Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York.
Division of Cardiology, Westchester Medical Center, Valhalla, New York.
JACC Cardiovasc Interv. 2020 May 11;13(9):1030-1042. doi: 10.1016/j.jcin.2020.02.005. Epub 2020 Mar 16.
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.
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.
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.
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.
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.
本研究旨在评估 Sapien 3、Evolut 和 Acurate-neo 经导管心脏瓣膜初始部署方向对其最终方向和新交界重叠与冠状动脉的影响。
初始经导管主动脉瓣置换术（TAVR）后冠状动脉入路和再次 TAVR 可能受经导管心脏瓣膜方向的影响。本研究评估了经导管心脏瓣膜部署方向对交界对齐的影响。
2016 年 3 月至 2019 年 9 月，在 5 个中心对 828 例接受 TAVR（Sapien 3 483 例，Evolut 245 例，Acurate-neo 100 例）的患者进行了术前 CT 和术中透视分析。将共面透视视图与术前 CT 配准，以确定交界对齐情况。新交界后柱与冠状动脉之间严重重叠定义为 0°至 20°。Sapien 3 的 1 个交界后柱在 3、6、9 和 12 点钟处卷曲。Evolut 的“帽”标记和 Acurate-neo 的交界后柱在部署时分为后中（CB）、内曲线（IC）、外曲线（OC）或前中（CF），并与最终方向相匹配。
初始 Sapien 3 卷曲方向对交界对齐无影响。初始部署时 Evolut 的“帽”位于 OC 或 CF 处，与左主干（15.7%比 66.0%）和右冠状动脉（7.1%比 51.1%）的重叠程度较轻。在降主动脉的 OC 处追踪 Evolut 的“帽”（n=107），可使部署时的 OC 从 70.2%提高到 91.6%（p=0.002），并使冠状动脉重叠减少 36%至 60%（p<0.05）。在部署时，Acurate-neo 的交界后柱位于 CB 或 IC 处与 CF 或 OC 处相比，与冠状动脉重叠程度较小（p<0.001），在 7 例中有 5 例成功实现了有意对齐。
这是对 TAVR 中交界对齐的首次系统评估。超过 30%至 50%的病例与 1 条或 2 条冠状动脉有重叠。初始 Sapien 3 方向对对齐没有影响，但 Evolut 和 Acurate 的特定初始方向可改善对齐。优化瓣膜对齐以避免冠状动脉重叠对于冠状动脉入路和再次 TAVR 非常重要。
