Double S-Curve Versus Cusp-Overlap Technique: Defining the Optimal Fluoroscopic Projection for TAVR With a Self-Expanding Device

Current Trends and Future Challenges in Transcatheter Aortic Valve Replacement: Utility of Cardiac Computed Tomography Angiography

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis. As TAVR continues to evolve, precise pre-procedural planning and imaging have become increasingly critical. While transthoracic echocardiography remains indispensable for assessing the severity of aortic stenosis, cardiac computed tomography angiography (CCTA) has emerged as the benchmark imaging modality for pre-procedural planning for TAVR. CCTA provides detailed anatomical information essential for patient selection, procedural success, and the mitigation of complications. This review aims to equip practitioners with the knowledge to effectively integrate CCTA into the TAVR workflow, ensuring a systematic approach to patient evaluation and procedural planning while addressing future challenges in the field.

Safety and effectiveness of self-expanding TAVR in Japanese dialysis patients with severe aortic stenosis: 1-year outcomes

BACKGROUND

In Japan, transcatheter aortic valve replacement (TAVR) with self-expanding valves (SEV) was approved for patients with severe aortic stenosis (AS) and on chronic maintenance dialysis in May 2023. This study assessed the safety and efficacy of TAVR with SEVs in this patient population.

METHODS

This prospective, non-randomized, single-center study evaluated the safety and effectiveness of TAVR using a supra-annular SEV in Japanese patients with severe AS on chronic maintenance dialysis. The primary endpoint of all-cause mortality or disabling stroke and several secondary endpoints were assessed at 12 months.

RESULTS

Ten patients underwent TAVR using the Evolut platform (Medtronic, Minneapolis, MN, USA) between June 2020 and August 2022. Mean patient age was 80.0 ± 5.5 years and 70 % were male. Mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 7.4 ± 2.2 %. At 1 year, the primary endpoint occurred in two patients (20 %), and there were no strokes, aortic valve reinterventions, or new permanent pacemaker implantations. Valve hemodynamics improved postprocedure and were maintained in all patients reaching 12-month follow-up (mean effective orifice area 2.1 ± 0.4 cm2, mean gradient 6.8 ± 1.6 mmHg), and no patients had moderate or severe aortic regurgitation.

CONCLUSIONS

Japanese dialysis patients with severe AS who underwent TAVR using SEVs experienced favorable clinical and hemodynamic outcomes at 1-year follow-up. Further investigations are needed to assess long-term outcomes in this patient population.

Three-Year Clinical and Hemodynamic Evaluation of the Hydra Self-Expanding Transcatheter Aortic Valve in Patients With Severe Aortic Stenosis

BACKGROUND

The Hydra CE study revealed 1-year favorable efficacy of TAVR, showing a large effective orifice area (EOA), low gradient, and acceptable complication rates.

AIMS

We evaluated the 3-year clinical and hemodynamic outcomes of Hydra self-expanding transcatheter aortic valve (manufactured by Vascular Innovations Co Ltd, Nonthaburi, Thailand; a subsidiary of Sahajanand Medical Technologies Limited, India) in patients with symptomatic severe aortic stenosis at high or extremely high surgical risk.

METHODS

The Hydra CE study was a prospective, multicenter, single-arm study. A total of 157 patients were enrolled in the study, out of whom 54 patients from two centers (Lithuania and Poland) had provided consent for long-term follow-up at recruitment, with a planned 5-year follow-up period. The primary endpoint was all-cause mortality, and patients were followed up for up to 3 years, with an assessment of clinical and echocardiographic outcomes.

RESULTS

Among the 54 patients, the average age was 81.0 ± 4.1 years. The mean STS score was 3.2 ± 2.0%. At 3 years, all-cause mortality had occurred in 14.8% of patients, including 3.7% cardiovascular deaths and 1.9% device-related deaths. There was a progressive enhancement in EOA that is, 0.68 ± 0.15 cm2 at baseline to 1.97 ± 0.52 cm2 at 3 years (p < 0.001) as well as significant improvement in the mean aortic valve gradient that is, 53.4 ± 14.24 mmHg at baseline to 8.6 ± 2.80 mmHg at 3 years (p < 0.001). New permanent pacemaker implantation rates up to 3-year follow-up was 12.9%.

CONCLUSION

The 3-year results of the Hydra CE study demonstrated consistent improvements in hemodynamics over time. The study also revealed favorable safety and efficacy trends, along with low occurrences of new permanent pacemaker implantations and paravalvular leaks.

Decreasing pacemaker implantation rates with Evolut supra-annular transcatheter aortic valves in a large real-world registry

BACKGROUND

Permanent pacemaker implantation (PPI) rates following transcatheter aortic valve replacement (TAVR) remain a concern. We assessed the PPI rates over time in patients implanted with an Evolut supra-annular, self-expanding transcatheter valve from the US STS/ACC TVT Registry.

METHODS

Patients who underwent TAVR with an Evolut R, Evolut PRO or Evolut PRO+ valve between July 2018 (Q3) and June 2021 (Q2) were included. PPI rates were reported by calendar quarter. In-hospital PPI rates were reported as proportions and 30-day rates as Kaplan-Meier estimates. A Cox regression model was used to determine potential predictors of a new PPI within 30 days of the TAVR procedure.

RESULTS

From July 2018 to June 2021, 54,014 TAVR procedures were performed using Evolut valves. Mean age was 79.3 ± 8.8 years and 49.2 % were male. The 30-day PPI rate was 16.6 % in 2018 (Q3) and 10.8 % in 2021 (Q2, 34.9 % decrease, p < 0.001 for trend across all quarters). The in-hospital PPI rate decreased by 40.1 %; from 14.7 % in 2018 (Q3) to 8.8 % in 2021 (Q2) (p < 0.001 for trend across all quarters). Significant predictors of a new PPI within 30 days included a baseline conduction defect, history of atrial fibrillation, home oxygen, and diabetes mellitus.

CONCLUSION

From 2018 to 2021, TAVR with an Evolut transcatheter heart valve in over 50,000 patients showed a significant decreasing trend in the rates of in-hospital and 30-day PPI, representing the lowest rate of PPI in any large real-world registry of Evolut. During the same evaluated period, high device success and shorter length of stay was also observed.

