A Novel Method of Assessing Commissural Alignment for the SAPIEN 3 Transcatheter Aortic Valve

Redo-Transcatheter Aortic Valve Replacement Procedural Optimization and Patient Selection: From Bench to Clinical Practice

With recent guidelines expanding transcatheter aortic valve replacement (TAVR) to younger patients, indications for redo-TAVR will also likely increase. When compared with TAVR, redo-TAVR is a rare and novel procedure. Current clinical data derived from registries suggest excellent safety, with low rates of 30-day and 1-year mortality following redo-TAVR. Proper understanding of data from bench studies regarding optimal valve configurations, of patient anatomy and of the technical properties of transcatheter heart valves (THV) is essential for patient selection and procedural success. Lifetime management of redo-TAVR should start before the index procedure, as the choice of the index THV has a major impact on the feasibility of redo-TAVR. Procedural optimization by adequate valve sizing, commissural alignment and adequate implant depth of both index and redo-THV are critical determinants of optimal hemodynamics for maximized valve longevity, as well as lifelong coronary access.

The Incidence, Impact, and Techniques of Commissural Alignment in Transcatheter Aortic Valve Implantation: A Review

In current clinical practice, commissural alignment of the transcatheter heart valve (THV) during transcatheter aortic valve implantation (TAVI) is seldom achieved. Orientation of the THV within the aortic root and the subsequent influence upon leaflet haemodynamic function, coronary blood flow, and ease of access to the coronary ostia are gaining significant interest. Herein, we review the incidence and clinical implications of commissural misalignment in TAVI and offer thorough descriptions of how optimal alignment can be achieved with several different contemporary THV devices.

Comparison of the New-Generation Self-Expanding NAVITOR Transcatheter Heart Valve with Its Predecessor, the PORTICO, in Severe Native Aortic Valve Stenosis

BACKGROUND

Third-generation transcatheter heart valves (THVs) are designed to improve outcomes. Data on the new intra-annular self-expanding NAVITOR are scarce.

AIMS

The aim of this analysis was to compare outcomes between the PORTICO and the NAVITOR systems.

METHODS

Data from 782 patients with severe native aortic stenosis treated with PORTICO (n = 645) or NAVITOR (n = 137) from 05/2012 to 09/2022 were evaluated. The clinical and hemodynamic outcomes of 276 patients (PORTICO, n = 139; NAVITOR, n = 137) were evaluated according to VARC-3 recommendations.

RESULTS

Rates of postprocedural more-than-mild paravalvular leakage (PVL) were significantly lower for NAVITOR than for PORTICO (7.2% vs. 1.5%, p = 0.041). In addition, severe bleeding rates (27.3% vs. 13.1%, p = 0.005) and major vascular complications (5.8% vs. 0.7%, p = 0.036) were lower in the NAVITOR group. The mean gradients (7 vs. 8 mmHg, p = 0.121) and calculated aortic valve areas (1.90 cm² vs. 1.99 cm², p = 0.235) were comparable. Rates of PPI were similarly high in both groups (15.3 vs. 21.6, p = 0.299).

CONCLUSIONS

The NAVITOR demonstrated favorable in-hospital procedural outcome data, with lower rates of relevant PVL, major vascular complications, and severe bleeding than its predecessor the PORTICO and preserved favorable hemodynamic outcomes.

Commissural Alignment and Coronary Access after Transcatheter Aortic Valve Replacement

Transcatheter aortic valve implantation (TAVR) is the first therapeutic option for elderly patients with severe symptomatic aortic stenosis, and indications are steadily expanding to younger patients and subjects with lower surgical risk and longer life expectancy. Commissural alignment between native and transcatheter valves facilitates coronary access after TAVR and is thus considered a procedural goal, allowing long-term management of coronary artery disease. Moreover, commissural alignment may potentially have a positive impact on transvalvular hemodynamic and valve durability. This review focus on technical hints to achieve commissural alignment and current evidence for different transcatheter aortic valves.

Transcatheter heart valve commissural alignment: an updated review

Transcatheter aortic valve replacement (TAVR) indications recently extended to lower surgical risk patients with longer life expectancy. Commissural alignment (CA) is one of the emerging concepts and is becoming one of the cornerstones of the TAVR procedure in a patient with increased longevity. Indeed, CA may improve transcatheter heart valve (THV) hemodynamics, future coronary access, and repeatability. The definition of CA has been recently standardized by the ALIGN-TAVR consortium using a four-tier scale based on CT analysis. Progress has been made during the index TAVR procedure to optimize CA, especially with self-expandable platforms. Indeed, specific delivery catheter orientation, THV rotation, and computed-tomography-derived views have been proposed to achieve a reasonable degree of CA. Recent data demonstrate feasibility, safety, and a significant reduction in coronary overlap using these techniques, especially with self-expandable platforms. This review provides an overview of THV CA including assessment methods, alignment techniques during the index TAVR procedure with different THV platforms, the clinical impact of commissural misalignment, and challenging situations for CA.

Quantification of Commissural Alignment of Balloon-Expandable THV on Fluoroscopy: A Comparison Study With Post-TAVR CT

BACKGROUND

Coronary access may be challenging following transcatheter aortic valve replacement (TAVR) in the setting of transcatheter heart valve (THV) commissural misalignment.

OBJECTIVES

The authors aimed to quantify the degree of commissural alignment following balloon-expandable THV implantation using a fluoroscopy-based trigonometric approach and assess its correlation with post-TAVR computed tomography (CT).

METHODS

Twenty patients who had undergone both TAVR with the balloon-expandable SAPIEN 3 THV and post-TAVR CT were included in the analysis. Optimized, predeployment 3-cusp angiographic view and postdeployment angiographic view using identical fluoroscopic projections were required. The distance between the most central posterior commissural strut and the THV centerline was assessed. Commissural alignment was calculated by means of a trigonometrical approach using an arcsine function, assuming circular deployment of the THV. Commissural alignment was stratified using a 4-tier scale: aligned (0° to 15°); mildly misaligned (15° to 30°); moderately misaligned (30° to 45°), and severely misaligned (45° to 60°).

RESULTS

Seven patients (35.0%) were misclassified by 1 tier, and no patient was misclassified by 2 or more tiers, with strong agreement between CT and fluoroscopy (weighted Cohen's kappa coefficient = 0.724). Correlation of the commissural offset angle determined from fluoroscopy and CT was excellent (r = 0.986; 95% CI: 0.965 to 0.995). Bland-Altman analysis demonstrated a strong agreement between both modalities with a mean difference of 0.5° (95% limits of agreement: -12.7° to 13.7°).

CONCLUSIONS

The degree of commissural alignment of the balloon-expandable THV can be reliably assessed and quantified on postdeployment fluoroscopy using a standardized 3-cusp view and trigonometry-based analysis.