Commissural Alignment During TAVR With a New-Generation Self-Expandable Valve in a Single Coronary Artery

Figures

• 

  Figure 1. Preprocedural Planning in a Patient With Aortic Stenosis and a Single Coronary Artery Preprocedural computed tomography demonstrating a single coronary artery originating from the left coronary cusp with a solitary coronary ostium.

• 

  Figure 2. Procedural Commissural Alignment Strategy (A) Aortography in the cusp-overlap view. Two 5-F pigtail catheters are positioned in the noncoronary cusp (NCC) and left coronary cusp (LCC). (B) The cusp-overlap technique was employed. Partial deployment was performed with the transcatheter heart valve aligned to the NCC at a −3-mm implantation depth. The gold markers are visualized in a 2:1 configuration. (C) In the en face view, contrast injection from the LCC pigtail catheter demonstrates that the coronary ostium (circle) is located between 2 gold markers (arrows), indicating optimal commissural alignment. (D) After full release in the left anterior oblique view, aortography demonstrates preserved coronary flow and mild aortic regurgitation.

• 

  Figure 3. Coronary Access After Valve Implantation (A) Selective coronary engagement using a Judkins left catheter was easily achieved in the en face view. A large stent-frame cell (square) is aligned with the coronary ostium, indicating preserved coronary access. (B) Coronary angiography demonstrating no flow limitation.

• 

  Figure 4. Postprocedural Assessment of Coronary Access (A) Postprocedural computed tomography demonstrating the relationship between the transcatheter heart valve frame and the coronary ostium. A large stent-frame cell (arrow) is aligned with the coronary ostium (circle), indicating preserved coronary access. (B) Three-dimensional reconstruction confirming optimal commissural alignment without overlap of neo-commissural posts.

• 

  Visual Summary. Commissural Alignment to Preserve Coronary Access in Transcatheter Aortic Valve Replacement With a Single Coronary Artery (A) Preprocedural computed tomography demonstrated a single coronary artery with a solitary coronary ostium. (B) Transcatheter aortic valve replacement was performed using a self-expandable Evolut FX+ valve with intentional commissural alignment guided by cusp-overlap and en face fluoroscopic views. Optimal valve orientation avoided overlap between neo-commissural posts and the coronary ostium. (C and D) Postprocedural imaging confirmed preserved coronary access, with a large stent-frame cell facing the coronary ostium.