Commissural Alignment of Bioprosthetic Aortic Valve and Native Aortic Valve Following Surgical and Transcatheter Aortic Valve Replacement and its Impact on Valvular Function and Coronary Filling

Abstract

Commissural alignment is excellent in case of SAVR but random in case of TAVR. There is no association between CMA and transvalvular gradient or coronary filling; however, there is a significantly higher rate of mild central aortic regurgitation in case of moderate or greater CMA.

Percutaneous access to coronary arteries in patients after transcatheter aortic valve implantation procedures – is it a real problem?

“…In 96% (27/28) of the patients the valve was aligned in relation to the commissures after SAVR, and in the case of the TAVI procedure, as many as 53% of the patients showed moderate or severe misalignment of the commissures. This means that in more than a half of the patients, regardless of the valve used, conditions impeding access to the coronary arteries were present [13].…”

“…In the case of self-expandable aortic valves based on a Nitinol stent, the mesh constituting the stent, which is of various density, depending on the type of aortic valve (CoreValve, Evolut R, Portico), poses some difficulties in positioning catheters or guidewires for coronary angiography, and in some cases, selective insertion into the orifice of a coronary artery is impossible. Another factor that hinders the performance of coronary angiography and PCI for this type of aortic valve is the position of the new commissures, which may be located in front of the coronary ostia [13]. Due to anatomical differences in the location of the bulb, its displacement, as well as the use of various access routes, so far there has been no reliable method for implanting the aortic valves in such a way that the native aortic valve leaflets were located in front of the implanted aortic valve leaflets and the native aortic valve commissures and implanted aortic valve commissures overlapped.…”

Transcatheter Bioprosthetic Aortic Valve Dysfunction: What We Know So Far

“…The need to crimp the THV into a delivery catheter may theoretically damage the bioprosthetic leaflet tissue, thereby impairing THV durability (26). During TAVR, it is not aimed to align the commissures of the THV to those of the native aortic valve, and commissural misalignment might increase the stress on the leaflets and has been reported to increase the risk of mild intra-prosthetic regurgitation (27). Lastly, there is no data on the impact of elliptical THV geometry due to calcified native aortic annulus or incomplete expansion of the THV due to oversizing.…”

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

“…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). While native leaflets are excised and commissures are aligned during surgical aortic valve replacement (SAVR), native leaflets during TAVR often act as barriers over open stent frames and may impair coronary cannulation (1,7).…”