Impact of aortic angle on transcatheter aortic valve implantation outcome with Evolut‐R, Portico, and Acurate‐NEO

Abstract

Objectives: To investigate paravalvular leak (PVL) and devices success rates according to aortic angle (AA) in patients undergoing transcatheter aortic valve implantation (TAVI) with three new-generation self-expanding devices. Background: The impact of aortic angle (AA) on TAVI device success and PVL rates is controversial. Methods: This retrospective study included 392 patients submitted to TAVI for severe aortic stenosis with Portico, Evolut-R and Acurate-NEO, and available AA measurements at computed tomography (CT) angiography. AA was calculated from the implantation projection and was defined as the angle between the plane of aortic annulus and an ideal horizontal plane. Aorta was defined horizontal if AA>57 (75th percentile). Results: In the horizontal group, the rates of moderate/severe PVL was higher in the Evolut-R group (20.8%), which was also characterized by a lower implant compared to that of Acurate-NEO, whereas device success was comparable among the three devices. AA was a significant predictor of moderate/severe PVLs (AUC 0.72, p = .002) only in the Evolut-R population. On multivariate analysis, calcium volume 850HU, bicuspid aortic valve, and implantation depth at the level of left coronary cusp were independent predictors of moderate/ severe PVL. On univariate analysis in the horizontal aorta population, implantation depth was confirmed among the most significant predictors of moderate/severe PVL. Conclusions: Despite comparable device success rates, horizontal aorta represented a technical challenge only in the Evolut-R subgroup, which showed higher rates of moderate/severe PVL than Portico and Acurate-NEO, and was associated with a low implant.

Implantation depth and its influence on complications after TAVI with self-expanding valves

“…The geometric specialty of the Evolut R is a highest radial force at the LVOT edge of the prosthesis and a continuously decreasing diameter towards the stent center. With respect to this, a recently published study identified the implantation depth as predictor for moderate or severe PVL [15]. Our data showed no influence of the implantation depth or the eccentricity of the annular plane (native or the prosthesis on this height) on PVL.…”

Self‐expanding transcatheter aortic valve replacement in patients with extremely horizontal aortas

“…Notably, first-generation prostheses were used in most patients. According to the existing knowledge, although some studies have pointed out the association between increased angulation and worse clinical outcomes in Evolut R and Pro, 11,16,21 studies have also indicated that next-generation self-expanding valves might reduce the adverse impact of an increased AA. 10,11,15,22,23 Recently, the fourth-generation device Evolut FX, with improved delivery system flexibility, has just been approved by the Food and Drug Administration.…”

“…An extremely horizontal aorta was defined as an aortic root angle ≥70° between the horizontal plane and the aortic annulus (Figure 1). 10,11 Valve calcification severity was classified into four grades (none, mild, moderate, and severe) as previously described 12 . The aortic valve type was identified by two experienced cardiologists according to Sievers' classification 13 .…”

A patient‐specific algorithm to achieve commissural alignment with Acurate Neo: The sextant technique

“…All events, including procedural and device success, were classified according to the Valve Academic Research Consostium‐2 (VARC‐2) criteria 8 . Horizontal aorta was defined as an aortic angle >57° 9 …”

“…Coronary artery overlap was deemed severe if a neocommissure and coronary orifice were 0 to 20 apart as reported by other Authors. 6 According to measurements proposed by Fuchs et al 9 THV commissural alignment was defined as: (1) aligned (angle deviation 0 to 15 );…”