Predictors of permanent pacemaker implantation for transcatheter self-expandable aortic valve implant in the cusp overlap era

BACKGROUND

Predictors of permanent pacemaker implantation (PPMI) after self-expanding transcatheter aortic valve implant (TAVI) were described. Is unknown if PPMI predictors remain in the era of high implants using the cusp overlap (COP).

METHODS

Single-center, prospective, consecutive case series of patients undergoing self-expanding TAVI with the COP approach. The status of PPMI and other clinical events were ascertained at 30 days.

RESULTS

A total of 261 patients were included (84% with Evolut, n = 219). Implant depth >4 mm was infrequent (13.8%). TAVI depth (OR 1.259; p = 0.005), first or second-degree auriculo-ventricular block (OR 3.406; p = 0.033), right-bundle (OR 15.477; p < 0.0001), and incomplete left-bundle branch block (OR 7.964; p = 0.036) were found to be independent predictors of PPMI. The risk of PPMI with deep implant and no electrical disturbances was 3%, and 0% with high implant and no prior electrical disturbances. Those who received PPMI had no statistically significant increased risk of death, myocardial infarction, stroke, bleeding events, or vascular complications at 30 days, but longer hospital stay (mean difference 1.43 days more, p = 0.003).

CONCLUSIONS

Implant depth and prior conduction abnormalities remain the main predictors of PPMI using self-expanding TAVI in the COP era. Patients with high implants and no prior conduction abnormalities may be candidates for early discharge after uneventful self-expanding TAVI, while the rest may need inpatient monitoring regardless of achieving a high implant. The need for PPMI was associated with longer hospital stays.

[The role of implant projection in optimizing transcatheter aortic valve implantation]

Severe aortic stenosis is the most frequent valve condition requiring surgery, and its incidence is increasing yearly. Transcatheter aortic valve implantation (TAVI) is the first-line treatment for patients at all levels of surgical risk. Nevertheless, modifications to the procedure often appear to improve clinical outcomes. A major concern after TAVI is the higher rate of permanent pacemaker implantation (PPMI) compared with surgical valve replacement. Optimal implantation depth is crucial to reduce the burden of PPMI without causing serious complications such as valve embolization. The classic implantation technique, where the 3 cusps are aligned in the same plane, has been modified to a cusp overlap projection by isolating the noncoronary cusp and superimposing the left and right cusps. This simple modification provides optimal visualization during deployment and helps to achieve the desired implant depth to reduce conduction disturbances and PPMI. Another limitation after TAVI is coronary reaccess due to the frame of the transcatheter valve obstructing the coronary ostia. Commissural alignment of the prostheses with the native valve may facilitate selective cannulation of the coronary arteries after this procedure. This review will discuss the techniques and supporting evidence for these modifications to the deployment and implant projection methods, and how they can improve TAVI outcomes.

Steep right anterior oblique view of self-expandable transcatheter aortic valve to timely detect stent under-expansion or non-uniform expansion before final release: a case series

Background

Severely calcified aortic valves are a major limitation of transcatheter aortic valve replacement, because eccentric and heavy calcification of the aortic valve occasionally inhibits self-expansion of the valve frame, resulting in stent under-expansion, including non-uniform expansion or infolding. Nevertheless, the two-dimensional nature of fluoroscopic projection imaging can limit detection of stent under-expansion prior to the final release.

Case summary

We present two cases demonstrating the importance of the steep right anterior oblique (RAO) view (>50°) in detecting significant stent under-expansion of a self-expanding valve prior to the final release. In Case 1, despite enough pre-dilatation, the partially deployed transcatheter heart valve (THV) appeared to be a substantial under-expansion, which was detected only in steep RAO view. Immediately after the final release, the THV was spontaneously embolized into the ascending aorta (the so-called 'pop-up' phenomenon). Emergent implantation of balloon-expandable valve proved to be successful as a bailout. In Case 2, significant stent distortion and infolding, especially on the non-coronary cusp side, was successfully diagnosed only in a steep RAO view prior to the final release. This finding allowed THV recapture and replacement with a new THV.

Discussion

Notably, the steep RAO view can visualize the THV from its short axis while eliminating parallax, allowing for accurate diagnosis of THV under-expansion particularly in patients with severe calcification in the non- or right-coronary cusp. Therefore, the steep RAO view allows timely detection of THV under-expansion before the final release, enabling THV recapture and the adoption of several management strategies.

Impact of commissural versus coronary alignment on risk of coronary obstruction following transcatheter aortic valve implantation

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.

Factors Influencing Implantation Depth During Transcatheter Aortic Valve Replacement

Optimised implantation depth (OID) is crucial to obtain the best haemodynamic and clinical outcome during transcatheter heart valve (THV) deployment. OID ensures a better haemodynamic profile and is associated with a potential reduction in permanent pacemaker implantations, both of which are important during transcatheter aortic valve replacement (TAVR). Apart from patient-related anatomic conditions, many factors, such as THV and wire selection, as well as implantation strategies, can be controlled by the operator and facilitate the implantation process. However, there are only limited data dealing with predictors for OID. Therefore, the aim of this review was to outline factors and tools that might influence the final implantation depth during TAVR procedures, potentially influencing the outcome.

The impact of cusp overlap on permanent pacemaker requirement following self-expanding transcatheter aortic valve replacement

BACKGROUND/PURPOSE

The cusp overlap technique has standardized implantation for self-expanding valves with the goal of achieving more consistent implantation depths and lowering permanent pacemaker (PPM) implantation rates. We retrospectively compared short-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) with a self-expanding valve implanted using the cusp overlap technique vs. the traditional coplanar technique in a large tertiary referral center.

METHODS

We conducted a retrospective study among PPM-naïve patients who underwent TAVR using the CoreValve Evolut PRO/PRO+. We compared in-hospital PPM rates in patients who underwent TAVR using the cusp overlap technique vs. the coplanar technique. Additional outcomes included in-hospital all-cause mortality, stroke, major vascular complications, annular rupture, and >mild paravalvular leak. Furthermore, we compared outcomes over time to see whether there was evidence of a learning curve.

RESULTS

Of the 528 patients included, 270 underwent TAVR using the coplanar technique and 258 underwent TAVR using the cusp overlap technique. The rate of new PPM implantation did not differ between cohorts (17.0 % vs. 16.7 %; p = 0.910). Additionally, rates of in-hospital all-cause mortality (0.0 % vs. 0.4 %; p = 0.328), stroke (3.7 % vs. 1.6 %; p = 0.124), major vascular complications (0.7 % vs. 1.2 %; p = 0.617), annular rupture (0.4 % vs. 0.0 %; p = 0.328) and >mild paravalvular leak (0.0 % vs. 0.4 %; p = 0.444) were similar. Our secondary analysis did not identify any evidence of a learning curve.

