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Published on: June 3, 2018
Impact of commissural alignment on the hemodynamic performance of supra-annular self-expandable transcatheter aortic
Ignacio J Amat-Santos1,2, Javier Gómez-Herrero1, Pablo Pinon3
1Cardiology Department, University Clinic Hospital, Valladolid, Spain.
Insights
Commissural alignment (CA) strategies reduced commissural misalignment in self-expandable transcatheter aortic valve replacement (TAVR), leading to lower transvalvular gradients and regurgitation progression at one year.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Biomedical Engineering
Background:
- The hemodynamic impact of commissural alignment (CA) in self-expandable transcatheter aortic valve replacement (TAVR) remains under-investigated.
- Optimizing TAVR prosthesis deployment is crucial for long-term hemodynamic performance.
Purpose of the Study:
- To evaluate the hemodynamic consequences of commissural alignment (CA) strategies during self-expandable TAVR.
- To assess the impact of CA on transvalvular gradients and regurgitation post-TAVR.
Main Methods:
- A multicentric ambispective study compared patients receiving Evolut Pro/Pro+ (EP) and Acurate neo2 (AN2) TAVR with or without CA strategies.
- Commissural misalignment (CMA) was quantified using CT/angiography, and 1-year hemodynamic outcomes (gradients, regurgitation) were assessed via echocardiography.
- Matched comparisons were performed based on annular dimensions, prosthesis characteristics, and baseline patient data.
Main Results:
- CA strategies successfully reduced the incidence of moderate/severe commissural misalignment (CMA) compared to no CA (73.5% vs. 43.6%).
- Patients with moderate/severe CMA exhibited higher peak and mean transvalvular gradients at 1-year post-TAVR.
- A higher rate of central aortic regurgitation was observed in patients with moderate/severe CMA, though structural deterioration criteria were not met.
Conclusions:
- Commissural alignment strategies effectively minimize commissural misalignment in self-expandable TAVR devices (AN2 and EP).
- Reduced CMA is associated with favorable 1-year hemodynamic outcomes, including lower transvalvular gradients and less intra-prosthetic regurgitation progression.
- CA strategies appear beneficial for optimizing TAVR hemodynamic performance without immediate signs of structural valve deterioration.
Background:
Hemodynamic impact of commissural alignment (CA) with self-expandable transcatheter aortic valves (TAVR) has not been investigated yet.
Aims:
To determine hemodynamic impact of CA with self-expandable TAVR.
Methods:
Multicentric ambispective study comparing patients who underwent self-expandable TAVR in seven centers with the Evolut Pro/Pro+ (EP) (Medtronic) and Acurate neo2 (AN2) (Boston Scientific) with and without CA strategies. The degree of commissural misalignment (CMA) was assessed by computed tomography/angiography and 1-year transvalvular gradients/regurgitation evaluated by echocardiography. A matched comparison according to annular dimensions/eccentricity, prosthesis size/type, and baseline left ventricular function and gradients was performed.
Results:
A total of 557 patients, mean age 80.7 ± 6.6 years, 61.4% men, and STS score of 4.3 ± 3.1% were analyzed. A CA technique was attempted in 215 patients (38.6%), including 113 patients with AN2 and 102 patients with EP. None/mild CMA was found in 158 (73.5% vs. 43.6% if no CA attempted, p < 0.001) with no differences between devices (AN2:75.2%; EP:71.6%, p = 0.545). Patients with moderate/severe CMA had a greater aortic peak gradient (22.3 ± 8.7 vs. 19.7 ± 8.5, p = 0.001), significantly greater progression of both peak (p = 0.002) and mean gradients (p = 0.001) after matching, and higher rate of central aortic regurgitation (1.2% vs. 0.4%, p = 0.005) at 1-year, but not a greater proportion of patients with mean gradient ≥ 10 mmHg.
Conclusions:
The use of CA strategies significantly reduced the rate of CMA for the self-expandable TAVR devices ACN2 and EP which was associated to lower transvalvular gradients and intra-prosthetic regurgitation progression at 1-year although no criteria of structural deterioration were met at this follow up.
Clinicaltrials:
org: NCT05097183.
