Evaluation of Gold Marker Orientation in the Three-Cusp Coplanar View After Evolut FX Transcatheter Aortic Valve Implantation

Senile calcific aortic stenosis (AS) is the most common acquired valvular heart disease with an increasing prevalence attributable to an aging population. Survival is poor in patients with severe or critical AS, chiefly after the onset of symptomology that primarily includes angina, dyspnea, or syncope. On the onset of symptoms, mortality occurs at very high rates during the ensuing 2 to 3 years.1 Until recently, surgical aortic valve replacement represented the sole therapy that definitive reduced mortality and morbidity in patients with severe symptomatic AS, with medical therapy generally ineffective of these patients. Given the advanced age commonly associated with severe AS, a high proportion of these patients are denied surgical intervention because of multiple comorbidities and excessively high surgical risk.2 Recently, transcatheter aortic valve replacement (TAVR) has emerged as a novel disruptive technology that serves an alternative therapy to surgical AVR and has been shown to be an effective therapy in nonoperable and high-risk patients with severe symptomatic AS.3,4 TAVR was first described in humans by Cribier et al in 20025 by a transvenous approach delivered in an antegrade fashion. This technique requires a transseptal puncture and passage of the aortic stent valve across the mitral valve to the aortic position. Subsequently, array of alternative transvascular approaches have arisen, including transfemoral, transaortic, trans-subclavian, and aortic methods. Of these, the retrograde transarterial approach through the femoral artery, developed by Webb et al,6 has been the commonly used approach, with >60 000 such procedures performed worldwide to date. To date, the global experience with TAVR as documented in both single and multicenter registries as well as through multicenter trials have shown good clinical outcomes with improvement in hemodynamic and clinical status, establishing TAVR to be a feasible alternative therapy to traditional surgical aortic valve …

Coronary cannulation after TAVR is sometimes difficult due to an overlap between native and neo-commissures, especially in Evolut devices with a supra-annular position. The Evolut C-tab corresponds to a neo-commissure, and the hat marker is in a fixed position. Therefore, the orientation of the hat marker can be adjusted to minimise overlaps. We investigated whether the HAt marker-guided SHaft rotation method (HASH, stylised as the #rotation method) is effective in facilitating coronary artery access after transcatheter aortic valve replacement (TAVR) with an Evolut system. We retrospectively analysed 95 patients who underwent electrocardiogram-gated cardiac computed tomography after TAVR. In the #rotation method, the hat marker of the delivery catheter was adjusted to face the greater curvature of the descending thoracic aorta in the left anterior oblique view. Its orientation was maintained while the system passed through the aortic arch. In total, 60 and 35 patients underwent TAVR with the #rotation and non-#rotation methods, respectively. A ±15° angle between the native and neo-commissures was more frequent in the #rotation group (p=0.001). Favourable angles and appropriate frame orientation for access to the left coronary artery were significantly more frequent in the #rotation group than in the non-#rotation group (p<0.001 and p=0.001). Although the #rotation method showed a higher rate of favourable angles and frames in the right coronary artery, statistically significant differences were not found. The #rotation method is useful for improving commissural post alignment in TAVR with Evolut devices, especially in the ostium of the left coronary artery.

Coronary Computed Tomographic Angiography Often Allows for the Avoidance of Invasive Coronary Angiography Before Transcatheter Aortic Valve Implantation.

Missing Pieces of the Transcatheter Aortic Valve Replacement Subclinical Leaflet Thrombosis Puzzle.

Alignment of Transcatheter Aortic-Valve Neo-Commissures (ALIGN TAVR): Impact on Final Valve Orientation and Coronary Artery Overlap

Background Although surgical aortic valve replacement (SAVR) is recommended for symptomatic severe aortic stenosis (AS) patients at low surgical risk, there is a growing need for an expansion of transcatheter aortic valve replacement (TAVR) as an alternative to SAVR for elderly AS patients at low operative risk. Purpose We tried to compare the long-term clinical outcomes of TAVR versus SAVR in elderly AS patients (≥80 years old) at low surgical risk. Methods We consecutively enrolled 261 elderly patients (131 men; 83±3 years of age) with symptomatic severe AS and EuroSCORE II &lt;4%, who underwent SAVR or TAVR from 2010 to 2018. Heart Team made the decision between SAVR and TAVR according to the individual patient's preference and characteristics. SAVR was performed on 93 patients (SAVR group), whereas TAVR was chosen for 168 patients (TAVR group). The primary end point was cardiac mortality including procedure-related death, and the secondary end point was all-cause death and cardiovascular event. Results Baseline characteristics were similar between the two groups, but the TAVR group was significantly older than the SAVR group (83±3 vs 82±2 years; p&lt;0.01). Device was successfully implanted in all the patients and there was 1 in-hospital mortality in the TAVR group and 3 in-hospital mortalities in the SAVR group (p=0.13). During a median follow-up of 24 months (IQR, 9–45 months), there were 22 deaths (13.1%) including 8 cardiac deaths (4.8%) in the TAVR group and 16 deaths (17.2%) including 9 cardiac deaths (9.7%) in the SAVR group. The rates of the primary and secondary end points were similar between two groups in the overall cohort and the propensity score-matched cohort (table). On subgroup analysis according to the presence of coronary artery disease (CAD), the only independent variable associated with cardiac mortality, the SAVR group had a significantly higher cardiac mortality rate than the TAVR group (15±7% vs 7±6% at 5 years, p=0.048) in 185 (71%) patients without CAD, whereas there was no significant difference among those with CAD. Harzard ratio for clinical outcomes TAVR (n=168) SAVR (n=93) Overall cohort TAVR (n=76) SAVR (n=76) PS-matched cohort HR (95% CI) p value HR (95% CI) p value Cardiac mortality 8 9 0.65 (0.25–1.71) 0.386 2 7 0.34 (0.07–1.61) 0.173 All-cause mortality 22 16 1.08 (0.56–2.08) 0.831 6 12 0.86 (0.30–2.43) 0.774 Cardiovascular event* 18 12 1.09 (0.52–2.28) 0.826 6 10 0.72 (0.26–1.98) 0.525 *Cardiovascular event was defined as the composite of cardiac mortality, hospitalization for heart failure, stroke, myocardial infarction, and reoperation. Conclusion In elderly AS patients at low surgical risk, TAVR was similar to SAVR with respect to long-term clinical outcomes. TAVR should be considered a treatment option for elderly patients who refuse to undergo surgery despite low risk.

