Commissural vs. Coronary Optimized Alignment During TAVR

Quick Takes

  • Commissural alignment during TAVR can reduce coronary overlap but there is still a risk of this.
  • Optimized coronary alignment by CT may be able to further lower the risk of coronary overlap.

Study Questions:

What is the risk of coronary overlap (CO) during transcatheter aortic valve replacement (TAVR) deployment, and can computed tomography (CT) provide an improved deployment strategy to lower this risk?

Methods:

This study examined baseline CT studies in patients evaluated for TAVR and evaluated the distances from the commissures to the right and left coronary arteries. A virtual valve was simulated with commissural or coronary alignment, and the amount of CO was evaluated for each patient. Patients were stratified as no risk, moderate risk, and severe risk of CO (>35, 20-35, and ≤20 degrees from neo-commissure to coronary ostia).

Results:

The CTs for 107 patients were evaluated, and after excluding seven cases (poor image quality or bicuspid valve), 100 patients were included in the study. The right coronary artery had greater eccentricity compared to the left coronary artery. Despite ideal commissural alignment, 32 (32%) patients had moderate or severe risk for CO. Greater coronary eccentricity and high intercoronary angle were associated with higher risk of moderate or severe CO despite commissural alignment (area under the curve, 0.97). If optimal coronary alignment was simulated, there were no cases of severe CO, and cases of moderate CO decreased from 75% to 5% (p < 0.001).

Conclusions:

Despite commissural alignment, 32% of patients treated with TAVR would have moderate or severe risk of CO as simulated on virtual valve deployment using CT. The use of optimal coronary alignment would markedly lower the risk of CO when simulated on CT.

Perspective:

Given the concerns for coronary artery obstruction with TAVR and challenges to coronary artery access after TAVR, there has been interest in commissural alignment during TAVR procedures to reduce risk of CO. However, the sinuses of Valsalva are not always symmetrical, and the coronary artery ostia are not always centered in the sinuses, resulting in the potential for CO even with commissural alignment. This study simulated virtual valve deployment based on CT images in patients assuming ideal commissural alignment of the device, and observed a significant residual potential risk of CO. An alternative approach using optimal coronary artery alignment on simulated virtual valve deployment may reduce this risk. Future studies are needed for evaluating the effectiveness and feasibility of this approach in nonsimulated TAVR procedures.

Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Coronary Vessels, Diagnostic Imaging, Heart Valve Diseases, Risk, Tomography, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement


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