CONCLUSIONS

The cusp overlap technique may not yield a reduction in PPM rates when compared with the coplanar technique. Other confounders should be explored to further minimize in-hospital PPM rates.

Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement

Background

There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate.

Objectives

This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV).

Methods

Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days.

Results

The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041).

Conclusions

TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.

The Influence of the Learning Curve on Clinical Outcomes in Balloon-Expandable versus Self-Expandable Transfemoral Transcatheter Aortic Valve Implantation

INTRODUCTION

Balloon-expandable (BE) and self-expandable (SE) prostheses are the main types of devices currently used in transcatheter aortic valve implantation (TAVI). Despite the different designs, clinical practice guidelines do not make any specific recommendation on the selection of one device over the other. Most operators are trained in using both BE and SE prostheses, but operator experience with each of the two designs might influence patient outcomes. The aim of this study was to compare the immediate and mid-term clinical outcomes during the learning curve in BE versus SE TAVI.

METHODS

The transfemoral TAVI procedures performed in a single center between July 2017 and March 2021 were grouped according to the type of implanted prosthesis. The procedures in each group were ordered according to the case sequence number. For each patient, a minimum follow-up time of 12 months was required for inclusion in the analysis. The outcomes of the BE TAVI procedures were compared with the outcomes of the SE TAVI procedures. Clinical endpoints were defined according to the Valve Academic Research Consortium 3 (VARC-3).

RESULTS

The median follow-up time was 28 months. Each device group included 128 patients. In the BE group, case sequence number predicted mid-term all-cause mortality at an optimal cutoff value ≤58 procedures (AUC 0.730; 95% CI: 0.644-0.805; p < 0.001), while in the SE group, the cutoff value was ≤85 procedures (AUC 0.625; 95% CI: 0.535-0.710; p = 0.04). A direct comparison of the AUC showed that case sequence number was equally adequate in predicting mid-term mortality, irrespective of prosthesis type (p = 0.11). A low case sequence number was associated with an increased rate of VARC-3 major cardiac and vascular complications (OR 0.98 95% CI: 0.96-0.99; p = 0.03) in the BE device group, and with an increased rate of post-TAVI aortic regurgitation ≥ grade II (OR 0.98; 95% CI: 0.97-0.99; p = 0.03) in the SE device group.

CONCLUSIONS

In transfemoral TAVI, case sequence number influenced mid-term mortality irrespective of prosthesis type, but the learning curve was longer in the case of SE devices.

3-Year Outcomes After Transcatheter or Surgical Aortic Valve Replacement in Low-Risk Patients With Aortic Stenosis

BACKGROUND

Randomized data comparing outcomes of transcatheter aortic valve replacement (TAVR) with surgery in low-surgical risk patients at time points beyond 2 years is limited. This presents an unknown for physicians striving to educate patients as part of a shared decision-making process.

OBJECTIVES

The authors evaluated 3-year clinical and echocardiographic outcomes from the Evolut Low Risk trial.

METHODS

Low-risk patients were randomized to TAVR with a self-expanding, supra-annular valve or surgery. The primary endpoint of all-cause mortality or disabling stroke and several secondary endpoints were assessed at 3 years.

RESULTS

There were 1,414 attempted implantations (730 TAVR; 684 surgery). Patients had a mean age of 74 years and 35% were women. At 3 years, the primary endpoint occurred in 7.4% of TAVR patients and 10.4% of surgery patients (HR: 0.70; 95% CI: 0.49-1.00; P = 0.051). The difference between treatment arms for all-cause mortality or disabling stroke remained broadly consistent over time: -1.8% at year 1; -2.0% at year 2; and -2.9% at year 3. The incidence of mild paravalvular regurgitation (20.3% TAVR vs 2.5% surgery) and pacemaker placement (23.2% TAVR vs 9.1% surgery; P < 0.001) were lower in the surgery group. Rates of moderate or greater paravalvular regurgitation for both groups were <1% and not significantly different. Patients who underwent TAVR had significantly improved valve hemodynamics (mean gradient 9.1 mm Hg TAVR vs 12.1 mm Hg surgery; P < 0.001) at 3 years.

CONCLUSIONS

Within the Evolut Low Risk study, TAVR at 3 years showed durable benefits compared with surgery with respect to all-cause mortality or disabling stroke. (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients; NCT02701283).

Impact of implantation technique on conduction disturbances for TAVR with the self-expanding portico/navitor valve

BACKGROUND

Use of a right-left (R-L) cusp overlap view for transcatheter aortic valve replacement (TAVR) with self-expanding valves has recently been proposed aiming to reduce permanent pacemaker implantation (PPMI). An objective, data-driven explanation for this observation is missing.

AIMS

To assess the impact of different implantation techniques on the risk of PPMI following TAVR with the Portico/NavitorTM transcatheter heart valve (THV; Abbott).

METHODS

A TAVR-population treated with Portico/NavitorTM had the THV implanted in a right versus left anterior oblique (RAO/LAO) fluoroscopic view with no parallax in the delivery system. The impact of these different implantation views on the spatial relationship between THV and native aortic annulus and the risk of conduction disturbances and PPMI after TAVR was studied.

RESULTS

A total of 366 matched TAVR patients were studied: 183 in the RAO group and 183 in the LAO group. The degree of aortic annulus plane tilt was significantly smaller in the RAO versus LAO group (median: 0° vs. 23°, p < 0.001), with no plane tilt in 105 out of 183 cases (57.3%) in the RAO group. At 30 days after TAVR, the overall PPMI and guideline-directed PPMI rates were 12.6% versus 18.0% (p = 0.15) and 8.2% versus 15.3% (p = 0.04) in the RAO versus LAO group, respectively.

CONCLUSIONS

Use of a R-L cusp overlap (RAO-caudal) view for implantation of the Portico/NavitorTM valve results in less tilt of the native aortic annulus plane and a clear trend toward a lower 30-day PPMI rate as compared to TAVR using the conventional LAO implantation view.

