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Pavitt C, Arunothayaraj S, Broyd C, Michail M, Cockburn J, Hildick-Smith D. Impact of commissural versus coronary alignment on risk of coronary obstruction following transcatheter aortic valve implantation. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03142-7. [PMID: 38795237 DOI: 10.1007/s10554-024-03142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 05/13/2024] [Indexed: 05/27/2024]
Abstract
Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.
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Affiliation(s)
- Christopher Pavitt
- Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England.
| | - Sandeep Arunothayaraj
- Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England
| | - Christopher Broyd
- Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England
| | - Michael Michail
- Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England
| | - James Cockburn
- Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England
| | - David Hildick-Smith
- Sussex Cardiac Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BE, England
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Moscarelli M, Sollami G, Lentini E, Prestera R, Pernice V, Milo S, Violante F, Cuffari F, Di Pasquale C, Ferlisi A, La Grutta L, Grassedonio E, Speziale G, Fattouch K. About different localization of hypoattenuated lesions following transcatheter aortic valve replacement. Int J Cardiol 2024; 398:131597. [PMID: 37979790 DOI: 10.1016/j.ijcard.2023.131597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Subclinical leaflet thrombosis is diagnosed using multidetector computed tomography (MDCT) and is characterised by a meniscal-shaped hypoattenuated lesion of one or more leaflets. Transcatheter aortic self-expandable valves are commonly manufactured with pliable pericardium over a nitinol frame that forms leaflet and extra-leaflet components such as the valve skirt. Little is known about extra-leaflet hypoattenuated lesion localisation, including that at the anatomical sinus level. Thus, the main aim of this study was to describe leaflet and extra-leaflet (anatomic sinus and subvalvular level) hypoattenuated lesions following transcatheter aortic valve replacement with a self-expandable prosthesis. As a secondary aim, we sought to investigate predictors of hypoattenuated lesions. METHODS Fifty patients underwent MDCT at the follow-up. RESULTS At a follow-up of 12 months, hypoattenuated leaflet lesions with mild to severe restricted movement were detected in eight individuals (16%), anatomic sinus lesions were identified in nine patients (18%), with higher prevalence in the non-coronary sinus (16%), and subvalvular lesions with variable extension toward the valve inflow were diagnosed in eight patients (16%). In 4 patients (8%) the anatomic sinus thrombus was 'in overlap' with leaflet thrombus; in 3 patients (6%) was in continuity with subvalvular frame thrombus. Bicuspid valve was the only independent predictor associated with hypoattenuated lesions (adj OR 8.25 (95% CI: 1.38, 49.21), p = 0.02)). CONCLUSIONS This study demonstrated that hypoattenuated lesions could be identified not only at the leaflet but also at the subvalvular and anatomic sinus levels. The clinical relevance of such lesions remains unclear.
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Affiliation(s)
- Marco Moscarelli
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy.
| | - Giulia Sollami
- Dept. of Radiology, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Emanuele Lentini
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Rosa Prestera
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Vincenzo Pernice
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Sabrina Milo
- Dept. of Radiology, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Francesco Violante
- Dept. of Radiology, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Federico Cuffari
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Claudia Di Pasquale
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Angelo Ferlisi
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy
| | - Ludovico La Grutta
- Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Emanuele Grassedonio
- Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giuseppe Speziale
- Dept. of Cardiovascular Surgery, Anthea Hospital, GVM Care&Research, Bari, Italy
| | - Khalil Fattouch
- Dept. of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care&Research, Palermo, Italy; University of Palermo, DICHIRONS, Palermo, Italy
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Vinayak M, Tang GHL, Li K, Berdan M, Koshy AN, Khera S, Lerakis S, Dangas GD, Sharma SK, Kini AS, Krishnamoorthy P. Commissural vs Coronary Alignment to Avoid Coronary Overlap With THV-Commissure in TAVR: A CT-Simulation Study. JACC Cardiovasc Interv 2024:S1936-8798(24)00076-1. [PMID: 38456886 DOI: 10.1016/j.jcin.2024.01.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Manish Vinayak
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. https://twitter.com/manishvinayak
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA.
| | - Keva Li
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Megan Berdan
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Anoop N Koshy
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA; The Royal Melbourne Hospital & The University of Melbourne, Victoria, Australia. https://twitter.com/DrAnoop_Koshy
| | - Sahil Khera
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. https://twitter.com/Khera_MD
| | | | - George D Dangas
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. https://twitter.com/georgedangas
| | - Samin K Sharma
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA
| | - Annapoorna S Kini
- Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. https://twitter.com/DoctorKini
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Jung S, Ammon F, Smolka S, Moshage M, Marwan M, Achenbach S. Commissural misalignment independently predicts leaflet thrombosis after transcatheter aortic valve implantation. Clin Res Cardiol 2024; 113:29-37. [PMID: 37022472 PMCID: PMC10808532 DOI: 10.1007/s00392-023-02192-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/24/2023] [Indexed: 04/07/2023]
Abstract
AIMS Transcatheter aortic valve implantation (TAVI) has become a minimally invasive alternative to surgical aortic valve replacement. Hypo-attenuated leaflet thickening (HALT)-a marker of subclinical leaflet thrombosis commonly detected by cardiac computed tomography (CT) after TAVI-may influence valve durability and function. The purpose of this study was to compare commissural alignment of the native and prosthetic aortic valves in cardiac CT in subjects with and without HALT and thereby identify commissural misalignment as potential predictor for leaflet thrombosis after TAVI. METHODS AND RESULTS In 170 subjects, 85 with and 85 without HALT in post-TAVI CT, commissural orientation of the prosthesis was determined comparing native and prosthetic aortic valve orientation in cardiac CT by measuring the commissural angle relative to the right coronary ostium in the aortic valve plane. For the prosthetic valve, any deviation ≤ 15° compared to the native valve was classified as "aligned"; 16-30° as "mild", 31-45° as "moderate" and ≥ 45° as "severe" misalignment. Among subjects with HALT, median angular deviation was higher (36°, IQR 31°) than in the control group (29°, IQR 29°, p = 0.042). "Severe" misalignment was more frequent in subjects who developed HALT (n = 31, 37%) compared to the control group (n = 17, 20%, p = 0.013). In logistic regression analysis, more severe deviation (p = 0.015, OR = 1.02 per 1° deviation) and "severe" misalignment (p = 0.018, OR = 2.2) represented independent predictors for the occurrence of HALT after TAVI. CONCLUSION Subclinical leaflet thrombosis after TAVI is associated with commissural misalignment. Potential clinical advantages of obtaining commissural alignment remain to be systematically assessed.
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Affiliation(s)
- Susanne Jung
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany.
| | - Fabian Ammon
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Silvia Smolka
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Maximilian Moshage
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
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Mosquera VX, Muinelo-Paul A, Pato-López O, Bouzas-Mosquera A, Cuenca-Castillo JJ. Clinical and structural outcomes of neocommissural alignment in transaxillary and transcarotid transcatheter aortic valve implantation with a self-expandable transcatheter heart valve. JTCVS Tech 2023; 22:150-158. [PMID: 38152173 PMCID: PMC10750428 DOI: 10.1016/j.xjtc.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/09/2023] [Accepted: 06/29/2023] [Indexed: 12/29/2023] Open
Abstract
Objectives This study analyzes neocommissural alignment and the clinical and hemodynamic outcomes after transaxillary and transcarotid implantation of the Acurate neo2 transcatheter heart valve. Methods We performed a retrospective, single-center analysis of early outcomes after transaxillary and transcarotid implantation of the Acurate neo2 transcatheter heart valve. Primary outcomes were neocommisural alignment, in-hospital mortality, and valve hemodynamic performance. Commissural alignment between native and transcatheter heart valves was assessed by transesophageal echocardiogram before and after the procedure. Results Between October 2021 and November 2022, 40 consecutive patients were treated with the Acurate neo2 through a transaxillary or transcarotid approach. Access was achieved via the left subclavian artery in 30 cases and the left common carotid artery in 10 cases, with a mean vessel diameter of 6.7 mm. Implants most commonly used were size M (37.5%), L (35%), and S (27.5%). On the basis of transesophageal echocardiogram analysis, there was no significant difference in mean commissural orientation between native (mean, 65.1°; SD, 41.3°) and neocommissures (mean, 64°; SD, 44.1°) (P = .661). Mean commissural orientation did not significantly differ between native and neocommissures (P = .661). Optimal alignment or mild commissural misalignment was achieved in 99.5% of cases. There were no cases of severe commissural misalignment. Postprocedural mean values for peak and mean gradients were 12.7 mm Hg and 5.2 mm Hg, respectively. There were 2 cases of moderate paravalvular leak and 4 cases of mild paravalvular leak. Conclusions This patient-specific technique for transaxillary and transcarotid insertion of the Acurate neo2 delivery system prevents implantations with more than mild commissural misalignment and with a high device success rate.
