Commissural alignment in TAVI: a new frontier to facilitate coronary reaccess and Redo TAVI

Abstract

As transcatheter aortic valve implantation (TAVI) expands to younger and low-risk patients with longer life expectancies, the need for post-TAVI coronary access and reintervention for failing transcatheter heart valve (THV) is expected to increase. Commissural alignment in TAVI may facilitate subsequent coronary access, avoiding severe overlap with the THV commissures, and potentially redo-TAVI. The ability to traverse a THV to access the coronary ostia is related to anatomic factors (coronary height and sino-tubular junction (STJ) height and width) and valve-related features. Furthermore, recent evidence suggests that commissural alignment after TAVI may have an impact on THV’s hemodynamics and durability. Several studies have provided technique modifications to obtain commissural alignment with available self-expanding TAVI devices. However, future efforts should aim to refine THV and delivery system designs to make neo-commissural alignment easier and safer. An individualized decision-making approach is recommended in device selection when considering future coronary access and redo-TAVI to facilitate the lifetime management of patients with aortic valve and coronary artery disease. This review aims to provide an overview of available evidence for neo-commissural alignment and strategies to achieve more anatomic valve implantation further.

Keywords

Aortic stenosis / transcatheter aortic valve implantation / TAVI / commissural alignment / redo-TAVI

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