Aortic Annulus S-Curve: Implications for Transcatheter Aortic Valve Replacement and Related Procedures, Part 1

Most transcatheter aortic valve replacement-related procedures (eg, transcatheter aortic valve replacement implantation depth, commissural alignment, coronary access, bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, paravalvular leak closure) require an optimal fluoroscopic viewing angle located somewhere along the aortic annulus S-curve. Chamber views, coronary cusp and coronary anatomy, can be understood along the aortic annulus S-curve. A better understanding of the optimal fluoroscopic viewing angles along the S-curve may translate into increased operator confidence and improved safety and efficacy while reducing procedural time, radiation dose, contrast volume, and complication rates.

Hybrid Approach Using the Cusp-Overlap Technique for Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve

BACKGROUND

The cusp-overlap (CO) technique has recently been advocated and is being increasingly adopted for self-expandable transcatheter heart valve (THV) implantation.

OBJECTIVES

The aim of this study was to evaluate the feasibility, implantation depth, and outcomes of the CO technique for the balloon-expandable SAPIEN 3 THV.

METHODS

The CO technique was used in consecutive patients undergoing balloon-expandable THV implantation at one center between April 2021 and March 2022. Optimal fluoroscopic angles were determined from preprocedural computed tomography and confirmed on predeployment angiography. The THV radiolucent line was positioned 2 to 4 mm below the noncoronary cusp in the CO view, and positioning was confirmed in the 3-cusp view. Postdeployment THV implantation depth was assessed in both views. One-month outcomes were assessed using Valve Academic Research Consortium 3 criteria.

RESULTS

Among 137 patients eligible for the CO technique, the CO view was not used because of unfavorable ergonomics in 27 patients (26.5%) and hemodynamic instability in 8 patients (7.8%). Among 102 patients, the mean age was 81.1 ± 6.6 years, the mean Society of Thoracic Surgeons score was 3.3% ± 2.2%, and 64.7% were men. The mean measured THV implantation depth was 3.0 ± 1.4 mm in the CO view and 2.5 ± 1.4 mm in the 3-cusp view. At 1-month follow-up, 1 patient (1.0%) had died, 1 (1.0%) had had a stroke, and 7 (6.8%) had undergone permanent pacemaker implantation.

CONCLUSIONS

The CO technique is feasible and safe and may facilitate more accurate balloon-expandable THV positioning, especially when deep implantation needs to be avoided. Further studies are required to explore potential reduction in atrioventricular conduction block, pacemakers, or paravalvular regurgitation.

Real-world experience with the cusp-overlap deployment technique in transcatheter aortic valve replacement: A propensity-matched analysis

Background

The implantation depth (ID) is a critical condition for optimal hemodynamic and clinical outcomes in transcatheter aortic valve replacement (TAVR). The recently recommended cusp-overlap technique (COT) offers optimized fluoroscopic projections facilitating a precise ID. This single-center observational study aimed to investigate short-term clinical performance, safety, and efficacy outcomes in patients undergoing TAVR with self-expandable prostheses and application of COT in a real-world setting.

Materials and methods

From September 2020 to April 2021, a total of 170 patients underwent TAVR with self-expandable devices and the application of COT, while 589 patients were treated from January 2016 to August 2020 with a conventional three-cusp coplanar view approach. The final ID and 30-day outcomes were compared after 1:1 propensity score matching, resulting in 150 patients in both cohorts.

Results

The mean ID was significantly reduced in the COT cohort (−4.2 ± 2.7 vs. −4.9 ± 2.3 mm; p = 0.007) with an improvement of ID symmetry of less than 2 mm difference below the annular plane (47.3 vs. 57.3%; p = 0.083). The rate of new permanent pacemaker implantation (PPI) following TAVR was effectively reduced (8.0 vs. 16.8%; p = 0.028). While the fluoroscopy time decreased (18.4 ± 7.6 vs. 19.8 ± 7.6 min; p = 0.023), the dose area product increased in the COT group (4951 ± 3662 vs. 3875 ± 2775 Gy × cm²; p = 0.005). Patients implanted with COT had a shorter length of in-hospital stay (8.4 ± 4.0 vs. 10.3 ± 6.7 days; p = 0.007).

Conclusion

Transcatheter aortic valve replacement using the cusp-overlap deployment technique is associated with an optimized implantation depth, leading to fewer permanent conduction disturbances. However, our in-depth analysis showed for the first time an increase of radiation dose due to extreme angulations of the gantry to obtain the cusp-overlap view.

From the Evolut Pro to the Evolut FX self-expanding transcatheter aortic valve replacement systems: current status and future perspectives

INTRODUCTION

Since the initial experience with the CoreValve (Medtronic, Minneapolis, Minnesota), there have been continuous iterations of this valve system in order to improve procedural success and reduce periprocedural complications. The Evolut Pro, Pro+, and FX are the latest generations of this transcatheter heart valve (THV).

AREAS COVERED

This review paper aims to analyze the main characteristics and clinical evidence about the Evolut Pro THV and summarize the main iterations of the newer generation Evolut FX valve system.

EXPERT OPINION

The Evolut Pro system has been associated with good clinical outcomes and excellent valve hemodynamic performance including reduced rates of paravalvular leaks. Technical enhancements to improve valve positioning, orientation, and vascular access have been implemented in the newer generation Evolut FX system.

Algorithm for Systematic Valve-Crossing in Transcatheter Aortic Valve Implantation

The retrograde valve-crossing of a stenotic aortic valve is a crucial step in the transcatheter aortic valve implantation (TAVI) procedure. In addition to being time-consuming and associated with an increased stroke risk, inappropriate valve-crossing may cause devastating complications. This tutorial review summarizes systematic and detailed techniques to cross the aortic valve. First, the main challenges in retrograde valve-crossing are depicted. Next, a step-by-step guidance on valve-crossing is provided, along with an in-depth description of the three-dimensional anatomy under a two-dimensional fluoroscopy view. Finally, modified techniques for different anatomies are described.

Center Valve Preference and Outcomes of Transcatheter Aortic Valve Replacement: Insights From the AMTRAC Registry

BACKGROUND

Data on outcomes of transcatheter aortic valve replacement (TAVR) using balloon-expandable valves (BEVs) or self-expandable valves (SEVs) as well as the impact of center valve preference on these outcomes are limited.

OBJECTIVES

The aim of this study was to compare outcomes of TAVR procedures using third-generation BEVs and SEVs stratified by center valve preference.