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Affiliation(s)
- Victor X. Mosquera
- Department of Cardiac Surgery, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
- Instituto de Investigación Biomédica de A Coruña (INIBIC), University of A Coruña, A Coruña, Spain
- University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Adrian Muinelo-Paul
- Department of Cardiac Surgery, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Oscar Pato-López
- Department of Anesthesiology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Alberto Bouzas-Mosquera
- Instituto de Investigación Biomédica de A Coruña (INIBIC), University of A Coruña, A Coruña, Spain
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - José J. Cuenca-Castillo
- Department of Cardiac Surgery, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
- Instituto de Investigación Biomédica de A Coruña (INIBIC), University of A Coruña, A Coruña, Spain
- University of Santiago de Compostela, Santiago de Compostela, Spain
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Oks D, Houzeaux G, Vázquez M, Neidlin M, Samaniego C. Effect of TAVR commissural alignment on coronary flow: A fluid-structure interaction analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 242:107818. [PMID: 37837886 DOI: 10.1016/j.cmpb.2023.107818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/07/2023] [Accepted: 09/15/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Coronary obstruction is a complication that may affect patients receiving Transcatheter Aortic Valve Replacement (TAVR), with catastrophic consequences and long-term negative effects. To enable healthy coronary perfusion, it is fundamental to appropriately position the device with respect to the coronary ostia. Nonetheless, most TAVR delivery systems do not control commissural alignment to do so. Moreover, no in silico study has directly assessed the effect of commissural alignment on coronary perfusion. This work aims to evaluate the effect of TAVR commissural alignment on coronary perfusion and device performance. METHODS A two-way computational fluid-structure interaction model is used to predict coronary perfusion at different commissural alignments. Moreover, in each scenario, hemodynamic biomarkers are evaluated to assess device performance. RESULTS Commissural misalignment is shown to reduce the total coronary perfusion by -3.2% and the flow rate to a single coronary branch by -6.8%. It is also observed to impair valvular function by reducing the systolic geometric orifice area by -2.5% and increasing the systolic transvalvular pressure gradients by +5.3% and the diastolic leaflet stresses by +16.0%. CONCLUSIONS The present TAVR patient model indicates that coronary perfusion, hemodynamic and structural performance are minimized when the prosthesis commissures are fully misaligned with the native ones. These results support the importance of enabling axial control in new TAVR delivery catheter systems and defining recommended values of commissural alignment in upcoming clinical treatment guidelines.
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Affiliation(s)
- David Oks
- Barcelona Supercomputing Center, Computer Applications in Science and Engineering, Plaça d'Eusebi Güell, 1-3, 08034, Barcelona, Spain; ELEM Biotech SL, Plaça Pau Vila, 1, Bloc A, Planta 3, Porta 3A1, 08003, Barcelona, Spain.
| | - Guillaume Houzeaux
- Barcelona Supercomputing Center, Computer Applications in Science and Engineering, Plaça d'Eusebi Güell, 1-3, 08034, Barcelona, Spain
| | - Mariano Vázquez
- Barcelona Supercomputing Center, Computer Applications in Science and Engineering, Plaça d'Eusebi Güell, 1-3, 08034, Barcelona, Spain; ELEM Biotech SL, Plaça Pau Vila, 1, Bloc A, Planta 3, Porta 3A1, 08003, Barcelona, Spain
| | - Michael Neidlin
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelstraße 20, 52074, Aachen, Germany
| | - Cristóbal Samaniego
- Barcelona Supercomputing Center, Computer Applications in Science and Engineering, Plaça d'Eusebi Güell, 1-3, 08034, Barcelona, Spain
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Moscarelli M, Sollami G, Lentini E, Prestera R, Pernice V, Violante F, Cuffari F, Pasquale CD, La Grutta L, Grassedonio E, Speziale G, Fattouch K. Self-Expandable Prosthesis Valve Adaptation: Non-Uniform Expansion and Stent Frame Decoupling. Am J Cardiol 2023; 207:93-99. [PMID: 37734306 DOI: 10.1016/j.amjcard.2023.08.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/20/2023] [Accepted: 08/20/2023] [Indexed: 09/23/2023]
Abstract
The incidence of non-uniform expansion in the context of the self-expandable transcatheter heart valve (THV) is little investigated, along with stent-frame decoupling, which is a form of stent adaptation, in which the lower part of the THV stent conforms to both the ellipticity of the left ventricle outflow tract and the native annulus while maintaining the higher part of the valve more circular. We analyzed post-implant multi-detector computed tomography scans in 50 patients. Prosthesis non-uniform expansion was assessed by computing the prosthesis eccentricity on 6 prespecified levels: (1) frame inflow, (2) native annulus, (3) leaflet inflow, (4) prosthesis waist, (5) leaflet outflow, and (6) frame outflow. Stent-frame decoupling was assessed by comparing the mean eccentricity on 6 different prosthesis levels. Implantation depth, leaflet expansion and alignment, and residual anatomic sinus area ratios were also calculated. Subclinical leaflet thrombosis was defined as hypoattenuated lesion of a meniscal shape. At a 12-month follow-up, non-uniform expansion was consistently detected at each valvular level. Highest eccentricity was measured at the native annulus level (eccentricity: 0.54 ± 0.12), while the lowest index at the frame outflow level (0.23 ± 0.11). Similar results were observed in the subgroup analyses of sizes 23, 26, 29, and 34. Eccentricity significantly decreased from the annulus level to the prosthesis frame outflow (p <0.001). Notably, the incidence of mild-to-severe subclinical leaflet thrombosis was relevant (16%). In conclusion, prosthesis non-uniform expansion and stent frame decoupling frequently occur after self-expandable THV replacement. The clinical and hemodynamic implications remain uncertain.
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Affiliation(s)
- Marco Moscarelli
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy.
| | - Giulia Sollami
- Departments of Radiology, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Emanuele Lentini
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Rosa Prestera
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Vincenzo Pernice
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Francesco Violante
- Departments of Radiology, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Federico Cuffari
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Claudia Di Pasquale
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Ludovico La Grutta
- Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Emanuele Grassedonio
- Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giuseppe Speziale
- Department of Cardiovascular Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Khalil Fattouch
- Departments of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy; Department of Surgical, Oncological and Stomatological Sciences (DICHIRONS), University of Palermo, Palermo, Italy
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Mylonas KS, Angouras DC. Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls. J Clin Med 2023; 12:7063. [PMID: 38002679 PMCID: PMC10672358 DOI: 10.3390/jcm12227063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.
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Affiliation(s)
| | - Dimitrios C. Angouras
- Department of Cardiac Surgery, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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Meier D, Tzimas G, Akodad M, Fournier S, Leipsic JA, Blanke P, Wood DA, Sellers SL, Webb JG, Sathananthan J. TAVR in TAVR: Where Are We in 2023 for Management of Failed TAVR Valves? Curr Cardiol Rep 2023; 25:1425-1431. [PMID: 37815660 DOI: 10.1007/s11886-023-01959-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE OF REVIEW As TAVR is increasingly performed on younger patients with a longer life expectancy, the number of redo-TAVR procedures is likely to increase in the coming years. Limited data is currently available on this sometimes challenging procedure. We provide a summary of currently published literature on management of patients with a failed transcatheter aortic valve. RECENT FINDINGS Recent registry data have increased the clinical knowledge on redo-TAVR. Additionally, numerous bench studies have provided valuable insights into the technical aspects of redo-TAVR with various combinations of valve types. Redo-TAVR can be performed safely in selected cases with a high procedural success and good short-term outcomes. However, at present, the procedure remains relatively infrequent and many patients are not eligible. Bench testing can be useful to understand important concepts such as valve expansion, neoskirt, leaflet overhang, and leaflet deflection as well as their potential clinical implications.
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Affiliation(s)
- David Meier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Cardiovascular Translational Laboratory, Providence Research & Centre for Heart Lung Innovation, Vancouver, Canada
| | - Georgios Tzimas
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mariama Akodad
- Ramsay Santé, Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques-Cartier, Massy, France
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jonathon A Leipsic
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada
- Cardiovascular Translational Laboratory, Providence Research & Centre for Heart Lung Innovation, Vancouver, Canada
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Philipp Blanke
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - David A Wood
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada
- Cardiovascular Translational Laboratory, Providence Research & Centre for Heart Lung Innovation, Vancouver, Canada
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Stephanie L Sellers
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada
- Cardiovascular Translational Laboratory, Providence Research & Centre for Heart Lung Innovation, Vancouver, Canada
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - John G Webb
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada
- Cardiovascular Translational Laboratory, Providence Research & Centre for Heart Lung Innovation, Vancouver, Canada
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada.
- Cardiovascular Translational Laboratory, Providence Research & Centre for Heart Lung Innovation, Vancouver, Canada.
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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10
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Revaiah PC, Jose J, Gunasekaran S, Mandalay A, Garg S, Bhatt S, Seth A, Soliman O, Onuma Y, Serruys PW. Neocommissural/Coronary Alignment With a Novel Balloon Expandable Transcatheter Aortic Valve: First-in-Human Experience. JACC Cardiovasc Interv 2023; 16:2581-2583. [PMID: 37737798 DOI: 10.1016/j.jcin.2023.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/12/2023] [Accepted: 07/11/2023] [Indexed: 09/23/2023]
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11
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Busto L, Veiga C, González-Nóvoa JA, Campanioni S, Juan-Salvadores P, Jiménez Díaz VA, Baz JA, Alba-Castro JL, Kütting M, Íñiguez A. Automatic Assessment of Transcatheter Aortic Valve Implantation Results on Four-Dimensional Computed Tomography Images Using Artificial Intelligence. Bioengineering (Basel) 2023; 10:1206. [PMID: 37892936 PMCID: PMC10604882 DOI: 10.3390/bioengineering10101206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is a procedure to treat severe aortic stenosis. There are several clinical concerns related to potential complications after the procedure, which demand the analysis of computerized tomography (CT) scans after TAVI to assess the implant's result. This work introduces a novel, fully automatic method for the analysis of post-TAVI 4D-CT scans to characterize the prosthesis and its relationship with the patient's anatomy. The method enables measurement extraction, including prosthesis volume, center of mass, cross-sectional area (CSA) along the prosthesis axis, and CSA difference between the aortic root and prosthesis, all the variables studied throughout the cardiac cycle. The method has been implemented and evaluated with a cohort of 13 patients with five different prosthesis models, successfully extracting all the measurements from each patient in an automatic way. For Allegra patients, the mean of the obtained inner volume values ranged from 10,798.20 mm3 to 18,172.35 mm3, and CSA in the maximum diameter plane varied from 396.35 mm2 to 485.34 mm2. The implantation of this new method could provide information of the important clinical value that would contribute to the improvement of TAVI, significantly reducing the time and effort invested by clinicians in the image interpretation process.
