A Proposed Anatomical-Fluoroscopic Workflow to Identify the Optimal Split Line for Leaflet Modification in Redo-TAVR

The optimal leaflet modification strategy in redo transcatheter aortic valve replacement (TAVR) needs further refinement.

The aims of this study were to clarify the anatomical relationship between transcatheter aortic valve leaflets and related structures by assessing leaflet suture lines, nodes, and commissural tabs and to propose a workflow to guide leaflet modification in redo-TAVR.

The leaflet suture line and its relationship with nodes and commissural posts on the frames of SAPIEN 3, Evolut, Navitor, and ACURATE neo2 transcatheter aortic valves were identified. Leaflet regions were classified as modifiable, challenging, or nonmodifiable. Vertical leaflet split lines within the modifiable zone were proposed, and the lowest node along each split line was identified as a fluoroscopic landmark to guide leaflet modification. Preprocedural computed tomography helped determine the relationship between commissural orientation and coronary ostia to identify ideal split line(s) in proximity to the ostia to avoid obstruction.

For each valve type, the leaflet suture line and its relationship to commissural posts and valve frame were visible at multiple perspectives. The number and respective lengths of proposed split lines were identified (SAPIEN 3, A-D, 6.0-16.0 mm; Evolut, A-E, 5.0-13.0 mm; Navitor, A-C, 10.0-23.0 mm; and ACURATE neo2, A-D, 7.0-18.0 mm). Preprocedural computed tomography identified the ideal split line(s) facing the coronary ostia. A 4-step workflow to guide leaflet modification in redo-TAVR was proposed.

The authors propose a systematic, imaging-guided approach to leaflet modification in redo-TAVR. Further studies are ongoing to evaluate and validate its feasibility and effectiveness.