Noncoronary Sinus Pivot Implantation for Transcatheter Aortic Valve Replacement With Self-Expanding Valve for Aortic Regurgitation

Figures

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  Figure 1. Position, Axiality, Shape, and Sizing Assessment Principle (A) Position: the noncoronary cusp (NCC) side implantation depth (white arrow) of the valve should be between −2 and 2 mm. The red dashed line represents the plane of annulus, and the next 3 panels are the same. (B) Axiality: the valve should be relatively coaxial to the aorta, in which the implant depth of the valve on the left coronary cusp (LCC) side (white arrow) should be <12 mm. (C) Shape: the inferior end of valve stent in noncoronary sinus side should be in a slightly concave shape (white arc). (D) Sizing: the oversizing rate of the valve (derived from annuls diameter and valve stent diameter) should be 15% to 30%.

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  Figure 2. Steps of the Noncoronary Sinus Pivot Implantation Procedure (A) The valve was at a high position at the beginning, which was 0 to 2 mm above the bottom of noncoronary sinus (white arrow). Then the valve was released upon fast pacing. The red dashed line represents the plane of annulus, and the next 3 panels are the same. (B) During the releasing, noncoronary sinus bottom provided a support force to prevent the valve stent from moving down during release, because the inferior end of valve stent was attached to the noncoronary sinus bottom (white arc). (C) The valve was released to a retrievable limit, and the PASS (Position, Axiality, Shape, and Sizing) principle was used to assess whether the valve was on NCPI status. The inferior end of valve stent in noncoronary sinus side was in a slightly concave shape for providing a support force to the valve (white arc). (D) The valve was completely released, and the successful noncoronary sinus pivot implantation was achieved.

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  Figure 3. Distribution of Aortic Angulation in 2 Groups In the noncoronary sinus pivot implantation (NCPI) group, 93.5% of patients had an aortic angulation of 30° to 60° and 4.3% had an aortic angulation of >60°. In the non-NCPI group, 68.3% of patients had an aortic angulation of 30° to 60° and 19.5% had an aortic angulation of >60°. The aortic angulation distribution was significantly different between the 2 groups (P < 0.001).

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  Central Illustration. Design and Main Findings of the NCPI Study The noncoronary sinus pivot implantation (NCPI) strategy was a superior approach for transcatheter aortic valve replacement (TAVR) with common self-expanding valves in patients with pure aortic regurgitation (PAR). This technique offers a higher device success rate and reduces complications to the conventional method. The white arrow indicates that the valve is 0 to 2 mm higher than the bottom of the noncoronary sinus. The red dashed line represents the plane of annulus, and the white arc represents the valve stent.