Clinical and structural outcomes of neocommissural alignment in transaxillary and transcarotid transcatheter aortic valve implantation with a self-expandable transcatheter heart valve

Figures

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  The Acurate neo2 THV has 3 radiopaque commissural posts and “free stent struts.”

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  Figure 1. The Acurate neo2 THV has 3 radiopaque commissural posts (red arrows) and “free stent struts” (yellow arrows) in line with the valve commissures.

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  Figure 2. Technique for neocommissural alignment. A, Depiction of how one of the posts and one of the free stent struts must be orientated toward the intercoronarian RCC and LCC commissure. The orientation of one of the posts and one of the free stent struts to the right of the screen in the RCC and LCC overlap view (B) facilitates the THV implantation with neocommissural alignment.

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  Figure 3. Commissural alignment between native and THV was assessed by TEE before (A) and after the procedure (B). The midpoint of the junction between the interatrial septum and the noncoronary sinus was identified in a short-axis aortic valve view perpendicular to the aortic root axis in end diastole. The virtual line between this landmark and the center of the aortic leaflet coaptation was taken as a reference, and the angles with the lines between the center of the aortic valve and each of the native (pre) and prosthetic (post) aortic valve commissures were measured.

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  Figure 4. Commissural alignment between native and THV was assessed by a preoperative MDCT (A) and a 3-month postoperative MDCT (B) in the end-diastolic phase of the heart cycle. The origin of the RCA was identified in a cross-section perpendicular to the axis of the aorta, and then it was rotated around the center of the aorta until it was on top at 12 o'clock in the image. A vertical line was drawn through the RCA and the center of the aorta. Thereafter, 3 angles were measured through the center of the aorta from the RCA to the RCC/LCC commissure, from the RCA to the LCC/NCC commissure, and from the RCA to the NCC/RCC commissure.

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  Figure 5. The bar chart depicts the mean difference in commissural orientation between native and neocommissures. SD, Standard deviation; THV, transcatheter heart valve.

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  Figure 6. This patient-specific technique for transaxillary and transcarotid insertion of the Acurate neo2 delivery system prevents THV implantations with more than mild CMA and with a high device success rate. TAVI, Transcatheter aortic valve implantation; THV, transcatheter heart valve; TEE, transesophageal echocardiogram; CT, computed tomography.