Abstract
Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinical implications as TAVI expands to younger patients in whom lifetime treatment of aortic valve disease and coronary artery disease is of particular importance. Numerous studies have shown that lack of commissural alignment may adversely affect coronary reaccess and the feasibility of redo-TAVI in this patient population. To assess the risk of commissural misalignment more accurately, we have pioneered and validated the use of a preprocedural imaging protocol that determines valve orientation using multi-detector computed tomography-fluoroscopy co-registration. Furthermore, we have shown that a modified delivery system insertion technique during initial valve deployment results in improved commissural alignment and reduced coronary artery overlap following TAVI with a self-expanding device. However, numerous unanswered questions remain about the impact of commissural misalignment on balloon-expandable valve-in-valve TAVI, especially in patients with unfavorable aortic root anatomy. It is imperative that clinicians consider these anatomic, device-related, and procedure factors, among others, when evaluating patients for transcatheter therapies.
Highlights
With the conclusion of the recent low-risk trials, transcatheter aortic valve implantation (TAVI) has been approved for patients with symptomatic, severe aortic stenosis across all surgical risk categories[1,2]
Given that coronary reaccess and redo-TAVI will become more prevalent in the future, achieving commissural alignment during initial TAVI may impact the feasibility of both these procedures
Achieving neo-commissural alignment during initial TAVI has important clinical implications for future coronary reaccess and aortic valve reintervention, especially in younger patients in whom lifetime treatment of aortic valve and coronary artery disease must be taken into consideration
Summary
With the conclusion of the recent low-risk trials, transcatheter aortic valve implantation (TAVI) has been approved for patients with symptomatic, severe aortic stenosis across all surgical risk categories[1,2]. One such example is transcatheter heart valve (THV) orientation during initial deployment and its impact on commissural alignment. While TAVI-in-SAVR is a relatively simple procedure, redoTAVI in the current era is associated with a number of anatomic risks, including coronary obstruction, that are exacerbated in the absence of neo-commissural alignment[8].
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