Looking Beyond the Annulus

Q: What is the clinical evidence from this study?

Study design: Editorial. Population: Aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Intervention: Preprocedural CT assessment of the sinotubular junction (STJ).

Q: What does this research mean for the field?

A narrow and severely calcified sinotubular junction acts as a rigid supra-annular constraint that impairs transcatheter heart valve expansion and hemodynamics, necessitating preprocedural CT evaluation of the entire aortic root beyond annular sizing. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Ana Paula Tagliari

doi:10.1016/j.jaccas.2026.109795

September 1, 2026JACC Case ReportsOpen Access

Looking Beyond the Annulus

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Key result

Preprocedural computed tomography evaluation of the sinotubular junction beyond simple annular sizing is crucial for anticipating device-anatomy interactions and optimizing TAVR procedural strategies.

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Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND

Why the study?

Standardized preprocedural CT assessment of the sinotubular junction (STJ) and its impact on transcatheter aortic valve replacement (TAVR) outcomes is still evolving despite its clinical relevance.

Key Points

To review the biomechanical impact of sinotubular junction anatomy on transcatheter heart valve expansion and evaluate the role of comprehensive preprocedural computed tomography planning.
Reviewed bench testing models, fluid–structure interaction simulations, and procedural protocols for transcatheter aortic valve replacement (TAVR).
Evaluated standardized definitions of hostile sinotubular junction (STJ) anatomy, defined by a minimum diameter smaller than a 10% oversized annulus area and circumferential calcification >90°.
Assessed procedural adaptations, including valve selection and a 2-stage balloon inflation technique utilizing deployment balloon filling at 2 mL below nominal volume followed by 1 to 2 mm repositioning.
Narrow and calcified sinotubular junction anatomy is present in approximately 13% of patients undergoing TAVR.
Severe STJ narrowing can reduce prosthetic frame cross-sectional area by more than 50% at the crown region, causing asymmetric frame expansion, leaflet crowding ('cogwheeling'), and elevated transvalvular gradients.

PICO

P

Population

Aortic stenosis undergoing transcatheter aortic valve replacement (TAVR)

I

Intervention / Comparator

Preprocedural CT assessment of the sinotubular junction (STJ)

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Cite This Study

Ana Paula Tagliari (2026) conducted an editorial in Aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Preprocedural CT assessment of the sinotubular junction (STJ) was evaluated. Preprocedural computed tomography evaluation of the sinotubular junction beyond simple annular sizing is crucial for anticipating device-anatomy interactions and optimizing TAVR procedural strategies.

synapsesocial.com/papers/6ace6e0db52af824ab02bc55 https://doi.org/10.1016/j.jaccas.2026.109795

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Looking Beyond the Annulus

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Cite This Study

Looking Beyond the Annulus

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