METHODS

In a multicenter registry (n = 17), 13 centers exhibited valve preference (66.6%-90% of volume) and were included. Outcomes were compared between BEVs and SEVs stratified by center valve preference.

RESULTS

In total, 7,528 TAVR procedures (3,854 with SEVs and 3,674 with BEVs) were included. The mean age was 81 years, and the mean Society of Thoracic Surgeons score was 5.2. Baseline characteristics were similar between BEVs and SEVs. Need for pacemaker implantation was higher with SEVs at BEV- and SEV-dominant centers (17.8% vs 9.3% [P < 0.001] and 12.7% vs 10.0% [P = 0.036], respectively; HR: 1.51; P for interaction = 0.021), risk for cerebrovascular accident was higher with SEVs at BEV-dominant but not SEV-dominant centers (3.6% vs 1.1% [P < 0.001] and 2.2% vs 1.4% [P = 0.162]; HR: 2.08; P for interaction < 0.01). Aortic regurgitation greater than mild was more frequent with SEVs at BEV-dominant centers and similar with BEVs regardless of center dominance (5.2% vs 2.8% [P < 0.001] and 3.4% vs 3.7% [P = 0.504], respectively). Two-year mortality was higher with SEVs at BEV-dominant centers but not at SEV-dominant centers (21.9% vs 16.9% [P = 0.021] and 16.8% vs 16.5% [P = 0.642], respectively; HR: 1.20; P for interaction = 0.032).

CONCLUSIONS

Periprocedural outcomes, aortic regurgitation greater than mild, and 2-year mortality are worse when TAVR is performed using SEVs at BEV-dominant centers. Outcomes are similar regardless of valve type at SEV-dominant centers. The present results stress the need to account for this factor when comparing BEV and SEV outcomes. (The Aortic+Mitral Transcatheter [AMTRAC] Valve Registry; NCT04031274).

Coronary access after transcatheter aortic valve replacement in bicuspid versus tricuspid aortic stenosis

BACKGROUND

It is unknown whether there are differences in coronary access after transcatheter aortic valve replacement (TAVR) between bicuspid and tricuspid anatomy.

AIMS

Our aim was to investigate coronary access after TAVR using a self-expanding transcatheter heart valve (THV) in bicuspid versus tricuspid aortic valves (BAV vs TAV), based on CT simulation.

METHODS

A total of 86 type 0 BAV, 70 type 1 BAV, and 132 TAV patients were included. If the coronary ostium faced the sealed parts of the THV or the tilted-up native leaflet (NL), this was defined as THV- or NL-related challenging coronary access, respectively. If coaxial engagement was not allowed due to interference from the unwrapped frame, THV-related complex coronary access was defined.

RESULTS

The incidence of THV-related challenging coronary access was 21.2% for the left coronary artery (LCA) and 17.7% for the right coronary artery (RCA), and type 0 BAV patients encountered fewer THV-related challenging LCA access than their TAV counterparts (OR 0.42, 95% CI: 0.20-0.89). NL-related challenging coronary access was observed in 3.1% for LCA and 1.4% for RCA, and THV-related complex coronary access was identified in 5.9% for LCA and 17.0% for RCA; however, no significant differences were found among groups. The proportion of optimal fluoroscopic viewing angles suitable for guiding LCA engagement was similar among groups (64.0% vs 70.0% vs 62.1%), but those suitable for guiding RCA engagement were significantly higher in the type 0 BAV group (31.4% vs 4.3% vs 9.1%).

CONCLUSIONS

Coronary access may be challenging or complex in a significant proportion of both BAV and TAV patients after TAVR. Type 0 BAV anatomy may be more favourable for post-TAVR coronary access.

Preoperative TAVR Planning: How to Do It

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for patients with severe symptomatic aortic stenosis (AS) whose procedural efficacy and safety have been continuously improving. Appropriate preprocedural planning, including aortic valve annulus measurements, transcatheter heart valve choice, and possible procedural complication anticipation is mandatory to a successful procedure. The gold standard for preoperative planning is still to perform a multi-detector computed angiotomography (MDCT), which provides all the information required. Nonetheless, 3D echocardiography and magnet resonance imaging (MRI) are great alternatives for some patients. In this article, we provide an updated comprehensive review, focusing on preoperative TAVR planning and the standard steps required to do it properly.

Transcatheter Aortic Valve Replacement Optimization Strategies: Cusp Overlap, Commissural Alignment, Sizing, and Positioning

As transcatheter aortic valve replacement (TAVR) rapidly expands to younger patients and those at low surgical risk, there is a compelling need to identify patients at increased risk of post-procedural complications, such as paravalvular leak, prosthesis-patient mismatch, and conduction abnormalities. This review highlights the incidence and risk factors of these procedural complications, and focuses on novel methods to reduce them by using newer generation transcatheter heart valves and the innovative cusp-overlap technique, which provides optimal fluoroscopic imaging projection to allow for precise implantation depth which minimizes interaction with the conduction system. Preserving coronary access after TAVR is another important consideration in younger patients. This paper reviews the significance of commissural alignment to allow coronary cannulation after TAVR and discusses recently published data on modified delivery techniques to improve commissural alignment.

2-Year Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients

BACKGROUND

The Evolut Low Risk Trial (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients) showed that transcatheter aortic valve replacement (TAVR) with a supra-annular, self-expanding valve was noninferior to surgery for the primary endpoint of all-cause mortality or disabling stroke at 2 years. This finding was based on a Bayesian analysis performed after 850 patients had reached 1 year of follow-up.

OBJECTIVES

The goal of this study was to report the full 2-year clinical and echocardiographic outcomes for patients enrolled in the Evolut Low Risk Trial.

METHODS

A total of 1,414 low-surgical risk patients with severe aortic stenosis were randomized to receive TAVR or surgical AVR. An independent clinical events committee adjudicated adverse events, and a central echocardiographic core laboratory assessed hemodynamic endpoints.

RESULTS

An attempted implant was performed in 730 TAVR and 684 surgical patients from March 2016 to May 2019. The Kaplan-Meier rates for the complete 2-year primary endpoint of death or disabling stroke were 4.3% in the TAVR group and 6.3% in the surgery group (P = 0.084). These rates were comparable to the interim Bayesian rates of 5.3% with TAVR and 6.7% with surgery (difference: -1.4%; 95% Bayesian credible interval: -4.9% to 2.1%). All-cause mortality rates were 3.5% vs 4.4% (P = 0.366), and disabling stroke rates were 1.5% vs 2.7% (P = 0.119), respectively. Between years 1 and 2, there was no convergence of the primary outcome curves.

