Patient-Specific Strategy for Coronary Alignment in TAVI With Evolut FX

Coronary access after transcatheter aortic valve implantation (TAVI) is an increasingly relevant issue, particularly in patients who may require future coronary interventions or redo-TAVI procedures. Although commissural alignment is routinely achieved in surgical valve replacement, it remains challenging during TAVI because of anatomical variability and reliance on two-dimensional fluoroscopic guidance. Moreover, optimal commissural alignment does not necessarily ensure adequate coronary alignment, as the spatial relationship between native commissures and coronary ostia varies substantially among individuals. This work describes a patient-specific, CT- and fluoroscopy-guided strategy to optimize coronary alignment during TAVI using the Evolut FX+ platform. The proposed approach integrates systematic pre-procedural CT analysis of coronary ostial position, intercoronary angle, and valve geometry with the identification of a customized fluoroscopic implantation view, termed the Coronary Customized Projection. This projection is applied during valve deployment to guide valve orientation and enable mono-coronary or bi-coronary alignment according to individual anatomy. The strategy enhances procedural control and aims to preserve coronary access without increasing procedural complexity. Prospective studies are warranted to evaluate its impact on coronary reaccess and long-term clinical outcomes.