Underlying coronary misalignment after latest generation supra-annular self-expandable transcatheter heart valves in the asian population

Background The latest generation supra-annular self-expandable transcatheter heart valve (Evolut FX+) features three apertures positioned 120 degrees apart designed to facilitate coronary cannulation after implantation. However, it is unknown whether the coronary artery ostia align with these apertures in the Asian population, and the optimal implantation depth of Evolut FX+ is also unclear. Purpose We aimed to clarify the optimal implantation depth by evaluating the positional relationship between the coronary artery ostium and the Evolut FX+ apertures in the Asian population, as predicted from preoperative computed tomography (CT). Methods We retrospectively analyzed 496 patients who underwent transcatheter aortic valve replacement (TAVR) at our hospital between October 2015 and June 2025. We excluded cases in which contrast-enhanced CT were unavailable and a total of 470 cases were included in the present analysis. A 26-mm Evolut FX+ valve was virtually implanted at depths of 0, 3, and 6 mm below the annular plane, and we assessed whether the coronary artery ostium matched the inside of the apertures, and if it did not, we defined it as a coronary misalignment. Results The median age of the entire cohort was 84 years, and 61.9 % of patients were female. The mean annulus perimeter was 73.0 mm and the average sinus of valsalva (SOV) diameter was 30.5 mm. The mean coronary height was 16.9 mm in the right coronary artery (RCA) and 13.2 mm in the left coronary artery (LCA). The relationship between the coronary ostium of LCA and RCA and the flame apertures at implantation depth of 0, 3, and 6 mm is shown in Figure 1. For the RCA, the coronary ostium and apertures were most closely matched at an implanted position of 3 mm. On the other hand, for LCA, the best match was observed at the 6 mm position. For both LCA and RCA, the coronary ostium and aperture locations matched in 44 % of cases at the 3mm position and in 54 % of cases at the 6mm position (Figure 2). At the 3 mm implantation depth, the coronary artery ostium was statistically more likely to be aligned with the apertures in men (p< 0.001), and in those with a larger annulus perimeter (p< 0.001), a larger right coronary cusp SOV (p< 0.001) and a larger non-coronary cusp SOV (p< 0.001), a higher RCA ostium (p< 0.001), a higher LCA ostium (p< 0.001). Conclusions In the Asian populations, the implantation depth most likely to align the RCA ostium with the Evolut FX + valve was 3 mm, whereas a depth of 6 mm was most likely to match the LCA ostium.