Impact of Initial Evolut Transcatheter Aortic Valve Replacement Deployment Orientation on Final Valve Orientation and Coronary Reaccess
Year: 2019
Type: article
Study design: Observational Study
Abstract: ◼ incidence ◼ retrospective studies ◼ transcatheter aortic valve replacement U nlike surgery, transcatheter heart valve (THV) neo-commissures in transcatheter aortic valve replacement (TAVR) cannot be predictably aligned with native commissures and may interfere with coronary orifices and affect reaccess.[1][2][3] We evaluate the impact of initial deployment orientation of EvolutR/ Pro (ERP) transcatheter valve (Medtronic, Inc, Minneapolis, MN) on its final neocommissural orientation and severity of overlap with the coronaries.From April 2018 to January 2019, among 118 transfemoral ERP TAVR performed at 2 centers, the capsule Hat orientation during initial ERP deployment was categorized as outer curve (OC), center front (CF), inner curve, and center back of the aortic root (Figure [A]).The resulting final C-tab (one of the neo-commissures) orientation was similarly categorized (Figure [B]).Per manufacturer recommendation, the ERP is loaded with C-tab facing up and 90° clockwise from the Hat, and this relationship is preserved during valve deployment.In our study, C-tab positions on fluoroscopy at the same coplanar view as the initial aortogram were co-registered onto computed tomography (CT) axial images of aortic annulus and sinus of valsalva using 3Mensio Valves software (Pie Medical Imaging, Masstricht, the Netherlands).Our co-registration technique is as follows (Figure [C]): first, aortogram and final valve orientation images were obtained at the 3-cusp coplanar view on fluoroscopy.Second, the 3-cusp view was identified on 3Mensio.Third, an orange circle with 15 spokes (corresponding to an ERP with 15 crowns including the C-tab) is projected onto CT axial images, with C-tab orientation of the depicted ERP on CT images matching the fluoroscopic image (co-registration).The ERP neocommissural orientation (120° apart from the C-tab) and relationship to coronary orifices could, therefore, be identified (Figure [C]).Overlap between coronaries and neo-commissures were categorized as severe (0°-20.0°),moderate (20.1°-40.0°),and mild (40.1°-60.0°),as previously described (Figure [D]). 1 A representative case example with post-TAVR CT confirmed the ERP orientation as predicted by our co-registration technique (Figure [E]).Our retrospective study was approved by the institutional review board, and patient consent was waived.Statistical analysis was performed on SPSS version 23 (IBM, Armonk, NY) using χ 2 test or Fisher exact test as appropriate, 2-tailed with P<0.05 considered significant.The authors declare that all supporting data are available within the article.Overall, severe neo-commissural overlap with left main was 33.1%, right coronary artery 20.3%, both 14.4%, and 1 or both 39.0%.With Hat position at OC/ CF, severe overlap with left main was 19.5%, right coronary artery 6.1%, both 2.4%, and 1 or both 23.2% (Figure [F]).Having Hat position at inner curve/center back increased severe overlap with left main to 63.9%, right coronary artery 52.8%, both 41.7%, and 1 or both 75.0%(all P<0.001).
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2954413928