Alignment of Transcatheter Aortic-Valve Neo-Commissures (ALIGN TAVR): Impact on Final Valve Orientation and Coronary Artery Overlap.,JACC: Cardiovascular Interventions

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Alignment of Transcatheter Aortic-Valve Neo-Commissures (ALIGN TAVR): Impact on Final Valve Orientation and Coronary Artery Overlap.
JACC: Cardiovascular Interventions ( IF 11.7 ) Pub Date : 2020-03-16 , DOI: 10.1016/j.jcin.2020.02.005
Gilbert H L Tang ₁ , Syed Zaid ₂ , Andreas Fuchs ₃ , Tsuyoshi Yamabe ₄ , Farhang Yazdchi ₅ , Eisha Gupta ₆ , Hasan Ahmad ₂ , Klaus F Kofoed ₇ , Joshua B Goldberg ₈ , Cenap Undemir ₈ , Ryan K Kaple ₉ , Pinak B Shah ₁₀ , Tsuyoshi Kaneko ₅ , Steven L Lansman ₈ , Sahil Khera ₆ , Jason C Kovacic ₆ , George D Dangas ₆ , Stamatios Lerakis ₆ , Samin K Sharma ₆ , Annapoorna Kini ₆ , David H Adams ₁ , Omar K Khalique ₁₁ , Rebecca T Hahn ₁₁ , Lars Søndergaard ₃ , Isaac George ₄ , Susheel K Kodali ₁₁ , Ole De Backer ₃ , Martin B Leon ₁₁ , Vinayak N Bapat ₄

Affiliation

Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York.
Division of Cardiology, Westchester Medical Center, Valhalla, New York.
The Heart Center, Rigshospitalet, Copenhagen, Denmark.
Division of Cardiac Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.
Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Division of Cardiology, Mount Sinai Medical Center, New York, New York.
Department of Cardiology & Radiology, Rigshospitalet University of Copenhagen, Copenhagen, Denmark.
Section of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, New York.
Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut.
Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts.
Division of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.

OBJECTIVES The aim of this study was to evaluate the impact of initial deployment orientation of SAPIEN 3, Evolut, and ACURATE-neo transcatheter heart valves on their final orientation and neocommissural overlap with coronary arteries. BACKGROUND Coronary artery access and redo transcatheter aortic valve replacement (TAVR) following initial TAVR may be influenced by transcatheter heart valve orientation. In this study the impact of transcatheter heart valve deployment orientation on commissural alignment was evaluated. METHODS Pre-TAVR computed tomography and procedural fluoroscopy were analyzed in 828 patients who underwent TAVR (483 SAPIEN 3, 245 Evolut, and 100 ACURATE-neo valves) from March 2016 to September 2019 at 5 centers. Coplanar fluoroscopic views were coregistered to pre-TAVR computed tomography to determine commissural alignment. Severe overlap between neocommissural posts and coronary arteries was defined as 0° to 20° apart. The SAPIEN 3 had 1 commissural post crimped at 3, 6, 9, and 12 o'clock. The Evolut "Hat" marker and ACURATE-neo commissural post at deployment were classified as center back (CB), inner curve (IC), outer curve (OC), or center front (CF) and matched with final orientation. RESULTS Initial SAPIEN 3 crimped orientation had no impact on commissural alignment. Evolut "Hat" at OC or CF at initial deployment had less severe overlap than IC or CB (p < 0.001) against the left main (15.7% vs. 66.0%) and right coronary (7.1% vs. 51.1%) arteries. Tracking Evolut "Hat" at OC of the descending aorta (n = 107) improved OC at deployment from 70.2% to 91.6% (p = 0.002) and reduced coronary artery overlap by 36% to 60% (p < 0.05). ACURATE-neo commissural post at CB or IC during deployment had less coronary artery overlap compared to CF or OC (p < 0.001), with intentional alignment successful in 5 of 7 cases. CONCLUSIONS This is the first systematic evaluation of commissural alignment in TAVR. More than 30% to 50% of cases had overlap with 1 or both coronary arteries. Initial SAPIEN 3 orientation had no impact on alignment, but specific initial orientations of Evolut and ACURATE improved alignment. Optimizing valve alignment to avoid coronary artery overlap will be important in coronary artery access and redo TAVR.

中文翻译：

经导管主动脉瓣新口对准（ALIGN TAVR）：对最终瓣膜方向和冠状动脉重叠的影响。

目的本研究的目的是评估SAPIEN 3，Evolut和ACURATE-neo经导管心脏瓣膜的初始部署取向对其最终取向和与冠状动脉的新连合重叠的影响。背景技术在初始TAVR之后，冠状动脉通路和重做经导管主动脉瓣置换术（TAVR）可能受到经导管心脏瓣膜取向的影响。在这项研究中，评估了经导管心脏瓣膜部署方向对连合对齐的影响。方法对2016年3月至2019年9月在5个中心接受828例行TAVR的患者（483例SAPIEN 3、245例Evolut和100例ACURATE-neo瓣膜）进行了TAVR前计算机断层扫描和透视检查。共面透视透视图与TAVR前计算机断层扫描共同登记以确定连合对齐。新连合柱与冠状动脉之间的严重重叠定义为相隔0°至20°。SAPIEN 3在3、6、9和12点钟处压接了1个连合柱。Evolut的“帽子”标记和展开时的ACURATE-neo合缝柱被分类为中心靠背（CB），内部曲线（IC），外部曲线（OC）或中心前面（CF），并与最终方向匹配。结果最初的SAPIEN 3卷曲方向对连合对齐没有影响。初次部署时，OC或CF处的Evolut“帽子”相对于左主干动脉（15.7％对66.0％）和右冠状动脉（7.1％对51.1％）的重叠程度不如IC或CB（p <0.001）。在降主动脉（n = 107）的OC处追踪Evolut“ Hat”可使部署时的OC从70.2％提高至91.6％（p = 0.002），并使冠状动脉重叠减少36％至60％（p <0）。05）。与CF或OC相比，部署期间CB或IC的ACURATE-neo连合后冠状动脉重叠少（p <0.001），其中有7例中有5例成功进行了有意对准。结论这是TAVR中对连合对准的首次系统评价。超过30％至50％的病例有1个或两个冠状动脉重叠。SAPIEN 3的初始方向对对齐没有影响，但是Evolut和ACURATE的特定初始方向改善了对齐。优化瓣膜对准以避免冠状动脉重叠对冠状动脉通路和重做TAVR至关重要。结论这是TAVR中对连合对准的首次系统评价。超过30％至50％的病例有1个或两个冠状动脉重叠。SAPIEN 3的初始方向对对齐没有影响，但是Evolut和ACURATE的特定初始方向改善了对齐。优化瓣膜对准以避免冠状动脉重叠对冠状动脉通路和重做TAVR至关重要。结论这是TAVR中对连合对准的首次系统评价。超过30％至50％的病例有1个或两个冠状动脉重叠。SAPIEN 3的初始方向对对齐没有影响，但是Evolut和ACURATE的特定初始方向改善了对齐。优化瓣膜对准以避免冠状动脉重叠对冠状动脉通路和重做TAVR至关重要。

更新日期：2020-03-16

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