Commissural vs Coronary Alignment to Avoid Coronary Overlap With THV-Commissure in TAVR: A CT-Simulation Study

Manish Vinayak; Gilbert H L Tang; Keva Li; Megan Berdan; Anoop N Koshy; Sahil Khera; Stamatios Lerakis; George D Dangas; Samin K Sharma; Annapoorna S Kini; Parasuram Krishnamoorthy

doi:10.1016/j.jcin.2024.01.073

Commissural vs Coronary Alignment to Avoid Coronary Overlap With THV-Commissure in TAVR: A CT-Simulation Study

JACC Cardiovasc Interv. 2024 Mar 25;17(6):715-726. doi: 10.1016/j.jcin.2024.01.073. Epub 2024 Mar 6.

Authors

Affiliations

¹ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. Electronic address: https://twitter.com/manishvinayak.
² Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA. Electronic address: gilbert.tang@mountsinai.org.
³ Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA.
⁴ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA; The Royal Melbourne Hospital & The University of Melbourne, Victoria, Australia. Electronic address: https://twitter.com/DrAnoop_Koshy.
⁵ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. Electronic address: https://twitter.com/Khera_MD.
⁶ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA.
⁷ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. Electronic address: https://twitter.com/georgedangas.
⁸ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. Electronic address: https://twitter.com/DoctorKini.
⁹ Mount Sinai Heart, Mount Sinai Hospital, New York, New York, USA. Electronic address: parasuram.krishnamoorthy@mountsinai.org.

PMID: 38456886
DOI: 10.1016/j.jcin.2024.01.073

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.

Keywords: TAVR; commissural alignment; coronary alignment.

MeSH terms

Aortic Valve / diagnostic imaging
Aortic Valve / surgery
Heart Valve Prosthesis*
Humans
Multidetector Computed Tomography
Transcatheter Aortic Valve Replacement* / adverse effects
Transcatheter Aortic Valve Replacement* / methods
Treatment Outcome