CONCLUSIONS

The complete 2-year follow-up from the Evolut Low Risk Trial found that TAVR is noninferior to surgery for the primary endpoint of all-cause mortality or disabling stroke, with event rates that were slightly better than those predicted by using the Bayesian analysis. (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients [Evolut Low Risk Trial]; NCT02701283).

Membranous septum morphology and risk of conduction abnormalities after transcatheter aortic valve implantation

BACKGROUND

There are limited data on the association of membranous septum (MS) morphology and transcatheter heart valve (THV) implantation depth, and the development of new conduction abnormalities (CA) after transcatheter aortic valve implantation (TAVI).

AIMS

The aim of this study was to describe the morphology of the MS and predict the risk of new CA after TAVI based on the MS morphology and THV implantation depth.

METHODS

Based on preprocedural CT scans, the MS depth was measured for every 25% of the entire MS width in 272 TAVI patients without preprocedural bundle branch block (BBB) or pacemaker. Post-procedural CT scans for THV implantation depth assessment were available in 130 of these patients.

RESULTS

The MS depth was a median of 2.5 mm (IQR 1.4-3.8) deeper at the posterior edge when compared to the anterior edge of the MS. New CA developed in 7.1% of patients in whom the THV did not cross the lower MS border at its anterior edge (3.6% with new BBB and high degree CA, respectively), in 18.8% of patients (15.6% with new BBB and 3.1% with new high-degree CA) where the THV overlapped the lower MS border by <2.5 mm and in 47.1% of patients (24.3% with new BBB and 22.9% with new high-degree CA) with THV overlap of the lower MS border by ≥2.5 mm.

CONCLUSIONS

The difference of the MS depth and THV implantation depth measured at the anterior edge of the MS predicted new CA after TAVI.

Permanent Pacemaker Reduction Using Cusp-Overlapping Projection in TAVR: A Propensity Score Analysis

OBJECTIVES

The aim of this study was to determine if modifying the classical implantation technique for self-expanding (SE) transcatheter aortic valve replacement to a novel cusp-overlapping projection (COP) technique results in a higher implantation depth (ID) and subsequently reduces the rate of permanent pacemaker implantation (PPMI).

BACKGROUND

The COP technique presents the potential benefit of an optimized ID to reduce the rate of PPMI. However, only a few studies have compared clinical outcomes with those achieved using the standard technique. This is the first study to systematically evaluate this approach for SE transcatheter heart valves (THVs) in different populations METHODS: Beginning in February 2015, 444 patients were consecutively included. Propensity score matching was used to control baseline characteristics because of the observational nature of the study. In total, 161 pairs of patients were analyzed. Three methods were used to measure ID (noncoronary cusp [NCC] to the THV, mean of the NCC and the left coronary cusp [LCC] to the THV, and the deepest edge from the LCC and the NCC to the THV).

RESULTS

ID was significantly higher in COP cases when measuring from the NCC (4.2 mm vs 5.3 mm; P < 0.001) and the mean from the NCC and the LCC (5.3 mm vs 5.9 mm; P = 0.04), but not from the deepest edge. The PPMI rate was lower in the COP group: 19 (11.8%) vs 35 (21.7%) (P = 0.03; relative risk: 0.54; 95% CI: 0.32-0.91).

CONCLUSIONS

The present study showed that the COP technique significantly reduces PPMI in SE THV implantation compared with the classical implantation technique, with similar rates of complications.

Cusp Symmetry and Coronary Ostial Eccentricity and its Impact on Coronary Access Following TAVR

OBJECTIVES

The aim of this study was to assess cusp symmetry and coronary ostial eccentricity and its impact on coronary access following transcatheter aortic valve replacement (TAVR) using a patient-specific commissural alignment implantation technique.

BACKGROUND

TAVR implantation techniques to obtain neocommissural alignment have been introduced. The impact of cusp symmetry and coronary ostial eccentricity on coronary access after TAVR remains unknown.

METHODS

Cardiac computed tomographic scans from 200 tricuspid aortic valves (TAVs) and 200 type 1 bicuspid aortic valves (BAVs) were studied. Cusp symmetry and coronary ostial eccentricity were assessed. In addition, the right coronary cusp/left coronary cusp and right coronary artery (RCA)/left coronary artery (LCA) ostia overlap views were calculated and compared.

RESULTS

Severe cusp asymmetry (>135°) was more frequent in BAVs (52.5%) than in TAVs (2.5%) (P < 0.001), with the noncoronary cusp being the most common dominant cusp. The RCA ostium was found to be more often eccentric (>20°) than the LCA ostium (28% vs 6%, respectively; P < 0.001). Considering the right/left cusp overlap view, there was <20° deviation between the right coronary cusp-left coronary cusp centered line and the RCA-LCA centered line in 95% of all patients (TAV, 97%; BAV, 93%). The right/left cusp and coronary ostia overlap view differed by <10° and <20° fluoroscopic angulation in 75% and 98% of all cases, respectively.

CONCLUSIONS

Using the right/left cusp overlap view to obtain commissural alignment in TAVR is also an effective approach to implant one of the transcatheter heart valve commissures in the near center between both coronary ostia in most TAVs and type 1 BAVs. Preprocedural CT assessment remains crucial to assess cusp symmetry and coronary ostial eccentricity.

Myval versus alternative balloon- and self-expandable transcatheter heart valves: A central core lab analysis of conduction disturbances

BACKGROUND

Several studies have compared surface electrocardiographic changes following different self-expandable (SE) (Evolut (Medtronic, USA); Acurate (Boston Scientific, USA); Portico (Abbott, USA); and Allegra (NVT, Germany)) and balloon-expandable (BE) Sapien-3 (Edwards Lifesciences, USA) transcatheter heart valves. We aimed to compare these prosthesis with the novel Myval BE prosthesis (Meril Life, India).

METHODS

Academic European registry of consecutive patients with severe aortic stenosis who received any of the 6 aforementioned valves. Baseline, post-procedural, and discharge 12‑leads electrocardiograms (ECG) were centrally analyzed and compared.

