Feasibility of coronary alignment in TAVI with balloon-expandable valves: insights from a COMPARE-TAVI 1 substudy

Coronary alignment may be an important prerequisite for redo-transcatheter aortic valve implantation (TAVI) and may be achieved with balloon-expandable valves (BEV) by intentional orientation of neo-commissures during crimping.

The aim of this study was to evaluate whether coronary alignment is possible during implantation of BEVs and to assess the risk of coronary obstruction limiting the feasibility of redo-TAVI.

On post-TAVI CT scans available in 375 patients enrolled in the COMPARE-TAVI 1 study, we assessed coronary alignment defined by neo-commissure-to-coronary-angles and assessed coverage of coronary ostia by the THV frame and valve-to-aorta distance.

Patients were randomized to treatment with Sapien 3 (Group A) or Myval (Group B) with random orientation of neo-commissures during valve crimping (Period 1), or Sapien 3 (Group C) or Myval Octacor (Group D) (Period 2), where intentional orientation of neo-commissures during crimping was attempted according to pre-TAVI CT-scan.

Left main alignment or mild misalignment occurred in 50%, 51%, 47%, and 55% of patients in groups A, B, C, and D, P = .33, and right coronary alignment or mild misalignment occurred in 52%, 62%, 54%, and 53%, P = .53. The proportion of patients considered feasible for redo-TAVI defined as a) no coronary coverage by the THV frame, b) coronary coverage but VTA ≥2 mm, or c) coronary coverage and VTA <2 mm but coronary alignment optimal or only mild misalignment, was 81%, 78%, 80%, 87% in groups A, B, C, and D, P = .33.

Crimping BEV neo-commissures at predefined angles did not increase coronary alignment; however, the majority of patients treated with BEVs were still considered eligible for redo-TAVI.