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Affiliation(s)
- Laura Busto
- Cardiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain; (L.B.); (J.A.G.-N.); (S.C.); (P.J.-S.)
| | - César Veiga
- Cardiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain; (L.B.); (J.A.G.-N.); (S.C.); (P.J.-S.)
| | - José A. González-Nóvoa
- Cardiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain; (L.B.); (J.A.G.-N.); (S.C.); (P.J.-S.)
| | - Silvia Campanioni
- Cardiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain; (L.B.); (J.A.G.-N.); (S.C.); (P.J.-S.)
| | - Pablo Juan-Salvadores
- Cardiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain; (L.B.); (J.A.G.-N.); (S.C.); (P.J.-S.)
| | - Víctor Alfonso Jiménez Díaz
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (SERGAS), Álvaro Cunqueiro Hospital, 36312 Vigo, Spain; (V.A.J.D.); (J.A.B.); (A.Í.)
| | - José Antonio Baz
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (SERGAS), Álvaro Cunqueiro Hospital, 36312 Vigo, Spain; (V.A.J.D.); (J.A.B.); (A.Í.)
| | - José Luis Alba-Castro
- atlanTTic Research Center for Telecommunication Technologies, University of Vigo, 36310 Vigo, Spain;
| | | | - Andrés Íñiguez
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (SERGAS), Álvaro Cunqueiro Hospital, 36312 Vigo, Spain; (V.A.J.D.); (J.A.B.); (A.Í.)
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12
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Konami Y, Sakamoto T, Suzuyama H, Horio E, Yamaguchi J. Commissural alignment in the Evolut TAVR procedure: conventional versus hat marker-guided shaft rotation methods. ASIAINTERVENTION 2023; 9:156-165. [PMID: 37736211 PMCID: PMC10507608 DOI: 10.4244/aij-d-23-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/20/2023] [Indexed: 09/23/2023]
Abstract
Background Coronary cannulation after TAVR is sometimes difficult due to an overlap between native and neo-commissures, especially in Evolut devices with a supra-annular position. The Evolut C-tab corresponds to a neo-commissure, and the hat marker is in a fixed position. Therefore, the orientation of the hat marker can be adjusted to minimise overlaps. Aims We investigated whether the HAt marker-guided SHaft rotation method (HASH, stylised as the #rotation method) is effective in facilitating coronary artery access after transcatheter aortic valve replacement (TAVR) with an Evolut system. Methods We retrospectively analysed 95 patients who underwent electrocardiogram-gated cardiac computed tomography after TAVR. In the #rotation method, the hat marker of the delivery catheter was adjusted to face the greater curvature of the descending thoracic aorta in the left anterior oblique view. Its orientation was maintained while the system passed through the aortic arch. Results In total, 60 and 35 patients underwent TAVR with the #rotation and non-#rotation methods, respectively. A ±15° angle between the native and neo-commissures was more frequent in the #rotation group (p=0.001). Favourable angles and appropriate frame orientation for access to the left coronary artery were significantly more frequent in the #rotation group than in the non-#rotation group (p<0.001 and p=0.001). Although the #rotation method showed a higher rate of favourable angles and frames in the right coronary artery, statistically significant differences were not found. Conclusions The #rotation method is useful for improving commissural post alignment in TAVR with Evolut devices, especially in the ostium of the left coronary artery.
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Affiliation(s)
- Yutaka Konami
- Division of Cardiology, Cardiovascular Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Cardiovascular Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hiroto Suzuyama
- Division of Cardiology, Cardiovascular Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Eiji Horio
- Division of Cardiology, Cardiovascular Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
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13
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Jaworek M, Gelpi G, Perico F, Romagnoni C, Tasca G, Salurso E, Contino M, Redaelli A, Fiore GB, Vismara R. Coronary Perfusion After Valve-in-Valve Transcatheter Aortic Valve Implantation in Small Aortic Root: In Vitro Experimental Assessment. J Cardiovasc Transl Res 2023; 16:956-967. [PMID: 37097591 PMCID: PMC10480284 DOI: 10.1007/s12265-023-10364-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/13/2023] [Indexed: 04/26/2023]
Abstract
Coronary flow obstruction following transcatheter aortic valve-in-valve implantation (VIV-TAVI) is associated with a high mortality risk. The aim of this work was to quantify the coronary perfusion after VIV-TAVI in a high-risk aortic root anatomy. 3D printed models of small aortic root were used to simulate the implantation of a TAVI prosthesis (Portico 23) into surgical prostheses (Trifecta 19 and 21). The aortic root models were tested in a pulsatile in vitro bench setup with a coronary perfusion simulator. The tests were performed at baseline and post-VIV-TAVI procedure in aligned and misaligned commissural configurations under simulated hemodynamic rest and exercise conditions. The experimental design provided highly controllable and repeatable flow and pressure conditions. The left and right coronary mean flow did not differ significantly at pre- and post-VIV-TAVI procedure in any tested configurations. The commissural misalignment did not induce any significant alterations to the coronary flow. High-risk aortic root anatomy did not trigger coronary ostia obstruction or coronary flow alteration after transcatheter aortic valve implantation in a surgical bioprosthesis as shown from in-vitro flow loop tests.
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Affiliation(s)
- Michal Jaworek
- Department of Electronics, Information and Bioengineering, Politecnico Di Milano, Via Golgi 39, 20133 Milan, Italy
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Guido Gelpi
- Cardiac Surgery Unit, Fondazione IRCCS Ca’ Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Perico
- Department of Electronics, Information and Bioengineering, Politecnico Di Milano, Via Golgi 39, 20133 Milan, Italy
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Claudia Romagnoni
- Cardiac Surgery Unit, Fondazione IRCCS Ca’ Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Giordano Tasca
- Cardiac Surgery Department, Heart Health Center, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Eleonora Salurso
- Department of Electronics, Information and Bioengineering, Politecnico Di Milano, Via Golgi 39, 20133 Milan, Italy
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Monica Contino
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
- Cardiac Surgery Unit, Fondazione IRCCS Ca’ Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico Di Milano, Via Golgi 39, 20133 Milan, Italy
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Gianfranco Beniamino Fiore
- Department of Electronics, Information and Bioengineering, Politecnico Di Milano, Via Golgi 39, 20133 Milan, Italy
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Riccardo Vismara
- Department of Electronics, Information and Bioengineering, Politecnico Di Milano, Via Golgi 39, 20133 Milan, Italy
- ForcardioLab—Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
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14
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Meduri CU, Rück A, Linder R, Verouhis D, Settergren M, Sorajja A, Daher D, Saleh N. Commissural Alignment With ACURATE neo2 Valve in an Unselected Population. JACC Cardiovasc Interv 2023; 16:670-677. [PMID: 36990556 DOI: 10.1016/j.jcin.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/08/2022] [Accepted: 01/10/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Commissural alignment has become an important topic in transcatheter aortic valve replacement (TAVR) because it may improve coronary access, facilitate future valve procedures, and possibly improve valve durability. The efficacy of commissural alignment with ACURATE neo2 has not yet been shown in a large population. OBJECTIVES The authors sought to determine the feasibility and success of attempting commissural alignment in an unselected TAVR population treated with the ACURATE neo2 prosthetic heart valve. METHODS A total of 170 consecutive patients underwent TAVR with a dedicated implantation technique to align the TAVR valve to the native valve. Using right-left overlap and 3-cusp views, valve orientation was adjusted by rotation of the unexpanded valve at the level of the aortic root. Effectiveness was assessed postprocedure as the degree of misalignment determined by analyzing fluoroscopic valve orientation to corresponding cusp orientation on preprocedural computed tomography. Safety endpoints included mortality, stroke/transient ischemic attack, and additional complications through 30 days. RESULTS Of 170 patients, 167 (98.2%) could be analyzed for alignment, and all 170, for safety outcomes. Most patients (97%) had successful alignment (≤ mild misalignment), with 80% with commissural alignment, while the degrees of misalignment were 17% mild, 1.2% moderate, 1.8% severe. CONCLUSIONS In this large evaluation of a commissural alignment technique, alignment was achieved in nearly all patients without safety concerns or impact to procedure duration. Commissural alignment appears effective and safe across all patients with this novel technique.
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Affiliation(s)
| | - Andreas Rück
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden. https://twitter.com/AndreasRck2
| | - Rickard Linder
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Dinos Verouhis
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Magnus Settergren
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Amalin Sorajja
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Daniel Daher
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Nawzad Saleh
- Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
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15
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Gada H, Salem M, Vora AN. Commissural Alignment During TAVR: Flush Ports and Goal Posts. JACC Cardiovasc Interv 2023; 16:678-680. [PMID: 36990557 DOI: 10.1016/j.jcin.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Hemal Gada
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Harrisburg, Pennsylvania, USA.
| | - Mahmoud Salem
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Harrisburg, Pennsylvania, USA
| | - Amit N Vora
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Harrisburg, Pennsylvania, USA
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16
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Quagliana A, Montarello NJ, Willemen Y, Bække PS, Jørgensen TH, De Backer O, Sondergaard L. Commissural Alignment and Coronary Access after Transcatheter Aortic Valve Replacement. J Clin Med 2023; 12:jcm12062136. [PMID: 36983139 PMCID: PMC10056242 DOI: 10.3390/jcm12062136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVR) is the first therapeutic option for elderly patients with severe symptomatic aortic stenosis, and indications are steadily expanding to younger patients and subjects with lower surgical risk and longer life expectancy. Commissural alignment between native and transcatheter valves facilitates coronary access after TAVR and is thus considered a procedural goal, allowing long-term management of coronary artery disease. Moreover, commissural alignment may potentially have a positive impact on transvalvular hemodynamic and valve durability. This review focus on technical hints to achieve commissural alignment and current evidence for different transcatheter aortic valves.
