Coronary Access After Transcatheter Aortic Valve Replacement With Commissural Alignment: The ALIGN-ACCESS Study

Area of Science:

• Cardiology
• Interventional Cardiology
• Medical Devices

Background:

• Coronary access (CA) post-transcatheter aortic valve replacement (TAVR) is challenging with supra-annular transcatheter heart valves (THVs).
• Specific THV orientations can reduce neo-commissure overlap with coronary ostia.
• SAPIEN 3 THV orientation cannot be adjusted, unlike Evolut R/Pro and Acurate Neo THVs.

Purpose of the Study:

• To investigate the impact of commissural alignment on the feasibility of coronary access after TAVR.
• To compare coronary access success rates between different THV types and orientations.

Main Methods:

• Coronary angiography was performed post-TAVR in 206 patients with SAPIEN 3, Evolut R/Pro, and Acurate Neo THVs.
• Evolut THVs were implanted aiming for commissure alignment; Acurate Neo alignment was assessed retrospectively and intentionally attempted.
• The primary endpoint was the rate of unfeasible and nonselective CA after TAVR.

Main Results:

• Selective CA was higher for SAPIEN 3 (95%) than aligned (71%) and misaligned (46%) supra-annular THVs (P<0.001).
• Unfeasible CA occurred in 11% of misaligned supra-annular, 3% of aligned supra-annular, and 0% of SAPIEN 3 THVs.
• Independent predictors of impaired CA included misaligned supra-annular THV, low sinus of Valsalva height, and higher THV-sinus of Valsalva relation.

Conclusions:

• Commissural alignment enhances selective CA after TAVR with supra-annular THVs.
• Aligned supra-annular THVs present a greater risk of unfeasible/nonselective CA than SAPIEN 3.
• Patients with misaligned supra-annular THVs, low sinus of Valsalva, and specific THV-sinus relations face the highest risk of impaired CA.