Commissural Versus Coronary Optimized Alignment During Transcatheter Aortic Valve Replacement.

Area of Science:

• Cardiovascular Imaging and Interventions
• Structural Heart Disease
• Transcatheter Aortic Valve Replacement (TAVR)

Background:

• Commissural alignment in TAVR aims to reduce coronary overlap (CO) risk.
• However, non-centered coronary ostia can lead to CO even with perfect commissural alignment.

Purpose of the Study:

• To determine the incidence of non-centered coronary ostia and their associated CO risk.
• To develop an improved TAVR device orientation strategy using anatomical cues to predict CO risk.
• To compute an alternative, CO-free TAVR rotation angle for at-risk patients.

Main Methods:

• Baseline computed tomography (CT) scans of TAVR candidates were analyzed.
• Distances from commissures to coronary arteries (RCA and LCA) were measured.
• Virtual valve simulations assessed CO degree under different alignment strategies (commissural vs. coronary).
• Patients were stratified into risk groups (no, moderate, severe CO) based on angular measurements.

Main Results:

• Of 100 analyzed patients, 32 faced moderate to severe CO risk despite ideal commissural alignment.
• Right coronary artery (RCA) ostia showed greater eccentricity than left coronary artery (LCA) ostia.
• Increased coronary eccentricity and specific intercoronary angles were significant predictors of CO risk.
• Simulated optimal coronary alignment prevented severe CO and reduced moderate CO risk from 27% to 5%.

Conclusions:

• A significant proportion of patients (one-third) remain at risk for CO during TAVR-in-TAVR, even with commissural alignment.
• Optimized coronary alignment strategies can decrease CO risk by six-fold.
• Coronary eccentricity and intercoronary angle are key predictors for identifying patients at risk of CO.