Impact of commissural alignment on the hemodynamic performance of supra‐annular self‐expandable transcatheter aortic valves

Abstract Background Hemodynamic impact of commissural alignment (CA) with self‐expandable transcatheter aortic valves (TAVR) has not been investigated yet. Aims To determine hemodynamic impact of CA with self‐expandable TAVR. Methods Multicentric ambispective study comparing patients who underwent self‐expandable TAVR in seven centers with the Evolut Pro/Pro+ (EP) (Medtronic) and Acurate neo2 (AN2) (Boston Scientific) with and without CA strategies. The degree of commissural misalignment (CMA) was assessed by computed tomography/angiography and 1‐year transvalvular gradients/regurgitation evaluated by echocardiography. A matched comparison according to annular dimensions/eccentricity, prosthesis size/type, and baseline left ventricular function and gradients was performed. Results A total of 557 patients, mean age 80.7 ± 6.6 years, 61.4% men, and STS score of 4.3 ± 3.1% were analyzed. A CA technique was attempted in 215 patients (38.6%), including 113 patients with AN2 and 102 patients with EP. None/mild CMA was found in 158 (73.5% vs. 43.6% if no CA attempted, p < 0.001) with no differences between devices (AN2:75.2%; EP:71.6%, p = 0.545). Patients with moderate/severe CMA had a greater aortic peak gradient (22.3 ± 8.7 vs. 19.7 ± 8.5, p = 0.001), significantly greater progression of both peak ( p = 0.002) and mean gradients ( p = 0.001) after matching, and higher rate of central aortic regurgitation (1.2% vs. 0.4%, p = 0.005) at 1‐year, but not a greater proportion of patients with mean gradient ≥ 10 mmHg. Conclusions The use of CA strategies significantly reduced the rate of CMA for the self‐expandable TAVR devices ACN2 and EP which was associated to lower transvalvular gradients and intra‐prosthetic regurgitation progression at 1‐year although no criteria of structural deterioration were met at this follow up. Clinicaltrials.org : NCT05097183.