Commissural Misalignment Following Valve-in-Valve Transcatheter Aortic Valve Implantation

Data on commissural misalignment (CMA) during valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for valve failure after surgical aortic valve replacement (SAVR) is scarce.

To study the impact of CMA on clinical and hemodynamic outcomes following ViV-TAVI for failed SAVR.

Data of patients who underwent ViV-TAVI for failed SAVR valves at two institutions (Heart Center Leipzig at Leipzig University, Leipzig, Germany; Cedars-Sinai Smidt Heart Institute, Los Angeles, USA) were retrospectively collected and compared regarding the existence of CMA. Outcomes of interest included Valve Academic Research Consortium (VARC)-3-based clinical endpoints, Computed Tomography-based hypoattenuated leaflet thickening (HALT), hemodynamic outcome, and mid-term all-cause mortality.

Of the 687 patients who underwent ViV-TAVI, post-procedural CT of sufficient quality to measure commissural alignment was available in 180 patients (47.8% females, mean age 78.0 years). Self-expanding TAVI valves were used in 49.2% of the cases. CMA was found in 35 individuals (19.4%) and was associated with reduced VARC-3-based technical success (80% vs. 93%, p = 0.03), driven by increased rates of coronary obstruction (17.1% vs. 5.6%, p = 0.03). The incidence of HALT was 31.7%, without differences in patients with and without CMA. VARC-3-based device success was 62.9%, driven by an incidence of residual mean valve gradient (≥ 20 mmHg) of 35.4%, without differences between groups. Midterm survival after a mean of 747 days was 84.6% and comparable between groups.

For patients undergoing ViV-TAVI for failed SAVR, technical success is reduced for cases of CMA due to higher odds of coronary obstruction, without differences in mid-term survival.