Prospective evaluation of transcatheter aortic valve implantation (TAVI) with coronary alignment and impact on coronary access

Abstract Introduction Transcatheter aortic valve implantation (TAVI) with optimised coronary alignment aims to reduce coronary-commissural overlap (CCO) to facilitate future coronary intervention and reduce the risk of coronary obstruction after re-do TAVI, however, in-vivo data are lacking. Aims To determine the feasibility of TAVI with coronary alignment assessed by post-TAVI CT. Secondary endpoints included the incidence of adverse anatomical features which could impede coronary access (severe CCO and ostia below valve skirt) and their association with coronary engagement during invasive angiography. Methods 30 patients underwent TAVI with optimised coronary alignment with either ACURATE neo2 or Evolut Pro+ and invasive coronary angiography and cardiac CT performed after valve deployment. Results 15 patients received ACURATE neo2 (50%) and 26 patients (86.7%) underwent CT after TAVI. The mean inter-coronary angle was 140 (19.5)° and the median observed angular deviation from perfect alignment (0°) was 0.8° (IQR -4.5 to +10) ° with perfect alignment (±15°) observed in 21/26 cases (80.8%) and ≤mild misalignment (±30°) in 24/26 of cases (92.3%). The remaining two cases had moderate misalignment (30-45°) with no cases of severe misalignment. The angle between the coronary ostia and the nearest TAVI commissure was 46 (40 - 57) ° for the RCA and 50.5 (43 - 54) ° for the LCA which did not differ significantly from the native situation (both p>0.2), with 1 (3.8%) case of severe overlap. 46/55 (83.6%) coronary engagements were selective, 7/55 (12.7%) semi-selective and 2/55 (3.6%) unable to intubate. Non-selective engagement/unable to engage affected the RCA more than the LCA (6/27 [22.2%] vs. 3/28 [10.7%]) and was three-fold more common with the Evolut (7/29 [24.1%]) than the Acurate (2/26 [7.7%]. Coronary>commissural angle in those with unselective engagement was 43° (IQR 37 to 51°). Conclusions TAVI with optimised coronary alignment is technically feasible, safe and reduces coronary-commissural overlap which is important for future re-do TAVI procedures. Difficult coronary access was encountered more frequently following Evolut Pro+ and when engaging the RCA, but was unrelated to angular distance to nearest commissure.