Improved commissural alignment in TAVI: novel approach versus conventional approach with Evolut FX

Abstract Background Commissural misalignment (CMA) critically affects coronary access and the feasibility of future reintervention following transcatheter aortic valve implantation (TAVI). The conventional commissural alignment technique for the supra-annular self-expanding valve (SASEV) involves positioning the delivery catheter with the flush port at the 3 o’clock position and confirming the Hat marker on the outer curve at the descending aorta. However, optimizing the Hat marker's position at the descending aorta may further improve commissural alignment between the SASEV and the native aortic valve. Purpose This study aimed to evaluate the effectiveness of a novel alignment technique compared to the conventional method in achieving optimal commissural alignment during TAVI. Methods We analyzed 150 consecutive patients who underwent TAVI with the Evolut FX valve and received postprocedural CT imaging between March 2023 and November 2024. We excluded the following cases from the analysis: 1)TAVI performed with approaches other than the transfemoral approach; 2) TAVI for failed surgical bioprostheses; 3) TAVI for a bicuspid aortic valve. The novel technique involved repositioning the Hat marker to the center-back position on the cusp overlap view at the descending aorta. CMA was assessed using the ALIGN-TAVR Consortium criteria. Clinical endpoints included all-cause mortality, pacemaker implantation, major vascular complications, and stroke. Results The median age of the study population was 85 years (IQR 81–88), with 87 (58.0%) male patients. Of the total cohort, 67 patients (44.7%) underwent the conventional technique, whereas 83 (55.3%) received the novel method. The novel method resulted in better commissural alignment compared to the conventional technique, with smaller misalignment angles (14.4° IQR 9.7, 25.7 vs. 20.3° IQR 11.0, 30.6, p=0.067). Moderate or severe CMA occurred less frequently in the novel method group than in the conventional group (15.7% vs. 29.9%, p=0.047). Although the reduction in severe coronary overlap was not statistically significant, it was numerically lower in the novel method group (7.2% vs. 13.4%, p=0.28). Clinical outcomes, including all-cause mortality, pacemaker implantation, major vascular complications, and stroke, were comparable between the two groups (6.0% vs. 9.0%, p=0.54). Conclusions The novel alignment technique demonstrated a trend towards improved commissural alignment in TAVI with the new-generation SASEV. Although the reduction in severe coronary overlap did not reach statistical significance, the technique may offer better anatomical outcomes without compromising clinical safety. Further large-scale studies are warranted to confirm its clinical utility and long-term benefits.Figure1 Figure2