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. 2023 Sep 21;9(2):156-165.
doi: 10.4244/AIJ-D-23-00017. eCollection 2023 Sep.

Commissural alignment in the Evolut TAVR procedure: conventional versus hat marker-guided shaft rotation methods

Yutaka Konami  1   2 , Tomohiro Sakamoto  1 , Hiroto Suzuyama  1 , Eiji Horio  1 , Junichi Yamaguchi  2
Affiliations

Commissural alignment in the Evolut TAVR procedure: conventional versus hat marker-guided shaft rotation methods

Yutaka Konami et al. AsiaIntervention. .

Abstract

Background: Coronary cannulation after TAVR is sometimes difficult due to an overlap between native and neo-commissures, especially in Evolut devices with a supra-annular position. The Evolut C-tab corresponds to a neo-commissure, and the hat marker is in a fixed position. Therefore, the orientation of the hat marker can be adjusted to minimise overlaps.

Aims: We investigated whether the HAt marker-guided SHaft rotation method (HASH, stylised as the #rotation method) is effective in facilitating coronary artery access after transcatheter aortic valve replacement (TAVR) with an Evolut system.

Methods: We retrospectively analysed 95 patients who underwent electrocardiogram-gated cardiac computed tomography after TAVR. In the #rotation method, the hat marker of the delivery catheter was adjusted to face the greater curvature of the descending thoracic aorta in the left anterior oblique view. Its orientation was maintained while the system passed through the aortic arch.

Results: In total, 60 and 35 patients underwent TAVR with the #rotation and non-#rotation methods, respectively. A ±15° angle between the native and neo-commissures was more frequent in the #rotation group (p=0.001). Favourable angles and appropriate frame orientation for access to the left coronary artery were significantly more frequent in the #rotation group than in the non-#rotation group (p<0.001 and p=0.001). Although the #rotation method showed a higher rate of favourable angles and frames in the right coronary artery, statistically significant differences were not found.

Conclusions: The #rotation method is useful for improving commissural post alignment in TAVR with Evolut devices, especially in the ostium of the left coronary artery.

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Conflict of interest statement

T. Sakamoto is a clinical proctor of the Evolut TAVR system. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1. Patient flow diagram and study design.
#rotation method: HAt marker-guided Shaft (HASH) rotation method; CT: computed tomography; eGFR: estimated glomerular filtration rate; TAVR: transcatheter aortic valve replacement
Figure 2
Figure 2. The #rotation method.
A) Positional relationship between the hat marker and the C-tab of the THV. B) The aortic valve viewed from the angle of overlap between the RCC (green curve) and LCC (red curve). When the hat marker is located in the centre front position, the C-tab is located near the native RLCC commissure. C,D) The hat marker (red arrow) should face the greater curvature of the descending thoracic aorta. Otherwise, the shaft of the delivery catheter should be rotated. E) If the hat marker passes through the aortic arch facing the greater curvature, it is positioned centre front (red arrow) at the position of the aortic valve (F). #rotation method: HAt marker-guided SHaft (HASH) rotation method; LCA: left coronary artery; LCC: left coronary cusp; RCA: right coronary artery; RCC: right coronary cusp; RLCC: right/left coronary cusp; THV: transcatheter heart valve
Figure 3
Figure 3. Examples of cardiac computed tomography measurements.
Angles between (A) the native RLCC commissure and the LCA; B) the C-tab commissure and the RCA or LCA; and (C) the C-tab commissure and the native RLCC commissure. When the native RLCC commissure is oriented clockwise or counterclockwise relative to the C-tab, the angle is indicated with a positive or negative value, respectively. D) The distance between the THV inflow and the inferior border of the LCA ostium (total length of the blue and yellow lines). LCA: left coronary artery; LCC: left coronary cusp; RCA: right coronary artery; RCC: right coronary cusp; RLCC: right/left coronary cusp; THV: transcatheter heart valve
Figure 4
Figure 4. Angles between the native RLCC commissure and C-tab commissure (ϕ).
The percentage of patients in whom the C-tab commissure is placed at ±15° relative to the native RLCC commissure is significantly higher in the #rotation group (56.7%) than in the non-#rotation group (22.9%). The percentage in the #rotation group is even higher (88.3%) when the permitted angle is increased to ±30°. #rotation method: HAt marker-guided SHaft (HASH) rotation method; RLCC: right/left coronary cusp<
Figure 5
Figure 5. Incidence of favourable angles for post-TAVR coronary access.
A) The percentage of patients with a favourable angle between the C-tab commissure and the ostium of the RCA is higher in the #rotation group, but the difference is not significantly significant. B) This difference is statistically significant in the LCA. #rotation method: HAt marker-guided SHaft (HASH) rotation method LCA: left coronary artery; RCA: right coronary artery; TAVR: transcatheter aortic valve replacement
Figure 6
Figure 6. Favourable orientation of THV cells for post-TAVR coronary access.
A, B) The x-axes show the angle between the C-tab commissure and the ostium of the coronary artery. The y-axes show the distance between the THV inflow and the ostium of the coronary artery. The pink and yellow areas correspond to the skirt and commissural triangle, respectively. The blue circles and orange squares represent the ostium of the coronary artery in the #rotation and non-#rotation groups, respectively. THVs with a size of 23 mm were excluded from analysis due to a low sample size. C) There is no between-group difference for THVs ≥26 mm with regard to coronary access to the RCA. D) The #rotation method is superior for coronary access to the LCA. #rotation method: HAt marker-guided SHaft (HASH) rotation method; LCA: left coronary artery; RCA: right coronary artery; RM: rotation method; TAVR: transcatheter aortic valve replacement; THV: transcatheter heart valve
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