1068 THE IMPACT OF COMMISSURAL ALIGNMENT ON CORONARY ARTERY ACCESS: A META ANALYSIS

Abstract

Abstract Background The use of TAVR has been spreading out globally due to its favorable safety profile and the excellent efficacy data from randomized controlled trials. With the growing number of treated patients, the attention is rising around specific issues, such as the treatment of intercurrent coronary artery disease. Commissural alignment of transcatheter heart valves (THV) has the potential to reduce the impact of the prosthesis on accessibility of coronary ostia, as misalignment of the neo-commissures could be responsible for partial overlap with coronary artery ostia. However, no definitive evidence is available, despite multiple trials have addressed this issue. Methods The aim of this meta-analysis was to investigate the impact of the commissural alignment on coronary filling. We examined the techniques of commissural alignment and their impact on coronary access and coronary overlap. Eligible studies were searched for on Pubmed and SCOPUS and selected using the PRISMA guidelines. The primary endpoint is a composite of severe coronary overlap and failure of transcatheter coronary access. Odds Ratio were used as the metric for comparison between the groups. A random effects meta-analysis was selected as the calculation model. Results Six studies with a total of 1213 patients were included in this analysis. Of these patients, 757 patients underwent TAVR with commissural alignment and 456 underwent TAVR without commissural alignment. The composite endpoint of coronary overlap and failure of coronary access occurred in 118 patients undergoing TAVR with commissural alignment and in 124 patients without commissural alignment (OR=0.20, 95% CI 0.08-0.48; p= 0.0003). Conclusions Commissural alignment was associated with significantly lower rates of commissure-to-coronary-ostia overlap and failure of coronary access. Therefore, a modified insertion technique could reduce coronary overlap and coronary occlusion, particularly in supra-annular valves. Commissural alignment performed during TAVR could therefore have an important role in coronary re-access and re-intervention especially in younger patients.