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Affiliation(s)
- Angelo Quagliana
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
- Cardiocentro Ticino Institute—EOC, Universita’della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Nicholas J. Montarello
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Yannick Willemen
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Pernille S. Bække
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Troels H. Jørgensen
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Ole De Backer
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Lars Sondergaard
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
- Correspondence:
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17
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Santos-Martínez S, Redondo A, González-Bartol E, Barrero A, Sánchez-Luna JP, Revilla-Orodea A, Baladrón C, Serrador A, San Román JA, Amat-Santos IJ. Feasibility of precise commissural and coronary alignment with balloon-expandable TAVI. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:19-24. [PMID: 35570121 DOI: 10.1016/j.rec.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/07/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES We aimed to describe the feasibility and preliminary outcomes of commissural alignment (CA) for the balloon-expandable transcatheter heart valve. METHODS The relationship among native commissures and transcatheter aortic valve implantation neocommissures was analyzed in 10 consecutive patients with tricuspid severe aortic stenosis undergoing transcatheter aortic valve implantation after guided implantation based on computed tomography analysis with a self-developed software. CA was predicted by in silico bio-modelling in the 10 patients and the calculated rotation was applied during crimping. Degrees of CA and coronary overlap (CO) were measured through 1-month follow up computed tomography. Transvalvular residual gradients and the rate of paravalvular leak were also analyzed. RESULTS Mean commissural misalignment was 16.7±8°. Four patients showed mild misalignment but none of them showed a moderate or severe degree of misalignment. The in silico model accurately predicted the final in vivo position with a correlation coefficient of 0.983 (95%CI, 0.966-0.992), P <.001. Severe CO with right coronary ostium occurred in 3 patients likely due to ostial eccentricity, and CO was not present with the left coronary artery in any of the patients. Mean transaortic gradient was 6.1±3.3mmHg and there were no moderate-severe paravalvular leaks. CONCLUSIONS Patient-specific rotation during valve crimping based on preprocedural computed tomography is feasible with balloon-expandable devices and is associated with the absence of moderate or severe commissural misalignment and left main CO.
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Affiliation(s)
- Sandra Santos-Martínez
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Alfredo Redondo
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Esther González-Bartol
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Alejandro Barrero
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Juan Pablo Sánchez-Luna
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ana Revilla-Orodea
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
| | - Carlos Baladrón
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
| | - Ana Serrador
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J Alberto San Román
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
| | - Ignacio J Amat-Santos
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain.
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18
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Rashid HN, Rajani R, Leipsic J, Maurovitch-Horvat P, Patterson T, Redwood S, Lee J, Hurrell H, Nicholls SJ, Nasis A, Seneviratne S, Cameron JD, Prendergast B, Gooley RP. Computed tomography imaging for subclinical leaflet thrombosis following surgical and transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr 2023; 17:2-10. [PMID: 36396555 DOI: 10.1016/j.jcct.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Subclinical leaflet thrombosis (LT) may occur following surgical and transcatheter aortic valve replacement. Computed tomography (CT) has become an established imaging modality to diagnose subclinical LT following bioprosthetic aortic valve replacement. Even so, there is a limited (but growing) experience in utilizing CT imaging for this indication. This review emphasizes a systematic approach to acquiring and analysing CT imaging for subclinical LT, highlighting evidence surrounding clinical sequelae of subclinical LT and anti-thrombotic implications following diagnosis.
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Affiliation(s)
- Hashrul N Rashid
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia; Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom.
| | - Ronak Rajani
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Pál Maurovitch-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary.
| | - Tiffany Patterson
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom; School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom.
| | - Simon Redwood
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom; School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom.
| | - Jack Lee
- Biomedical Engineering Department, King's College London, London, United Kingdom.
| | - Harriet Hurrell
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom; School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom.
| | - Stephen J Nicholls
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Arthur Nasis
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Sujith Seneviratne
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - James D Cameron
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Bernard Prendergast
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom.
| | - Robert P Gooley
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
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19
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Patient-Specific Immersed Finite Element-Difference Model of Transcatheter Aortic Valve Replacement. Ann Biomed Eng 2023; 51:103-116. [PMID: 36264408 PMCID: PMC9832092 DOI: 10.1007/s10439-022-03047-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/03/2022] [Indexed: 01/28/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) first received FDA approval for high-risk surgical patients in 2011 and has been approved for low-risk surgical patients since 2019. It is now the most common type of aortic valve replacement, and its use continues to accelerate. Computer modeling and simulation (CM&S) is a tool to aid in TAVR device design, regulatory approval, and indication in patient-specific care. This study introduces a computational fluid-structure interaction (FSI) model of TAVR with Medtronic's CoreValve Evolut R device using the immersed finite element-difference (IFED) method. We perform dynamic simulations of crimping and deployment of the Evolut R, as well as device behavior across the cardiac cycle in a patient-specific aortic root anatomy reconstructed from computed tomography (CT) image data. These IFED simulations, which incorporate biomechanics models fit to experimental tensile test data, automatically capture the contact within the device and between the self-expanding stent and native anatomy. Further, we apply realistic driving and loading conditions based on clinical measurements of human ventricular and aortic pressures and flow rates to demonstrate that our Evolut R model supports a physiological diastolic pressure load and provides informative clinical performance predictions.
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Akodad M, Lounes Y, Meier D, Sanguineti F, Hovasse T, Blanke P, Sathananthan J, Tzimas G, Leipsic J, Wood DA, Webb J, Chevalier B. Transcatheter heart valve commissural alignment: an updated review. Front Cardiovasc Med 2023; 10:1154556. [PMID: 37153454 PMCID: PMC10155866 DOI: 10.3389/fcvm.2023.1154556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/28/2023] [Indexed: 05/09/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) indications recently extended to lower surgical risk patients with longer life expectancy. Commissural alignment (CA) is one of the emerging concepts and is becoming one of the cornerstones of the TAVR procedure in a patient with increased longevity. Indeed, CA may improve transcatheter heart valve (THV) hemodynamics, future coronary access, and repeatability. The definition of CA has been recently standardized by the ALIGN-TAVR consortium using a four-tier scale based on CT analysis. Progress has been made during the index TAVR procedure to optimize CA, especially with self-expandable platforms. Indeed, specific delivery catheter orientation, THV rotation, and computed-tomography-derived views have been proposed to achieve a reasonable degree of CA. Recent data demonstrate feasibility, safety, and a significant reduction in coronary overlap using these techniques, especially with self-expandable platforms. This review provides an overview of THV CA including assessment methods, alignment techniques during the index TAVR procedure with different THV platforms, the clinical impact of commissural misalignment, and challenging situations for CA.
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Affiliation(s)
- Mariama Akodad
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Interventional Cardiology Department, Massy, France
- Correspondence: Mariama Akodad
| | - Youcef Lounes
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Vascular Surgery Department, Massy, France
| | - David Meier
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - Francesca Sanguineti
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Interventional Cardiology Department, Massy, France
| | - Thomas Hovasse
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Interventional Cardiology Department, Massy, France
| | - Philipp Blanke
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - Janarthanan Sathananthan
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - Georgios Tzimas
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - Jonathon Leipsic
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - David A. Wood
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - John Webb
- Division of Cardiology and Department of Radiology, Centresfor Heart Valve Innovation and for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, BC, Canada
| | - Bernard Chevalier
- Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Interventional Cardiology Department, Massy, France
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Quantification of Commissural Alignment of Balloon-Expandable THV on Fluoroscopy: A Comparison Study With Post-TAVR CT. JACC Cardiovasc Interv 2022; 15:2374-2383. [PMID: 36480984 DOI: 10.1016/j.jcin.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/22/2022] [Accepted: 08/04/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Coronary access may be challenging following transcatheter aortic valve replacement (TAVR) in the setting of transcatheter heart valve (THV) commissural misalignment. OBJECTIVES The authors aimed to quantify the degree of commissural alignment following balloon-expandable THV implantation using a fluoroscopy-based trigonometric approach and assess its correlation with post-TAVR computed tomography (CT). METHODS Twenty patients who had undergone both TAVR with the balloon-expandable SAPIEN 3 THV and post-TAVR CT were included in the analysis. Optimized, predeployment 3-cusp angiographic view and postdeployment angiographic view using identical fluoroscopic projections were required. The distance between the most central posterior commissural strut and the THV centerline was assessed. Commissural alignment was calculated by means of a trigonometrical approach using an arcsine function, assuming circular deployment of the THV. Commissural alignment was stratified using a 4-tier scale: aligned (0° to 15°); mildly misaligned (15° to 30°); moderately misaligned (30° to 45°), and severely misaligned (45° to 60°). RESULTS Seven patients (35.0%) were misclassified by 1 tier, and no patient was misclassified by 2 or more tiers, with strong agreement between CT and fluoroscopy (weighted Cohen's kappa coefficient = 0.724). Correlation of the commissural offset angle determined from fluoroscopy and CT was excellent (r = 0.986; 95% CI: 0.965 to 0.995). Bland-Altman analysis demonstrated a strong agreement between both modalities with a mean difference of 0.5° (95% limits of agreement: -12.7° to 13.7°). CONCLUSIONS The degree of commissural alignment of the balloon-expandable THV can be reliably assessed and quantified on postdeployment fluoroscopy using a standardized 3-cusp view and trigonometry-based analysis.
