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Published on: June 3, 2018
Commissural vs Coronary Alignment to Avoid Coronary Overlap With THV-Commissure in TAVR: A CT-Simulation Study
Manish Vinayak1, Gilbert H L Tang2, Keva Li2
1Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. Electronic address: https://twitter.com/manishvinayak.
Insights
Coronary alignment in transcatheter aortic valve replacement (TAVR) rarely causes overlap. Commissural alignment is generally preferred, though coronary alignment can reduce right coronary overlap.
Area of Science:
- Cardiovascular Imaging and Intervention
- Structural Heart Disease
- Transcatheter Aortic Valve Replacement
Background:
- Coronary alignment is a proposed alternative to commissural alignment to minimize coronary overlap during transcatheter aortic valve replacement (TAVR).
- Large-scale studies evaluating the incidence of coronary overlap with different alignment strategies are limited.
Purpose of the Study:
- To compare the incidence of coronary overlap between commissural and coronary alignment techniques.
- To utilize computed tomography (CT) simulation for assessing coronary overlap in patients undergoing TAVR evaluation.
Main Methods:
- Analysis of 1,851 CT scans from patients with native aortic stenosis evaluated for TAVR.
- Virtual valve implantation simulating both commissural and coronary alignment on axial aortic root images.
- Assessment of coronary overlap based on the angular gap between coronary artery origins and the nearest TAVR commissure.
Main Results:
- Moderate/severe coronary overlap was rare for both alignment techniques (coronary: 0.52% left, 0.52% right; commissural: 0.30% left, 3.27% right).
- Coronary alignment significantly reduced moderate/severe overlap for the right coronary artery (0.38% vs. 2.97%; P < 0.0001).
- Commissural alignment demonstrated higher no-overlap rates for the left coronary artery (91.1% vs. 84.9%; P < 0.0001).
Conclusions:
- Commissural alignment is associated with a rare incidence of coronary overlap during TAVR.
- Coronary alignment offers a benefit for reducing right coronary overlap but not left coronary overlap.
- Coronary alignment should be considered primarily when commissural alignment leads to severe coronary overlap.
Background:
Coronary alignment is proposed as an alternative to commissural alignment for reducing coronary overlap during transcatheter aortic valve replacement (TAVR). However, largescale studies are lacking.
Objectives:
This study aimed to determine the incidence of coronary overlap with commissural vs coronary alignment using computed tomography (CT) simulation in patients undergoing TAVR evaluation.
Methods:
In 1,851 CT scans of native aortic stenosis patients undergoing TAVR evaluation (April 2018 to December 2022),virtual valves simulating commissural and coronary alignment were superimposed on axial aortic root images. Coronary overlap was assessed based on the angular gap between coronary artery origin and the nearest transcatheter heart valve commissure, categorized as severe (≤15°), moderate (15°-30°), mild (30°-45°), and no-overlap (45°-60°).
Results:
The overall incidence of moderate/severe and severe overlap with either coronary artery remained rare with either coronary or commissural alignment (coronary 0.52% left, 0.52% right; commissural 0.30% left, 3.27% right). Comparing techniques, coronary alignment reduced moderate/severe overlap only for the right coronary artery (0.38% vs 2.97%; P <0.0001). For the left coronary artery, both techniques showed similar moderate/severe overlap, but commissural alignment had significantly higher no-overlap rates (91.1% vs 84.9%; P < 0.0001). Fluoroscopic angle during valve deployment was strongly correlated between commissural and coronary alignment (r = 0.80; P < 0.001).
Conclusions:
Using CT simulation, the incidence of coronary overlap with transcatheter heart valve-commissure is rare with commissural alignment. Coronary alignment reduced right coronary overlap, whereas commissural alignment had higher rates of no left coronary overlap. Coronary alignment should be reserved only when commissural alignment results in severe coronary overlap.
