results Pre-procedural CT findings classified 101 patients (50.3%) as high CO risk group, and among them, 99 patients (98.0%) showed actual high CO risk on post-procedural CT. On the other hand, 100 patients (49.8%) were classified as low CO risk group on pre-procedural CT, however 69 (69.0%) patients determined as high CO risk on post-procedural CT (sensitivity: 58.9%, specificity: 93.9%, accuracy: 64.7%). In patients who were in the low risk group before TAVR but changed to high risk group by CT after TAVR, the proportion of non-coronary cusp (NCC) calcium volume among all three leaflets was higher than in patients who remained in the low risk of CO group after TAVR. (NCC calcium volume/ Total calcium volume; median 48.8% IQR 41.7-56.0 vs. 34.4% 27.5-41.4; p 0.001) The receiver operating characteristic analysis revealed that the area under the curve (AUC) for the proportion of NCC calcium volume as an indicator of actual high risk of CO was 0.820.(95% confidence interval CI: 0.80–0.84, p 0.001) The optimal cutoff value for this proportion was 41.6%, with sensitivity: 80.7%, specificity: 75.4%. Multivariable logistic regression analysis revealed that the proportion of NCC calcium volume ≥ 41.6% was an independent predictor of high risk of CO during TAV in TAV. (odds ratio: 12.59 95% CI: 4.20–44.14, p 0.001) Conclusion The increase in NCC calcification is associated with the risk of coronary artery obstruction during future transcatheter aortic valve in valve procedures.