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22
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Tarantini G, Fabris T, Nai Fovino L, Cardaioli F, Pergola V, Montonati C, Rodinò G, Cabrelle G, Massussi M, Scotti A, Zuccarelli V, Sciarretta T, Masiero G, Gregori D, Napodano M, Fraccaro C, Continisio S, Iliceto S. Definition of trAnscatheter heart Valve orIeNtation in biCuspId aortic valve: The DA VINCI pilot study. Front Cardiovasc Med 2022; 9:1056496. [PMID: 36578836 PMCID: PMC9790995 DOI: 10.3389/fcvm.2022.1056496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
Objectives To assess the impact of conventional transcatheter heart valve (THV) commissural alignment techniques on THV/coronary overlap and coronary access (CA) after transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV). Background Specific Evolut Pro/Pro + and Acurate Neo2 THV orientations are associated with reduced neo-commissural overlap with coronary ostia in tricuspid aortic anatomy. Whether standard orientation techniques are effective also in the setting of BAV anatomy has not been studied. Methods The DA VINCI (Definition of trAnscatheter aortic Valve orIeNtation in biCuspId aortic valve) pilot study is a prospective registry enrolling consecutive patients with severe BAV stenosis undergoing TAVR with last generation supra-annular tall-frame THVs implanted with a cusp overlap view-based commissural alignment. Patients underwent pre- and post-TAVR computed tomography (CT) and coronary angiography. The study endpoint was the rate of favorable THV/coronary overlap, defined as an angle > 40° between the THV commissural post and coronary ostia. Other endpoints were the rates of successful THV alignment with respect to the raphe and of selective CA after TAVR. Moreover, different virtual THV alignment models were tested to identify which one would produce the lower degree of THV/coronary overlap. Results Thirty-four patients with type 1 BAV with right-left raphe undergoing TAVR (23 with Evolut Pro/Pro + and 11 with Acurate Neo2) were included. At pre-TAVR CT, moderate/severe cusp asymmetry was found in 50% of patients, severe coronary ostia eccentricity was observed in 47.1% for the RCA vs. 8.8% for the LCA (P < 0.007). Correct TVH orientation was achieved in 29 cases. At post-TAVR CT, optimal THV alignment/mild misalignment to the raphe was observed in 86.2%, but a moderate/severe overlap with the coronaries was seen in 13.7% for the RCA and 44.8% for the LCA (P = 0.019). After TAVR, selective RCA cannulation was possible in 82.8% vs. 75.9% for the LCA (P = 0.74), while combined selective CA of both coronaries was possible in less than two-thirds of the patients. Virtual THV alignment in the coronary ostia overlap view assuming a hypothetical circular THV expansion would produce an optimal THV/coronary overlap in almost 90% of cases. Conclusion Given cusp asymmetry and coronary ostia eccentricity of BAV combined with potential THV asymmetrical expansion, conventional commissural alignment techniques are associated with higher rates of THV misalignment and of moderate/severe neo-commissure overlap with the coronary ostia as compared to tricuspid aortic stenosis, resulting in lower rates of selective CA after TAVR. A modified THV orientation technique based on the coronary ostia overlap view might be preferable in BAV patients.
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Affiliation(s)
- Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy,*Correspondence: Giuseppe Tarantini,
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valeria Pergola
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulio Rodinò
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulio Cabrelle
- Department of Medicine—DIMED, University of Padua, Padua, Italy
| | - Mauro Massussi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy,Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Scotti
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy,Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Vittorio Zuccarelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Tommaso Sciarretta
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, University of Padua, Padua, Italy
| | - Massimo Napodano
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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23
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Ibrahim W, Rivera H, Mendoza CE. Commissural alignment: In the quest of the perfect transcatheter heart valve orientation. J Card Surg 2022; 37:5441-5442. [PMID: 35599012 DOI: 10.1111/jocs.16639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Walid Ibrahim
- Department of Cardiology, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Hector Rivera
- Department of Cardiology, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Cesar E Mendoza
- Department of Cardiology, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
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Lim Y, Anthony Tan K, Kuntjoro I, KF Hon J, Yip J, Tay E. Coronary Artery Disease in Patients Undergoing Transvalvular Aortic Valve Implantation. Interv Cardiol 2022; 17:e13. [PMID: 36304067 PMCID: PMC9585643 DOI: 10.15420/icr.2021.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 05/02/2022] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) is common in patients with severe aortic stenosis. With the advent of transcatheter aortic valve implantation (TAVI) as a therapeutic option, management of CAD in such patients has undergone a revolution. Younger patients are now candidates for treatment, and have a greater life-time probability of requiring post-TAVI coronary access. Considerations include pre-procedural assessment and revascularisation, procedural planning to avoid coronary obstruction as well as optimisation of post-procedural coronary access. The authors review the challenges of managing CAD in TAVI patients, shed light on the evidence base, and provide guidance on how to optimise management.
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Affiliation(s)
- Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore
| | - Kent Anthony Tan
- Department of Cardiology, National University Heart Centre, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, Singapore
| | - Jimmy KF Hon
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, Singapore
| | - James Yip
- Department of Cardiology, National University Heart Centre, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre, Singapore
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Khalid AM, O'Sullivan CJ. Commissural alignment in transcatheter aortic valve replacement: A literature review. Front Cardiovasc Med 2022; 9:938653. [PMID: 36017101 PMCID: PMC9396239 DOI: 10.3389/fcvm.2022.938653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure to replace a diseased and faulty aortic valve in patients with severe aortic stenosis. As TAVR gains popularity among lower-risk younger patients with a longer life expectancy; there is a need to investigate the long-term shortcomings and limitations of the procedure for this patient group. One such shortcoming is that commissural alignment of transcatheter heart valves (THV) appears to be random; meaning that the THV neo-commissures can misalign with the native commissures of the aortic valve during deployment or self-expansion. Objectives Identify techniques and procedures used to obtain commissural alignment in TAVR. Evaluate the effectiveness of these procedures in terms of the degree of commissural alignment. Analyse the impact of commissural alignment on coronary filling and re-access. Methods Two electronic online databases were searched to identify existing literature relevant to the aim and objectives of this review: EBSCOhost and PubMed. After search filters were applied and duplicates removed; a total of 64 articles from both databases were screened against the inclusion/exclusion criteria. This resulted in a total of thirteen articles which met the objectives of this review and thus; were included. Results All studies focused on a patient centered approach involving pre-TAVR computed tomography to obtain commissural alignment. Other studies modified this approach and combined techniques. All studies that implemented a technique to reduce commissural misalignment were significantly successful in obtaining commissural alignment when compared to a study in which alignment was random when no technique was implemented. Severe coronary overlapping in commissural aligned heart valves was relatively low compared to severe coronary overlapping when no technique was implemented. Conclusions An increase in optimal commissural alignment via introduction of an alignment technique may seem attractive; however; the categorization of commissural alignment is arbitrary and does not accurately reflect real life clinical implications. Further research is needed to determine whether a routine procedure to achieve commissural alignment is necessary in low-risk younger patients undergoing TAVR.
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26
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Tirado-Conte G, Gomez-Alvarez Z, Gheorghe L, Asmarats L, Jimenez-Quevedo P, Regueiro A, García Gamez AF, McInerney A, Pedro Li CH, Pozo E, Freixa X, Nombela-Franco L. Neo-Commissural Alignment and Coronary Artery Overlap Following Portico Aortic Valve Implantation. JACC Cardiovasc Interv 2022; 15:1590-1592. [PMID: 35926925 DOI: 10.1016/j.jcin.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/06/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
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27
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Tang GHL, Amat-Santos IJ, De Backer O, Avvedimento M, Redondo A, Barbanti M, Costa G, Tchétché D, Eltchaninoff H, Kim WK, Zaid S, Tarantini G, Søndergaard L. Rationale, Definitions, Techniques, and Outcomes of Commissural Alignment in TAVR: From the ALIGN-TAVR Consortium. JACC Cardiovasc Interv 2022; 15:1497-1518. [PMID: 35926918 DOI: 10.1016/j.jcin.2022.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 10/16/2022]
Abstract
Given the expanding indications of transcatheter aortic valve replacement (TAVR) in younger patients with longer life expectancies, the ability to perform postprocedural coronary access represents a priority in their lifetime management. A growing body of evidence suggests that commissural (and perhaps coronary) alignment in TAVR impacts coronary access and valve hemodynamics as well as coronary flow and access after redo-TAVR. Recent studies have provided modified delivery system insertion and rotation techniques to obtain commissural alignment with available transcatheter heart valve devices. Moreover, patient-specific preprocedural planning and postprocedural imaging tools have been developed to facilitate and evaluate commissural alignment. Future efforts should aim to refine transcatheter heart valve and delivery system designs to make neocommissural alignment easier and more reproducible. The aim of this review is to present an in-depth insight of commissural alignment in TAVR, including its rationale, standardized definitions, technical steps, outcomes, and future directions.