RESULTS

A total of 1131 patients were included: 135 Myval (11.9%), 290 Sapien-3 (25.6%), 298 Evolut (26.3%), 180 Acurate (15.9%), 125 Portico (11.1%), and 103 Allegra (9.1%). There were no baseline differences in intraventricular conduction disturbances rate. Compared to the novel BE Myval, there were similar procedural and in-hospital outcomes. Similar rates of early new permanent pacemaker implant (PPI) were observed amongst Myval (7.4%), Sapien-3 (13.4%), and Acurate (9.1%), but Evolut, Portico, and Allegra presented significantly higher rates (18.5%, p = 0.003; 29.5% p < 0.001 and 22%, p = 0.001, respectively). Central analysis of ECGs, unraveled significant prolongation of the PR segment with Evolut, Portico and Allegra whereas Evolut, Acurate, and Portico showed significant QRS widening compared to Myval. However, at discharge no differences in PR segment duration were observed while, Evolut, and Portico- but not Acurate, Allegra or Sapien-3 - still presented significant widening of QRS segment compared to Myval.

CONCLUSIONS

After blinded central ECG analysis, the novel Myval balloon-expandable prosthesis was associated with a low rate of early conduction disturbances.

The Predictors of Conduction Disturbances Following Transcatheter Aortic Valve Replacement in Patients With Bicuspid Aortic Valve: A Multicenter Study

Objective: To evaluate the predictors of new-onset conduction disturbances in bicuspid aortic valve patients using self-expanding valve and identify modifiable technical factors. Background: New-onset conduction disturbances (NOCDs), including complete left bundle branch block and high-grade atrioventricular block, remain the most common complication after transcatheter aortic valve replacement (TAVR). Methods: A total of 209 consecutive bicuspid patients who underwent self-expanding TAVR in 5 centers in China were enrolled from February 2016 to September 2020. The optimal cut-offs in this study were generated from receiver operator characteristic curve analyses. The infra-annular and coronal membranous septum (MS) length was measured in preoperative computed tomography. MSID was calculated by subtracting implantation depth measure on postoperative computed tomography from infra-annular MS or coronal MS length. Results: Forty-two (20.1%) patients developed complete left bundle branch block and 21 (10.0%) patients developed high-grade atrioventricular block after TAVR, while 61 (29.2%) patients developed NOCDs. Coronal MS <4.9 mm (OR: 3.08, 95% CI: 1.63-5.82, p = 0.001) or infra-annular MS <3.7 mm (OR: 2.18, 95% CI: 1.04-4.56, p = 0.038) and left ventricular outflow tract perimeter <66.8 mm (OR: 4.95 95% CI: 1.59-15.45, p = 0.006) were powerful predictors of NOCDs. The multivariate model including age >73 years (OR: 2.26, 95% CI: 1.17-4.36, p = 0.015), Δcoronal MSID <1.8 mm (OR: 7.87, 95% CI: 2.84-21.77, p < 0.001) and prosthesis oversizing ratio on left ventricular outflow tract >3.2% (OR: 3.42, 95% CI: 1.74-6.72, p < 0.001) showed best predictive value of NOCDs, with c-statistic = 0.768 (95% CI: 0.699-0.837, p < 0.001). The incidence of NOCDs was much lower (7.5 vs. 55.2%, p < 0.001) in patients without Δcoronal MSID <1.8 mm and prosthesis oversizing ratio on left ventricular outflow tract >3.2% compared with patients who had these two risk factors. Conclusion: The risk of NOCDs in bicuspid aortic stenosis patients could be evaluated based on MS length and prosthesis oversizing ratio. Implantation depth guided by MS length and reducing the oversizing ratio might be a feasible strategy for heavily calcified bicuspid patients with short MS.

A CT-based technique to predict optimal projection for self-expanding TAVI in patients with different aortic valve anatomies

Background

Optimal projection is essential for valve deployment during transcatheter aortic valve implantation (TAVI). The purpose of this study was to propose an approach to predict optimal projection in TAVI candidates with different aortic valve anatomies.

Methods

331 patients undergoing self-expanding TAVI were included and the so-called non-coronary cusp (NCC)-parallel technique was utilized, which generated the predicted projection by connecting NCC commissures on the transverse plane on the pre-procedural computed tomography images.

Results

37.8% of the study cohort were bicuspid aortic valve (BAV) patients. Around 80% of both NCC-parallel views and final views were in the right anterior oblique (RAO) and caudal (CAU) quadrant. There was less than 5° change required from the NCC-parallel view to the final implanted view in 79% of tricuspid aortic valve (TAV) patients but only in 27% (13/48) of type 0 BAV patients with coronary arteries originated from the different cusps. After excluding the above mentioned BAV patients, 62.3% (48/77) of BAV patients needed less than 5° change to achieve optimal projection and only in 8 patients, the angular change was larger than 10° in either left/right anterior oblique or cranial/caudal direction.

Conclusions

The NCC-parallel technique provides reliable prediction for optimal projection in self-expanding TAVI in all TAV and most BAV patients, with a vast majority of views in the RAO and CAU quadrant.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02387-7.

The incidence and predictors of high-degree atrioventricular block in patients with bicuspid aortic valve receiving self-expandable transcatheter aortic valve implantation

BACKGROUND

The high-degree atrioventricular block (HAVB) in patients with bicuspid aortic valve (BAV) treated with transcatheter aortic valve implantation (TAVI) remains high. The study aims to explore this poorly understood subject of mechanisms and predictors for HAVB in BAV self-expandable TAVI patients.

METHODS

We retrospectively included 181 BAV patients for analysis. Using computed tomography data, the curvature of ascending aorta (AAo) was quantified by the angle (AAo angle) between annulus and the cross-section at 35 mm above annulus (where the stent interacts with AAo the most). The valvular anatomy and leaflet calcification were also characterized.

RESULTS

The 30-day HAVB rate was 16.0% (median time to HAVB was three days). Type-1 morphology was found in 79 patients (43.6%) (left- and right-coronary cusps fusion comprised 79.7%). Besides implantation below membrane septum, large AAo angle [odds ratio (OR) = 1.08, P = 0.016] and type-1 morphology (OR = 4.97, P = 0.001) were found as the independent predictors for HAVB. Together with baseline right bundle branch block, these predictors showed strong predictability for HAVB with area under the cure of 0.84 (sensitivity = 62.1%, specificity = 92.8%). Bent AAo and calcified raphe had a synergistic effect in facilitating high implantation, though the former is associated with at-risk deployment (device implanted above annulus + prothesis pop-out, versus straight AAo: 9.9% vs. 2.2%, P = 0.031).