Coronary access (CA) after transcatheter aortic valve replacement (TAVR) with supra-annular transcatheter heart valves (THV) can be challenging. Specific Evolut R/Pro and Acurate Neo THVs orientations are associated with reduced neo-commissure overlap with coronary ostia, while SAPIEN 3 THV cannot be oriented. With the ALIGN-ACCESS study (TAVR With Commissural Alignment Followed by Coronary Access), we investigated the impact of commissural alignment on the feasibility of CA after TAVR. We performed coronary angiography after TAVR with intra-annular SAPIEN 3, supra-annular Evolut R/Pro, and Acurate Neo THVs in 206 patients. Evolut THVs were implanted aiming for commissure alignment. Alignment of Acurate Neo was retrospectively assessed in 36, intentionally attempted in 26 cases. The primary end point was the rate of unfeasible and nonselective CA after TAVR. Thirty-eight percent of patients received SAPIEN 3, 31.1% Evolut Pro/R, 30.1% Acurate Neo THV. Final valve orientation was favorable to commissural alignment in 85.9% of Evolut and 69.4% of Acurate Neo cases (with intentional alignment successful in 88.5%). Selective CA was higher for SAPIEN 3 than for aligned and misaligned supra-annular THVs (95% versus 71% versus 46%, P<0.001). Cannulation of at least one coronary was unfeasible with 11% misaligned supra-annular, 3% aligned supra-annular, and 0% SAPIEN 3 THVs. Independent predictors of unfeasible/nonselective CA were implantation of a misaligned supra-annular THV (odds ratio, 4.59 [95% CI, 1.81-11.61]; P<0.01), sinus of Valsalva height (odds ratio, 0.83 [95% CI, 0.7-0.98]; P=0.03), and THV-sinus of Valsalva relation (odds ratio, 1.06 [95% CI, 1.02-1.1]; P<0.01). Commissural alignment improves the rate of selective CA after TAVR with supra-annular THVs. Nevertheless, aligned supra-annular THVs carry higher risk of unfeasible/nonselective CA than SAPIEN 3. Patients with a misaligned supra-annular THV, low sinus of Valsalva, and higher THV-sinus of Valsalva relation are at highest risk of impaired CA after TAVR.

Self-Expanding Versus Balloon-Expandable Valve: Are We at the Cusp of Delivering a Perfect Transcatheter Aortic Valve?

Coronary Cannulation Following TAVR Using Self-Expanding Devices With Commissural Alignment: The RE-ACCESS 2 Study

Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.

Commissural vs Coronary Alignment to Avoid Coronary Overlap With THV-Commissure in TAVR: A CT-Simulation Study

Introduction Patients with severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI) often present with concomitant coronary artery disease (CAD). The management of CAD in these patients remains a topic of debate, encompassing the evaluation and timing of percutaneous coronary intervention (PCI). Areas Covered This review article aims to offer an overview of the role of coronary revascularization in TAVI patients, highlighting the advantages and disadvantages of different strategies: PCI before, concomitant with, and after TAVI. Considering that TAVI indications are expanding and patients with low surgical risk are now being referred for TAVI, the rate of PCI among patients undergoing TAVI is expected to increase. Historically, PCI was performed before TAVI. However, there is now a growing trend to defer PCI until after TAVI. Expert opinion It is plausible that in the future, there will be an increase in PCI after TAVI due to several factors: first, multiple studies have shown the safety of TAVI even in patients with severe untreated CAD; second, improvements in TAVI device implantation techniques, such as commissural alignment and patient-specific device selection, have improved access to the coronary arteries post-TAVI.

Neo-Commissural Alignment Technique for Transcatheter Aortic Valve Replacement Using the ACURATE Neo Valve.

The Devoted Grandma: Is a Social Indication for TAVR Acceptable?

Limitations of Transcatheter Heart Valve Replacement Depth Assessment by Invasive Angiography—a Multi-Detector Computed Tomography Analysis