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Affiliation(s)
- Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA.
| | | | - Ole De Backer
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alfredo Redondo
- CIRBERCV, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Department of Cardiology, Hospital Clinico Universitario de Santiago de Compostela, A Coruna, Spain
| | - Marco Barbanti
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco," Catania, Italy
| | - Giuliano Costa
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco," Catania, Italy
| | | | | | | | - Syed Zaid
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Lars Søndergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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28
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Meier D, Akodad M, Chatfield AG, Lutter G, Puehler T, Søndergaard L, Wood DA, Webb JG, Sellers SL, Sathananthan J. Impact of Commissural Misalignment on Hydrodynamic Function Following Valve-in-Valve Intervention With the ACURATE neo. JACC Cardiovasc Interv 2022; 15:1532-1539. [DOI: 10.1016/j.jcin.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 10/17/2022]
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Abdel-Wahab M, Kitamura M, Fitzgerald SJ, Dumpies O, Wilde J, Gohmann RF, Majunke N, Gutberlet M, Kiefer P, Noack T, Lurz P, Desch S, Frawley C, Ward K, Borger MA, Holzhey D, Thiele H. Neo-Commissural Alignment Technique for Transcatheter Aortic Valve Replacement Using the ACURATE Neo Valve. Circ Cardiovasc Interv 2022; 15:e011993. [PMID: 35775417 DOI: 10.1161/circinterventions.122.011993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mohamed Abdel-Wahab
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Mitsunobu Kitamura
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany.,Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan (M.K.)
| | - Sean J Fitzgerald
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Oliver Dumpies
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Johannes Wilde
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Robin F Gohmann
- Department of Diagnostic and Interventional Radiology (R.F.G., M.G.), Heart Center Leipzig at University of Leipzig, Germany
| | - Nicolas Majunke
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology (R.F.G., M.G.), Heart Center Leipzig at University of Leipzig, Germany
| | - Philipp Kiefer
- Department of Structural Heart Disease/Cardiac Surgery (P.K., T.N., M.A.B., D.H.), Heart Center Leipzig at University of Leipzig, Germany
| | - Thilo Noack
- Department of Structural Heart Disease/Cardiac Surgery (P.K., T.N., M.A.B., D.H.), Heart Center Leipzig at University of Leipzig, Germany
| | - Philipp Lurz
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Steffen Desch
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
| | - Christopher Frawley
- Structural Heart Valve Research and Development Campus, Boston Scientific Corporation, Ballybrit, Galway, Ireland (C.F., K.W.)
| | - Kevin Ward
- Structural Heart Valve Research and Development Campus, Boston Scientific Corporation, Ballybrit, Galway, Ireland (C.F., K.W.)
| | - Michael A Borger
- Department of Structural Heart Disease/Cardiac Surgery (P.K., T.N., M.A.B., D.H.), Heart Center Leipzig at University of Leipzig, Germany
| | - David Holzhey
- Department of Structural Heart Disease/Cardiac Surgery (P.K., T.N., M.A.B., D.H.), Heart Center Leipzig at University of Leipzig, Germany
| | - Holger Thiele
- Department of Structural Heart Disease/Cardiology (M.A.W., M.K., S.J.F., O.D., J.W., N.M., P.L., S.D., H.T.), Heart Center Leipzig at University of Leipzig, Germany
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30
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Raschpichler M, Flint N, Yoon SH, Kaewkes D, Patel C, Singh C, Patel V, Kashif M, Borger MA, Chakravarty T, Makkar R. Commissural Alignment After Balloon-Expandable Transcatheter Aortic Valve Replacement Is Associated With Improved Hemodynamic Outcomes. JACC Cardiovasc Interv 2022; 15:1126-1136. [PMID: 35680192 DOI: 10.1016/j.jcin.2022.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is generally performed without control over the alignment of the bioprosthesis to the native aortic valve (AV) commissures. Data on the impact of commissural misalignment (CMA) on the clinical and hemodynamic outcome after TAVR are scarce. OBJECTIVES The aim of this study was to investigate the impact of commissural misalignment (CMA) on the clinical and hemodynamic outcome in patients with severe tricuspid aortic stenosis undergoing TAVR using the balloon-expandable (BE) SAPIEN 3 valve (Edwards LifeSciences). METHODS Clinical data of consecutive patients who underwent BE TAVR at Cedars-Sinai Medical Center (Los Angeles, California, USA) enrolled in the RESOLVE (Assessment of TRanscathetER and Surgical Aortic BiOprosthetic Valve Thrombosis and Its TrEatment With Anticoagulation) registry were retrospectively analyzed to evaluate CMA, which was defined as a neocommissure position >30° compared with native commissures on computed tomography. RESULTS A total of 324 patients (36.6% female, median Society of Thoracic Surgeons score of 3.9%) were included in the analysis. CMA was present in 171 individuals (52.8%). At 30 days, rates of aortic regurgitation greater than mild (5.6%) and a residual AV gradient ≥20 mm Hg (7.4%) were not different between CMA and non-CMA patients. Commissural orientation was independently associated with a relative AV mean gradient increase >50% from discharge to 30 days (per increase of 10° misalignment; OR: 1.3; 95% CI: 1.0-1.4; P = 0.01). The long-term composite outcome of death or stroke was not different between groups (log-rank P = 0.29). CONCLUSIONS In patients with severe tricuspid aortic stenosis who undergo SAPIEN 3 TAVR, the neocommissures align randomly. Our data demonstrate that commissural alignment may impact device performance and clinical outcomes in patients undergoing BE TAVR. (Assessment of TRanscathetEr and Surgical Aortic BiOprosthetic VaLVve Dysfunction with Multimodality Imaging and Its TrEatment with Anticoagulation [RESOLVE]; NCT02318342).
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Affiliation(s)
- Matthias Raschpichler
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; Leipzig Heart Center, University Clinic of Cardiac Surgery, Leipzig, Germany
| | - Nir Flint
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; Tel Aviv Sourasky Medical Center affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sung-Han Yoon
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Danon Kaewkes
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chinar Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Chetana Singh
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Vivek Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mohammad Kashif
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael A Borger
- Leipzig Heart Center, University Clinic of Cardiac Surgery, Leipzig, Germany
| | - Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Tang GHL, Zaid S. Commissural (Mis)Alignment in TAVR and Hemodynamic Impact: More Questions Raised Than Answered. JACC Cardiovasc Interv 2022; 15:1137-1139. [PMID: 35680193 DOI: 10.1016/j.jcin.2022.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA.
| | - Syed Zaid
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
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Factibilidad del alineamiento comisural y coronario precisos con TAVI balón-expandible. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Prosthesis Geometrical Predictors of Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement With Intra-Annular Prostheses. Heart Lung Circ 2022; 31:678-684. [PMID: 35065896 DOI: 10.1016/j.hlc.2021.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/25/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the association between prosthesis geometry with leaflet thrombosis (LT). BACKGROUND Leaflet thrombosis following transcatheter aortic valve replacement (TAVR) is a recognised entity. The association between prosthesis geometry with LT is unclear but maybe a potential modifiable factor in its prevention. METHODS Patients who received an intra-annular TAVR prosthesis and were prospectively planned to undergo post-procedural computed tomography (CT) imaging were included. Leaflet thrombosis was defined as at least 50% restricted leaflet motion on CT. Prosthesis expansion and eccentricity was measured at prosthesis inflow, annulus and outflow levels. Prosthesis misalignment was defined as the average angle deviation between native and prosthesis leaflet commissure, greater than 30°. RESULTS Prevalence of LT was 13.7% in 117 patients. None of the patients with LT were on anticoagulation therapy. Patients with LT had reduced prosthesis annular expansion (89.4±5.2% vs 97.0±4.4%, p<0.01), greater prosthesis misalignment (81.3% vs 48.5%, p=0.02) and deeper implants (6.3±1.7 mm vs 4.3±1.5 mm, p<0.01). Threshold for the presence of LT on ROC analysis was an implant depth of 5.7 mm (AUC [area under curve]=0.81). Independent predictors of LT were annular under-expansion (Odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.7, p=0.03) prosthesis misalignment (OR 6.8, 95%CI 1.1-45.5, p=0.04) and implant depth (OR 1.9, 95%CI 1.1-3.2, p=0.03). Anticoagulation therapy was a protective factor (OR 0.2; 95%CI 0.1-0.4, p<0.01). CONCLUSION Geometrical predictors of LT post intra-annular TAVR were reduced prosthesis expansion at the annular level, lower implant depth and greater prosthesis misalignment. These factors may be important considerations during procedural planning for TAVR.
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Siddique S, Khanal R, Vora AN, Gada H. Transcatheter Aortic Valve Replacement Optimization Strategies: Cusp Overlap, Commissural Alignment, Sizing, and Positioning. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
As transcatheter aortic valve replacement (TAVR) rapidly expands to younger patients and those at low surgical risk, there is a compelling need to identify patients at increased risk of post-procedural complications, such as paravalvular leak, prosthesis–patient mismatch, and conduction abnormalities. This review highlights the incidence and risk factors of these procedural complications, and focuses on novel methods to reduce them by using newer generation transcatheter heart valves and the innovative cusp-overlap technique, which provides optimal fluoroscopic imaging projection to allow for precise implantation depth which minimizes interaction with the conduction system. Preserving coronary access after TAVR is another important consideration in younger patients. This paper reviews the significance of commissural alignment to allow coronary cannulation after TAVR and discusses recently published data on modified delivery techniques to improve commissural alignment.
