Commissural Misalignment Following Valve‐in‐Valve Transcatheter Aortic Valve Implantation

ABSTRACT Background Data on commissural misalignment (CMA) during valve‐in‐valve transcatheter aortic valve implantation (ViV‐TAVI) for valve failure after surgical aortic valve replacement (SAVR) is scarce. Aims To study the impact of CMA on clinical and hemodynamic outcomes following ViV‐TAVI for failed SAVR. Methods Data of patients who underwent ViV‐TAVI for failed SAVR valves at two institutions (Heart Center Leipzig at Leipzig University, Leipzig, Germany; Cedars‐Sinai Smidt Heart Institute, Los Angeles, USA) were retrospectively collected and compared regarding the existence of CMA. Outcomes of interest included Valve Academic Research Consortium (VARC)‐3‐based clinical endpoints, Computed Tomography‐based hypoattenuated leaflet thickening (HALT), hemodynamic outcome, and mid‐term all‐cause mortality. Results Of the 687 patients who underwent ViV‐TAVI, post‐procedural CT of sufficient quality to measure commissural alignment was available in 180 patients (47.8% females, mean age 78.0 years). Self‐expanding TAVI valves were used in 49.2% of the cases. CMA was found in 35 individuals (19.4%) and was associated with reduced VARC‐3‐based technical success (80% vs. 93%, p = 0.03), driven by increased rates of coronary obstruction (17.1% vs. 5.6%, p = 0.03). The incidence of HALT was 31.7%, without differences in patients with and without CMA. VARC‐3‐based device success was 62.9%, driven by an incidence of residual mean valve gradient (≥ 20 mmHg) of 35.4%, without differences between groups. Midterm survival after a mean of 747 days was 84.6% and comparable between groups. Conclusions For patients undergoing ViV‐TAVI for failed SAVR, technical success is reduced for cases of CMA due to higher odds of coronary obstruction, without differences in mid‐term survival.