Nordic consensus document on Evolut FX+ transcatheter aortic valve implantation: optimizing index implantation and longer-term outcomes

Figures

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  Figure 1. Evolut FX+ transcatheter aortic valve and delivery system. Novel design features of the latest-generation Evolut FX+ valve and its catheter delivery system (the catheter delivery system of the Evolut FX and FX+ valves). CDS, catheter delivery system.

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  Figure 2. Insertion of the Evolut FX+ catheter delivery system. The Evolut FX(+) valve can be implanted using either the integrated delivery catheter system or an introducer sheath. §Following pre-dilatation of the Python 14-Fr sheath with a 7- or 8-mm balloon.

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  Figure 3. Effective pre-dilatation prior to valve implantation. Pre-dilatation should be considered for most cases prior to valve implantation, with balloon sizing based on the dimensions and phenotype of the aortic annulus and valve. Pre-dilatation is best performed in an RAO view to better appreciate balloon expansion and calcified leaflet modification. Repeat inflation may be advised in case of excessively calcified leaflets and/or if a significant waist on the balloon is evident. Ca, calcified; LVOT, left ventricular outflow tract; RAO, right anterior oblique.

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  Figure 4. Step-by-step approach to achieve commissural alignment with the Evolut FX(+). Commissural alignment can be achieved by tracking the positions of the hat marker and specific radiopaque markers found on the catheter delivery system and Evolut FX(+) valve, respectively. LAO, left anterior oblique; R–L, right–left.

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  Figure 5. Optimized implantation technique with the Evolut FX(+). Valve implantation is commenced in the NCC isolation view. Assessment of the Evolut implant depth relative to the base of the NCC and LCC is then made in both the NCC and LCC isolation views, respectively, after removing parallax in the Evolut valve. CAU, caudal; CRA, cranial; LAO, left anterior oblique; LCC, left coronary cusp; NCC, non-coronary cusp; RAO, right anterior oblique; RCC, right coronary cusp; R–L, right–left; R–N, right–non.

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  Figure 6. Post-dilatation of the Evolut FX(+). Post-dilatation is recommended to address significant paravalvular regurgitation, elevated transvalvular gradients, or stent frame under-expansion. Balloon sizing is based on the dimensions of the native aortic annulus and aortic root, the bulkiness of calcium at the level of the leaflets, annulus, and left ventricular outflow tract, and the waist of the implanted Evolut valve. TAV, transcatheter aortic valve.

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  Figure 7. ACCESS algorithm for coronary access with the Evolut FX(+). A systematic approach to coronary access allows for potential challenges to be evaluated and specific techniques to be adopted to overcome coronary access challenges.