Assessment of commissural and coronary ostial alignment of aortic valve bioprosthesis after transcatheter aortic valve implantation

Abstract Background Commissural alignment (CA) is an emerging concept that has become fundamental to the transcatheter aortic valve implantation (TAVI) procedure. Optimizing CA is essential, as it facilitates future coronary access, enables re-intervention in case of valve failure, and enhances valvular function and durability by reducing leaflet stress and strain. Objective We aim to evaluate the degree of commissural alignment between the transcatheter heart valve (THV) and the native aortic valve following TAVI and to investigate the implications of CA on coronary access, valvular function, and procedural and clinical outcomes. Methods We performed multidetector computed tomography (MDCT) scans on 60 TAVI patients both before and after the TAVI procedure. TAVI procedure was performed with the aim of achieving commissural alignment in all patients. The degree of CA was assessed and categorized as either aligned, or as mild, moderate, or severe commissural misalignment (CMA). In addition, the coronary overlap (CO) between the THV commissures and the coronary ostia was evaluated and categorized as no, moderate, or severe coronary overlap. Results Ninety percent of our cases (n=54) were aligned, while the remaining 10% (n=6) exhibited only mild CMA and none of the patients in our study showed moderate or severe CMA. The assessment of coronary overlap revealed that the majority of participants (85%) had no CO. Moderate CO was observed in 15% (n= 9/60) of cases, with only one case exhibiting Left coronary artery (LCA) overlap and 8 cases exhibiting right coronary artery (RCA) overlap. None of the cases exhibited severe CO. Based on the degree of CA, patients were divided into two groups: the aligned group (n=54) and the CMA group (n=6). The CMA group demonstrated a notably higher mean calcium score (4710.3 ± 503.9 vs. 3022.1 ± 155.9 p=0.018), in addition to, a higher incidence of moderate CO (83.3% vs. 7.4%, p0.001), paravalvular leak (100% vs. 40.7% p=0.001), and complete heart block (CHB) followed by permanent pacemaker (PPM) implantation (33.3% vs. 9.3% p=0.044). Conclusion Commissural alignment significantly reduces the incidence of coronary ostial overlap, thereby mitigating the potential challenge of future coronary reaccess due to the proximity of a neo-commissure to the coronary ostium. Commissural misalignment is linked to a significantly higher incidence of paravalvular leak and complete heart block, necessitating PPM implantation.Assessment of commissural alignment Assessment of coronary ostial alignment