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Commissural and Coronary Alignment After Transcatheter Aortic Valve Replacement Using the New Supra-Annular, Self-Expanding Evolut FX System

2023; Lippincott Williams & Wilkins; Volume: 16; Issue: 4 Linguagem: Inglês

10.1161/circinterventions.122.012657

1941-7632

Sung‐Han Yoon, Shayef Gabasha, Luís Augusto Palma Dallan, Anene Ukaigwe, Gilbert H.L. Tang, Gregory Rushing, Mark Pelletier, Steven J. Filby, Cristián Baeza, Guilherme F. Attizzani,

Cardiovascular Function and Risk Factors

HomeCirculation: Cardiovascular InterventionsVol. 16, No. 4Commissural and Coronary Alignment After Transcatheter Aortic Valve Replacement Using the New Supra-Annular, Self-Expanding Evolut FX System Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBCommissural and Coronary Alignment After Transcatheter Aortic Valve Replacement Using the New Supra-Annular, Self-Expanding Evolut FX System Sung-Han Yoon, Shayef Gabasha, Luis Augusto Palma Dallan, Anene Ukaigwe, Gilbert H.L. Tang, Gregory Rushing, Mark Pelletier, Steven Filby, Cristian Baeza and Guilherme F. Attizzani Sung-Han YoonSung-Han Yoon https://orcid.org/0000-0003-0465-7061 Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Shayef GabashaShayef Gabasha Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Luis Augusto Palma DallanLuis Augusto Palma Dallan https://orcid.org/0000-0002-8122-6647 Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Anene UkaigweAnene Ukaigwe Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Gilbert H.L. TangGilbert H.L. Tang https://orcid.org/0000-0001-7219-990X Department of Cardiovascular Surgery, Mount Sinai Health System, New York (G.H.L.T.). , Gregory RushingGregory Rushing Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Mark PelletierMark Pelletier Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Steven FilbySteven Filby Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). , Cristian BaezaCristian Baeza https://orcid.org/0000-0003-2001-332X Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). and Guilherme F. AttizzaniGuilherme F. Attizzani Correspondence to: Guilherme F. Attizzani, MD, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9233-1242 Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH (S.-H.Y., S.G., L.A.P.D., A.U., G.R., M.P., S.F., C.B., G.F.A.). Originally published3 Apr 2023https://doi.org/10.1161/CIRCINTERVENTIONS.122.012657Circulation: Cardiovascular Interventions. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 3, 2023: Ahead of Print Transcatheter aortic valve replacement (TAVR) indications have expanded to younger patients with lower surgical risk and longer life expectancy. Accordingly, lifetime management of cardiovascular disease including future coronary access and redo TAVR is increasingly important. Coronary access is affected by multiple factors such as aortic root anatomy, type and implantation depth of transcatheter heart valves, and commissural alignment.1 Previous studies proposed optimizing commissural alignment using self-expanding valves.2,3 The newest generation supra-annular, self-expanding Evolut FX system (Medtronic, Inc) with 3 depth markers aligned with the valve commissures has the potential to improve commissural alignment. However, no studies exist to evaluate the relationship between commissural alignment on fluoroscopy and actual THV orientation with postprocedural computed tomography (CT) imaging after Evolut FX TAVR. We therefore evaluated commissural and coronary alignment as well as coronary interference after TAVR with the Evolut FX system.Thirty consecutive patients who underwent TAVR with Evolut FX and postprocedural CT were included in this study. The protocol has been approved by the institutional review board and the requirement to obtain written informed consent was waived because of the retrospective nature of the study. The data and materials used to conduct the research will not be made available to any researcher to reproduce the results or replicate the procedure. TAVR procedures were performed, as follows: the flush port of the delivery catheter was inserted facing 3 o'clock (ie, away from the operator), to attempt the "Hat" maker at the outer curve of the ascending aorta and annulus at the initial valve deployment (Figure [A]). Fluoroscopic assessment of the commissural alignment was performed before the final deployment at the cusp-overlap view. Commissural alignment on fluoroscopy was defined as one depth marker in the inner curve of the aortic annulus while 2 markers in the outer curve of the annulus (Figure [B]). Postprocedural CT was used to measure the angles of native commissures, neo-commissures of Evolut FX valve, left and right coronary arteries, and to assess the commissural and coronary alignment (Figure [C] through [E]). Commissural and coronary alignments were defined previously (Figure [F]).3 No patients required recapture and rotation of delivery system due to commissural misalignment on fluoroscopy.Download figureDownload PowerPointFigure. The procedural steps