CONCLUSIONS

AAo curvature and type-1 morphology are novel predictors for HAVB in BAV patients following self-expandable TAVI. For patients with bent AAo or calcified raphe, a progressive approach to implant the device above the lower edge of membrane septum is favored, though should be done cautiously to avoid pop-out.

Cusp Overlap Technique: Should It Become the Standard Implantation Technique for Self-expanding Valves?

PURPOSE OF REVIEW

Accurate imaging of the aortic root during valve implantation is crucial for proper prosthesis positioning during TAVR. The purpose of this review was to determine if routine use of the cusp-overlap view should be adopted for self-expanding valves.

RECENT FINDINGS

The use of the cusp-overlap view with the Evolut, Portico, ACURATE neo/neo2, and JenaValve systems is associated with lower post-procedural new permanent pacemaker implantation rates when compared with the standard 3-cusp view, presumably due to more precise valve implantation relative to the conduction system by the non-coronary cusp. By elongating the left ventricular outflow tract and accentuating the right-non commissure in the center of the fluoroscopic view, the cusp-overlap technique allows operators to more precisely control the prosthesis implant depth during self-expanding valve deployment. While the early experience with this approach in Evolut TAVR has been promising, the results of larger studies with longer follow-up across multiple self-expanding systems are warranted.

Pushing the limits for interventional treatment of aortic valve stenosis

As we approach 20 years of clinical experience with transcatheter aortic valve replacement (TAVR), a vast portfolio of high-quality clinical data has accumulated, confirming the safety and efficacy of TAVR across the entire spectrum of surgical risk. Although many aspects of this innovative therapy have been thoroughly studied, several challenges remain. As TAVR is expanding to include younger low-risk patients, with longer life expectancy, one major unsolved issue is represented by transcatheter heart valve (THV) durability, since robust THV durability data are currently limited to approximately 5-6 years. Additionally, steric interactions between THV components and coronary ostia may render coronary access particularly difficult, and thus personalized decisions regarding THV type and implanting techniques are of paramount importance to secure future coronary access. Since bicuspid aortic valve (BAV) stenosis may be associated with unfavorable anatomic factors, it has represented an exclusion criterion in major randomized TAVR trials. Albeit promising data are available from multicenter registries, results of specifically designed randomized trials are eagerly needed to inform use of TAVR for BAV stenosis. Although valve-in-valve (ViV) TAVR has emerged as an effective treatment option for degenerated aortic bioprostheses, ViV procedures are associated with specific risks, which mandated the development of specific techniques aimed at reducing the occurrence of periprocedural adverse events. Despite the transfemoral approach represents the access of choice for TAVR, a significant proportion of patients have significant peripheral artery disease and alternative vascular access routes have been increasingly evaluated with encouraging data regarding their safety and feasibility.

In-hospital outcomes and predictors of paravalvular leak and deep implantation with the Evolut-R 34 mm device: A comparison with smaller Evolut-R sizes

PURPOSE

To compare in-hospital outcome of Evolut-R 34 mm vs. smaller Evolut-R devices and to identify predictors of paravalvular leak (PVL) and deep implantation specific for Evolut-R 34 mm.

METHODS

This single-center retrospective study included 359 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with Evolut-R 34 mm (N = 84,23.4%) and Evolut-R 23/26/29 mm (N = 275,76.6%) between 2016 and 2019.

RESULTS

Patients in Evolut-R 34 mm group were more frequently males, had lower STS score, ejection fraction, and mean aortic gradient compared to the Evolut-R 23/26/29 mm group. Horizontal aorta and large LVOT were more frequent findings in the Evolut-R 34 mm group, whereas calcium volume was comparable among the groups. During TAVR, mean implantation depth and contrast volume were greater in the Evolut-R 34 mm group, compared to the Evolut 23/26/29 mm group. Post-procedurally, 30-day mortality, ≥moderate PVL, device success and pacemaker implantation (PM) rates were comparable between groups. Among independent predictors of ≥moderate PVL, calcium volume (OR:1.04; p < 0.001) was predictive with different thresholds in both groups, whereas aortic angulation (OR:1.40; p = 0.005) was predictive only in Evolut-R 34 mm group at a cutoff of 60° (AUC:0.73; p = 0.043). Body weight (OR:1.03; p = 0.027), left ventricular outflow tract (LVOT) diameter (OR:1.34; p = 0.001), and mean aortic gradient (OR:0.96; p = 0.006) were independent predictors of deep implantation (mean depth ≥ 6 mm), with LVOT>27 mm being predictive specifically for Evolut-R 34 mm (AUC:0.66; p = 0.024).

CONCLUSIONS

TAVR with Evolut-R 34 mm and Evolut-R 23/26/29 mm showed comparable in-hospital outcome. Aortic angulation >60° and LVOT >27 mm were predictive respectively of ≥moderate PVL and deep implantation specifically in Evolut-R 34 mm patients.

New Challenging Scenarios in Transcatheter Aortic Valve Implantation: Valve-in-valve, Bicuspid and Native Aortic Regurgitation

Transcatheter aortic valve implantation (TAVI) is the most frequently performed structural technique in the field of interventional cardiology. Initially, this procedure was only used in patients with severe symptomatic aortic stenosis and prohibitive risk. Now, barely one decade after its introduction, TAVI indications extend to low- and intermediate-risk patients. Despite these advances, several challenging scenarios are still on the periphery of the evidence base for TAVI. These include valve-in-valve procedures, lower-risk patients with bicuspid aortic valve and the treatment of pure aortic regurgitation. Whereas the valve-in-valve indication has expanded rapidly, evidence for the use of TAVI compared with conventional surgery for bicuspid aortic valve is limited, including the best choice of device should TAVI be used. Evidence for TAVI in pure aortic regurgitation is still anecdotal because of suboptimal outcomes. Operators worldwide have described variations in the TAVI procedural technique to achieve commissural alignment and to minimise the rate of pacemaker use through cusp overlap implantation. In light of the potential clinical benefits, this may also be an area of further development. This review aims to discuss the current evidence available supporting the use of TAVI for these new indications.