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Affiliation(s)
- Saima Siddique
- University of Pittsburgh Medical Center Heart and Vascular Institute, Harrisburg, PA
| | - Resha Khanal
- University of Pittsburgh Medical Center Heart and Vascular Institute, Harrisburg, PA
| | - Amit N Vora
- University of Pittsburgh Medical Center Heart and Vascular Institute, Harrisburg, PA; Duke University Medical Center, Durham, NC
| | - Hemal Gada
- University of Pittsburgh Medical Center Heart and Vascular Institute, Harrisburg, PA
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35
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Barbanti M, Valvo R, Costa G. Predicting neocommissural orientation during TAVI workup. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:194-195. [PMID: 34580041 DOI: 10.1016/j.rec.2021.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Marco Barbanti
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", Catania, Italy.
| | - Roberto Valvo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", Catania, Italy
| | - Giuliano Costa
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", Catania, Italy
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36
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Barbanti M, Valvo R, Costa G. La importancia de predecir la orientación de las neocomisuras al preparar un TAVI. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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37
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Wang X, De Backer O, Bieliauskas G, Wong I, Bajoras V, Xiong TY, Zhang Y, Kofoed KF, Chen M, Sondergaard L. Cusp Symmetry and Coronary Ostial Eccentricity and its Impact on Coronary Access Following TAVR. JACC Cardiovasc Interv 2022; 15:123-134. [PMID: 35057982 DOI: 10.1016/j.jcin.2021.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The aim of this study was to assess cusp symmetry and coronary ostial eccentricity and its impact on coronary access following transcatheter aortic valve replacement (TAVR) using a patient-specific commissural alignment implantation technique. BACKGROUND TAVR implantation techniques to obtain neocommissural alignment have been introduced. The impact of cusp symmetry and coronary ostial eccentricity on coronary access after TAVR remains unknown. METHODS Cardiac computed tomographic scans from 200 tricuspid aortic valves (TAVs) and 200 type 1 bicuspid aortic valves (BAVs) were studied. Cusp symmetry and coronary ostial eccentricity were assessed. In addition, the right coronary cusp/left coronary cusp and right coronary artery (RCA)/left coronary artery (LCA) ostia overlap views were calculated and compared. RESULTS Severe cusp asymmetry (>135°) was more frequent in BAVs (52.5%) than in TAVs (2.5%) (P < 0.001), with the noncoronary cusp being the most common dominant cusp. The RCA ostium was found to be more often eccentric (>20°) than the LCA ostium (28% vs 6%, respectively; P < 0.001). Considering the right/left cusp overlap view, there was <20° deviation between the right coronary cusp-left coronary cusp centered line and the RCA-LCA centered line in 95% of all patients (TAV, 97%; BAV, 93%). The right/left cusp and coronary ostia overlap view differed by <10° and <20° fluoroscopic angulation in 75% and 98% of all cases, respectively. CONCLUSIONS Using the right/left cusp overlap view to obtain commissural alignment in TAVR is also an effective approach to implant one of the transcatheter heart valve commissures in the near center between both coronary ostia in most TAVs and type 1 BAVs. Preprocedural CT assessment remains crucial to assess cusp symmetry and coronary ostial eccentricity.
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Affiliation(s)
- Xi Wang
- Department of Cardiology, West China Hospital, Sichuan University, China; The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gintautas Bieliauskas
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ivan Wong
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vilhelmas Bajoras
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tian-Yuan Xiong
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Yi Zhang
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Klaus Fuglsang Kofoed
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, China.
| | - Lars Sondergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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38
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Redondo A, Baladrón Zorita C, Tchétché D, Santos-Martinez S, Delgado-Arana JR, Barrero A, Gutiérrez H, Serrador Frutos A, Ybarra Falcón C, Gómez MG, Carrasco Moraleja M, Sevilla T, Sanchez Lite I, Sanz E, San Román JA, Amat-Santos IJ. Commissural Versus Coronary Optimized Alignment During Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2022; 15:135-146. [PMID: 35057983 DOI: 10.1016/j.jcin.2021.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/14/2021] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aims of this study were to determine the rate of noncentered coronary ostia and their risk for coronary overlap (CO) and to develop an improved orientation strategy for transcatheter aortic valve replacement (TAVR) devices taking into account anatomical cues to identify patients at risk for CO regardless of commissural alignment and compute an alternative, CO-free TAVR rotation angle for those patients. BACKGROUND Commissural alignment during TAVR reduces CO risk. However, eccentricity of coronary ostia from the center of the sinus of Valsalva may result in CO even after perfect alignment of TAVR commissures. METHODS Baseline computed tomography from TAVR candidates helped identify distance from commissures to the right coronary artery (RCA) and the left coronary artery (LCA). Then, for each case, a virtual valve was simulated with ideal commissural or coronary alignment, and the degree of CO was determined. On the basis of the potential BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) efficacy, 3 groups were defined: no risk for CO (>35° from neocommissure to coronary ostia), moderate risk (20°-35°), and severe risk (≤20°). RESULTS Computed tomographic studies from 107 patients were included. After excluding 7 patients (poor quality or bicuspid valve), 100 patients were analyzed. The RCA showed greater eccentricity compared with the LCA (18.5° [IQR: 3.3°-12.8°] vs 6.5° [IQR: 3.3°-12.8°]; P < 0.001). The mean intercoronary angle was 140.0° ± 18.7° (95% CI: 136.3°-143.7°). Thirty-two patients had moderate to severe risk for CO (≤35°) despite ideal commissural alignment. Greater coronary eccentricity (cutoff for RCA, 24.5°; cutoff for LCA, 19°) and intercoronary angle >147.5° or <103° were associated with greater risk for moderate to severe CO despite commissural alignment (area under the curve: 0.97; 95% CI: 0.91-0.99). If optimal coronary alignment was simulated, this prevented severe CO in all cases and reduced moderate CO from 27% to 5% (P < 0.001). CONCLUSIONS One third of patients would have CO during TAVR-in-TAVR despite commissural alignment; a 6-fold decrease in this risk was achieved with optimized coronary alignment. Coronary eccentricity and intercoronary angle were the main predictors.
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Affiliation(s)
- Alfredo Redondo
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | | | | | | | | | - Alejandro Barrero
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | - Hipólito Gutiérrez
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | - Ana Serrador Frutos
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | | | - Mario García Gómez
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | | | - Teresa Sevilla
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | | | - Esther Sanz
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
| | - J Alberto San Román
- CIBERCV, Cardiology Department, University Clinic Hospital, Valladolid, Spain
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39
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Lange R, Vitanova K. A Novel Transcatheter Heart Valve for an Overcrowded TAVR Market: What Should We Focus On? JACC Cardiovasc Interv 2022; 15:105-106. [PMID: 34991815 DOI: 10.1016/j.jcin.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Insure (Institute of Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; DZHK (German Center for Cardiovascular Research) - Partner Site Munich Heart Alliance, Munich.
| | - Keti Vitanova
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Insure (Institute of Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
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40
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Vogl BJ, Darestani YM, Lilly SM, Thourani VH, Alkhouli MA, Lindman BR, Hatoum H. Impact of blood pressure on coronary perfusion and valvular hemodynamics after aortic valve replacement. Catheter Cardiovasc Interv 2021; 99:1214-1224. [PMID: 34936723 DOI: 10.1002/ccd.30052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/05/2021] [Accepted: 11/27/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Our objective was to evaluate the impact of various blood pressures (BPs) on coronary perfusion and valvular hemodynamics following aortic valve replacement (AVR). BACKGROUND Lower systolic and diastolic (SBP/DBP) pressures from the recommended optimal target range of SBP < 120-130 mmHg and DBP < 80 mmHg after AVR have been independently associated with increased cardiovascular and all-cause mortality. METHODS The hemodynamic assessment of a 26 mm SAPIEN 3 transcatheter aortic valve (TAV), 29 mm Evolut R TAV, and 25 mm Magna Ease surgical aortic valve (SAV) was performed in a pulsed left heart simulator with varying SBP, DBP, and heart rate (HR) conditions (60 and 120 bpm) at 5 L/min cardiac output (CO). Average coronary flow (CF), effective orifice areas (EOAs), and valvulo-arterial impedance (Zva) were calculated. RESULTS At HR of 60 bpm, at SBP < 120 mmHg and DBP < 60 mmHg, CF decreased below the physiological lower limit with several different valves. Zva and EOA were found to increase and decrease respectively with increasing SBP and DBP. The same results were found with an HR of 120 bpm. The trends of CF variation with BP were similar in all valves however the drop below the lower physiological CF limit was valve dependent. CONCLUSION In a controlled in vitro system, with different aortic valve prostheses in place, CF decreased below the physiologic minimum when SBP and DBP were in the range targeted by blood pressure guidelines. Combined with recent observations from patients treated with AVR, these findings underscore the need for additional studies to identify the optimal BP in patients treated with AVR for AS.
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Affiliation(s)
- Brennan J Vogl
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
| | - Yousef M Darestani
- Department of Civil, Environmental and Geospatial Engineering, Michigan Technological University, Houghton, Michigan, USA
| | - Scott M Lilly
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian R Lindman
- Structural Heart and Valve Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA.,Center of Biocomputing and Digital Health and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, Michigan, USA.,Health Research Institute, Michigan Technological University, Houghton, Michigan, USA
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41
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Sá MP, Ramlawi B, Sicouri S, Torregrossa G, Al Abri Q, Kempfert J, Kofler M, Falk V, Unbehaun A, Van Praet KM. Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future. J Card Surg 2021; 37:205-213. [PMID: 34697831 DOI: 10.1111/jocs.16110] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 12/16/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has already received the green light for high-, intermediate- and low-risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve-in-valve procedures (TAVR-in-surgical aortic valve replacement [SAVR] and TAVR-in-TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Serge Sicouri
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Qasim Al Abri
- Department of Cardiothoracic Surgery, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Health Sciences and Technology, Institute of Translational Medicine, Swiss Federal Institute of Technology, Translational Cardiovascular Technologies, Zurich, Switzerland
| | - Axel Unbehaun
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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42
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Patient-Specific Implantation Technique to Obtain Neo-Commissural Alignment With Self-Expanding Transcatheter Aortic Valves. JACC Cardiovasc Interv 2021; 14:2097-2108. [PMID: 34538602 DOI: 10.1016/j.jcin.2021.06.033] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The authors sought to investigate whether a patient-specific implantation technique during transcatheter aortic valve replacement (TAVR) can result in a safe and reproducible neo-commissural alignment of self-expanding transcatheter heart valves (THVs). BACKGROUND To date, little attention has been paid to neo-commissural alignment during TAVR. METHODS A fluoroscopy-based, patient- and valve-specific TAVR implantation technique was applied in 60 patients treated with 3 different self-expanding THV platforms (Evolut R/PRO, Medtronic; ACURATE neo2, Boston Scientific; and Portico, Abbott-20 patients in each group). Post-TAVR cardiac computed tomography was used to assess THV neo-commissural alignment. RESULTS Considering all 60 patients, ≤mild commissural misalignment (CMA <30°) was obtained in 53 patients (88%) using this modified TAVR implantation technique-in 36 patients (60%), optimal commissural alignment (<15°) was obtained. In 2 patients, cardiac computed tomography revealed severe CMA (>45°) with overlap between the coronary ostia and THV commissures. Using the ACURATE neo2 platform, operators succeeded in avoiding ≥moderate CMA in all 20 cases. When analyzing those cases in which the optimal amount of THV rotation could be assessed and applied before THV expansion (n = 52; 87%), the success rate of TAVR with ≤mild CMA was 98%. No procedure- or valve-related complications occurred in this study cohort. CONCLUSIONS A patient-specific TAVR implantation technique aiming to obtain neo-commissural alignment is feasible and safe, and aides to prevent THV implantations with overlap between the coronary ostia and THV commissures. Optimized TAVR devices and design may further improve the success rate of TAVR with neo-commissural alignment.
