Alignment of Transcatheter Aortic-Valve Neo-Commissures (ALIGN TAVR)

Transcatheter aortic valve replacement aortic root orientation: implications for future coronary access and redo transcatheter aortic valve replacement

“…Based on the fluoroscopic THV orientation, we can superimpose a virtual image of the SAPIEN 3 THV with twelve crowns at the outflow (Edwards Lifesciences LLC, Irvine, CA, USA), or of the Evolut THV with twelve or fifteen crowns (depending on THV size, including the C-tab) at the outflow (Medtronic Inc, Minneapolis, MN, USA), over the MDCT axial annular and sinus of Valsalva images derived from the 3Mensio Valves software (4). Based on this co-registration technique, one can determine if there is severe overlap (0-20°) between a neo-commissure and coronary orifice (4,5,8).…”

“…The Evolut valve has a unique "hat" marker that can be positioned during valve deployment in one of four positions: anterior or posterior in the center of the deployment device [center front (CF), center back (CB)] or in the inner curve (IC) or outer curve (OC) of the aortic annulus (4,8). Our group found improved commissural alignment in 198 patients with OC/CF "hat" positions versus 47 patients with IC/CB positions.…”

“…This translated to a significant reduction in neo-commissure/LM overlap (15.7% vs. 66.0%, P<0.001), neo-commissure/RCA overlap (7.1% vs. 51.1%, P<0.001), neo-commissure/LM and RCA overlap (2.5% vs. 40.4%, P<0.001), and neo-commissure/LM or RCA or both overlap (20.2% vs. 76.6%, P<0.001) (4). The best method used to achieve OC/CF "hat" orientation involves starting with the flush port at 3 o'clock when inserting the Evolut delivery catheter into the femoral artery (4).…”

“…Performing BASILICA does not provide immunity to neo-commissure/coronary overlap; one has to ensure that the THV neo-commissure does not cover the lacerated opening or it would still cause coronary obstruction. One particular situation where BASILICA may not be possible is in TAVR-in-TAVR, where poor initial alignment may direct the trajectory of the electrified piercing wire into suboptimal territory (1,4).…”

“…As transcatheter aortic valve replacement (TAVR) evolves across the spectrum of younger and low-risk patients, the issue of transcatheter heart valve (THV) orientation during initial deployment is becoming increasingly more important. Lack of commissural alignment may lead to varying degrees of overlap between the neo-commissural posts and coronary arteries, thus disrupting laminar coronary flow and jeopardizing the success of redo-TAVR and coronary re-access procedures (1)(2)(3)(4)(5). Furthermore, THV leaflet stress and central aortic regurgitation may theoretically be exacerbated with suboptimal commissural alignment (6,7).…”