to optimize the commissural alignment with the Evolut FX system. "Hat" marker (circle) was oriented outer curve at initial valve deployment (A). The position of 3 markers before the final deployment at cusp overlap view. The 2 markers (arrow) located in the outer curve while another marker (asterisk) was at the inner curve, suggesting commissural alignment on fluoroscopy (B). Postprocedure computed tomography (CT) assessment of commissural and coronary artery alignment (C–E). The 3 markers were identified at inflow part of the Evolut FX valve (C). The angle between native left-right commissure (blue line) and the closest commissure of Evolut FX valve (red dashed line) was measured (D). The angle between left main coronary artery (LM; yellow line) and the closest commissure of Evolut FX valve (orange dashed line) was measured (E). Commissural and coronary misalignment were determined based on the angle according to the ALIGN-TAVR Consortium (Alignment of Transcatheter Aortic-Valve Neo-Commissures; F). The incidences of commissural and coronary alignment, respectively (G and H). LCA indicates left coronary artery; and RCA, right coronary artery.On post-TAVR CT analysis, commissures were aligned in 18 (60.0%) patients, mildly misaligned 11 (36.7%) patients, and moderately misaligned in 1 (3.3%) patient according to the previous study.3 No patients showed severe commissural misalignment (Figure [G]). Mean angles between left main or right coronary artery, and the closest neo-commissure of THV was 44.6±12.9° and 33.0±15.6°, respectively. The alignment of left main and right coronary arteries is shown in the Figure [H].The present study is the first study to evaluate the Evolut FX orientation with postprocedural CT to determine the degree of commissural and coronary alignments. Importantly, all 30 patients showed commissural alignment on fluoroscopy with the contemporary Evolut deployment technique although limited sample size warrants further investigations. Postprocedure CT showed that 29 out of 30 patients (96.7%) had aligned or mildly misaligned commissures. Therefore, the new 3 depth markers of Evolut FX system help operators confirm the commissural alignment during TAVR. The rate of moderate or severely misaligned left main coronary artery (13.3%) in the present study might be lower than that from the ALIGN TAVR study.2 Nonetheless, moderate or severely misaligned right coronary artery was more frequent (46.7%), likely due to the larger variability of right coronary artery ostium location in the aortic root. Our limited sample size, however, prevents us from drawing robust conclusions regarding coronary alignment in this setting. Our study did not explore whether further maneuvers such as recapture and retrieval the THV system, pulling back and rotating the delivery system in the descending aorta, and redeploying the THV may improve commissure alignment for patients in whom it was not obtained in the first attempt.Article InformationSources of FundingNone.Disclosures Dr Attizzani is a consultant and serves as a proctor and is on the advisory board of Medtronic and is a consultant for Abbott Vascular. Dr Tang is a physician proctor and consultant for Medtronic, a consultant and physician advisory board member for Abbott Structural Heart, and a physician advisory board member for JenaValve. The remaining authors have no relevant conflicts of interest to disclose.FootnotesThis manuscript was sent to S. Chiu C. Wong, Guest Editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 182.Correspondence to: Guilherme F. Attizzani, MD, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106. Email guilherme.attizzani@uhhospitals.orgReferences1. Tarantini G, Nai Fovino L, Scotti A, Massussi M, Cardaioli F, Rodinò G, Benedetti A, Boiago M, Matsuda Y, Continisio S, et al. Coronary access after transcatheter aortic valve replacement with commissural alignment: the ALIGN-ACCESS study.Circ Cardiovasc Interv. 2022; 15:e011045. doi: 10.1161/CIRCINTERVENTIONS.121.011045LinkGoogle Scholar2. Tang GHL, Zaid S, Fuchs A, Yamabe T, Yazdchi F, Gupta E, Ahmad H, Kofoed KF, Goldberg JB, Undemir C, et al. Alignment of transcatheter aortic-valve neo-commissures (ALIGN TAVR): impact on final valve orientation and coronary artery overlap.JACC Cardiovasc Interv. 2020; 13:1030–1042. doi: 10.1016/j.jcin.2020.02.005CrossrefMedlineGoogle Scholar3. Tang GHL, Amat-Santos IJ, Backer OD, Avvedimento M, Redondo A, Barbanti M, Costa G, Tchétché D, Eltchaninoff H, Kim W-K, et al. Rationale, definitions, techniques, and outcomes of commissural alignment in TAVR from the ALIGN-TAVR consortium.JACC Cardiovasc Interv. 2022; 15:1497–1518. doi: 10.1016/j.jcin.2022.06.001CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2023Vol 16, Issue 4 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.122.012657PMID: 37009735 Originally publishedApril 3, 2023 Keywordscommissural alignmenttranscatheter aortic valve replacementcoronary accessaortic rootheart valvePDF download Advertisement SubjectsCatheter-Based Coronary and Valvular Interventions