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43
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Tang GHL, Sengupta A, Alexis SL, Zaid S, Leipsic JA, Blanke P, Grubb KJ, Gada H, Yakubov SJ, Rogers T, Lerakis S, Khera S, Adams DH, Sharma SK, Kini A, Reardon MJ. Conventional versus modified delivery system technique in commissural alignment from the Evolut low-risk CT substudy. Catheter Cardiovasc Interv 2021; 99:924-931. [PMID: 34626449 DOI: 10.1002/ccd.29973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/03/2021] [Accepted: 09/29/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We assessed the impact of conventional delivery system (DS) insertion technique on "Hat-marker" orientation/commissural alignment in patients who underwent transcatheter aortic valve replacement (TAVR) in the Evolut Low Risk Trial CT substudy versus a modified technique. BACKGROUND Unlike surgical aortic valve replacement, where alignment of the surgical valve commissures with native commissures can be achieved virtually 100% of the time, commissural alignment during TAVR is not achieved consistently. This may subsequently impact the feasibility of both coronary access and reintervention after TAVR. METHODS "Hat-marker" orientations during deployment were characterized as outer curve (OC), center front (CF), inner curve, and center back. Severe commissure-to-CA overlap was 0-20°. "Hat-marker" orientations and CA overlap were compared to 240 patients from a single center using the modified 3-o'clock flush port DS technique. RESULTS In the CT substudy in which conventional DS insertion was performed (flush port at 12 o'clock); 154/249 had both analyzable CT and procedural fluoroscopy to validate "Hat-marker" to C-tab/commissural orientation. On post-TAVR CT, Evolut valve commissural orientation and coronary artery (CA) ostia were identified. Compared to conventional DS technique in the CT substudy, the modified technique had higher rates of "Hat-marker" at OC/CF orientation, improved commissural alignment and reduced severe CA overlap; (left main, 14.2 vs. 27.9%; right coronary artery, 11.7 vs. 27.3% both, 5.0 vs. 13.6%; 1 or both CA, 20.8 vs. 41.6%, all p < 0.01). CONCLUSIONS The modified technique improved initial "Hat-marker" orientation during Evolut deployment and resulted in better commissural alignment and reduced CA overlap.
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Affiliation(s)
- Gilbert H L Tang
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Aditya Sengupta
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Sophia L Alexis
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Syed Zaid
- Division of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Jonathan A Leipsic
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kendra J Grubb
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia, USA
| | - Hemal Gada
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Harrisburg, Pennsylvania, USA
| | - Steven J Yakubov
- Department of Interventional Cardiology, OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Toby Rogers
- Medstar Heart and Vascular Institute, Washington, District of Columbia, USA
| | - Stamatios Lerakis
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Sahil Khera
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Samin K Sharma
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Annapoorna Kini
- Department of Cardiovascular Surgery and Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Michael J Reardon
- Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
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Choosing Between Transcatheter Aortic Valve Replacement and Surgery in the Low-Risk Transcatheter Aortic Valve Replacement Era. Interv Cardiol Clin 2021; 10:413-422. [PMID: 34593105 DOI: 10.1016/j.iccl.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The landmark results of the low surgical risk pivotal transcatheter aortic valve replacement (TAVR) trials fueled speculation that the role of surgical aortic valve replacement (SAVR) would be limited in the future. Instead, the field has pivoted away from reductive surgical risk stratification toward understanding the complex interplay of anatomy, timing, and surgical risk to optimize the lifetime management of aortic stenosis. In this review, we systematically explore the subtleties that influence the choice between TAVR and surgery in the low-risk TAVR era.
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Hamid N, Ranard LS, Khalique OK, Hahn RT, Nazif TM, George I, Ng V, Leon MB, Kodali SK, Vahl TP. Commissural Alignment After Transfemoral Transcatheter Aortic Valve Replacement With the JenaValve Trilogy System. JACC Cardiovasc Interv 2021; 14:2079-2081. [PMID: 34556282 DOI: 10.1016/j.jcin.2021.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
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Santos-Martínez S, Amat-Santos IJ. New Challenging Scenarios in Transcatheter Aortic Valve Implantation: Valve-in-valve, Bicuspid and Native Aortic Regurgitation. Eur Cardiol 2021; 16:e29. [PMID: 34512800 PMCID: PMC8422266 DOI: 10.15420/ecr.2021.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 01/10/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is the most frequently performed structural technique in the field of interventional cardiology. Initially, this procedure was only used in patients with severe symptomatic aortic stenosis and prohibitive risk. Now, barely one decade after its introduction, TAVI indications extend to low- and intermediate-risk patients. Despite these advances, several challenging scenarios are still on the periphery of the evidence base for TAVI. These include valve-in-valve procedures, lower-risk patients with bicuspid aortic valve and the treatment of pure aortic regurgitation. Whereas the valve-in-valve indication has expanded rapidly, evidence for the use of TAVI compared with conventional surgery for bicuspid aortic valve is limited, including the best choice of device should TAVI be used. Evidence for TAVI in pure aortic regurgitation is still anecdotal because of suboptimal outcomes. Operators worldwide have described variations in the TAVI procedural technique to achieve commissural alignment and to minimise the rate of pacemaker use through cusp overlap implantation. In light of the potential clinical benefits, this may also be an area of further development. This review aims to discuss the current evidence available supporting the use of TAVI for these new indications.
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Affiliation(s)
- Sandra Santos-Martínez
- CIBERCV, Cardiology Department, University Clinic Hospital of Valladolid Valladolid, Spain
| | - Ignacio J Amat-Santos
- CIBERCV, Cardiology Department, University Clinic Hospital of Valladolid Valladolid, Spain
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Kitamura M, Wilde J, Gohmann R, Majunke N, Gutberlet M, Shibata M, Kiefer P, Desch S, Thiele H, Holzhey D, Abdel-Wahab M. Commissural Alignment of the ACURATE neo Valve in Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2021; 14:1740-1742. [PMID: 34353607 DOI: 10.1016/j.jcin.2021.05.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022]
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Spilias N, Sabbak N, Harb SC, Yun JJ, Vargo PR, Unai S, Puri R, Reed GW, Krishnaswamy A, Kapadia SR. A Novel Method of Assessing Commissural Alignment for the SAPIEN 3 Transcatheter Aortic Valve. JACC Cardiovasc Interv 2021; 14:1269-1272. [PMID: 34112468 DOI: 10.1016/j.jcin.2021.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/08/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
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De Marco F, Casenghi M, Spagnolo P, Popolo Rubbio A, Brambilla N, Testa L, Bedogni F. A patient-specific algorithm to achieve commissural alignment with Acurate Neo: The sextant technique. Catheter Cardiovasc Interv 2021; 98:E847-E854. [PMID: 33960624 PMCID: PMC9292557 DOI: 10.1002/ccd.29737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 11/07/2022]
Abstract
Aims The aim of this proof‐of‐concept study was to investigate safety and efficacy of a CT‐scan based patient‐specific algorithm to maximize coronary clearance and secondarily to achieve anatomically correct commissural alignment with the Acurate Neo device. Method and results A total of 45 consecutive patients undergoing TAVR with the Acurate Neo THV were prospectively enrolled in the study. Mean age was 81.6 ± 5.5 years, mean STS score was 6.1 ± 3.7. Device success rate was 100%. Aim of the technique was to rotationally deploy the TAVR device with a commissure lying on the bisector between the coronary ostia as calculated on the pre‐procedural CT‐scan. At post‐TAVR CT‐scan, coronary clearance was achieved in 98% of patients with no cases of severe coronary artery overlap. In 42 out of 45 patients, THV was aligned or, at most, mildly misaligned; there were 2 cases of moderate misalignment without any case of severe misalignment. Post‐TAVR selective coronary artery engagement was attempted and succeeded in all patients (100%). Conclusion Our CT‐scan based patient‐specific algorithm is safe and proven to be effective in avoiding coronary artery overlap and providing commissural alignment with Acurate Neo in all treated patients.
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Affiliation(s)
- Federico De Marco
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Matteo Casenghi
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy.,Department of Clinical and Molecular Medicine, School of Medicine and Psychology, University of Rome "Sapienza", Rome, Italy
| | - Pietro Spagnolo
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Antonio Popolo Rubbio
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Nedy Brambilla
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Luca Testa
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Francesco Bedogni
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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