Computed Tomography-Guided Commissural Alignment of the Evolut Valve Using the Cusp-Overlap Technique, a Retrospective Pilot Study

BACKGROUND Advancement of transcatheter aortic valve replacement (TAVR) and its long-term outcomes is warranted as it expands to a low-risk population. Procedural optimization using commissural alignment (CA) and the cusp-overlap technique have recently been suggested, especially for supra-annular self-expanding valves. The Evolut valve (EV) has two markers to guide valve position and orientation: the hat-marker and the flush port. Although the EV platform orientation with the flush port to the 3 o'clock position seems to improve the likelihood of CA, commissural malalignment (CMA) remains an issue in a significant number of patients. METHODS AND RESULTS To improve CA, starting October 2020, we implemented a systematic, simplified workflow for all patients receiving the EV. The workflow uses CT-guided fluoroscopic angles to determine the hat-marker position during cusp-overlap view. To determine if the CT-guided individualized positioning workflow of the EV improves CA, we retrospectively reviewed all patients with the EV implanted at our center. The study included only patients with native aortic valve stenosis, transfemoral access and the use of the cusp-overlap technique. From September 2019 to March 2021, a total of 52 patients were enrolled in the study. The Hat position during cusp overlap deployment angle was classified as Outer Curve (OC), Center Front (CF), Inner Curve (IC), and Center Back (CB). Overall, CF hat marker position was achieved in 25 (48%) patients. For this analysis, we combined CB and IC in one group (CBIC). CF position has optimal alignment in 23/25 (92%) patients, while CBIC position was associated with 6/13 (46%) of severe CMA. Severe commissural overlap with coronary orifices occurred more frequently in the CBIC position than the CF position (LAD 53.8% vs 4%, and RCA 53.8% vs 0%). The implementation of our workflow decreased the undesirable CBIC position from 41.4% to 4.3% (P=0.001). There was a significant decrease in Severe CMA (20.7% to 0% p=0.023), and proper alignment ( CONCLUSION This study showed that the Hat-marker position during cusp-overlap fluoroscopic view predicts CA, with the CF position being the best for optimal CA. Besides, this study showed that a systematic and simplified CT-guided workflow could potentially improve CA and minimize severe coronary orifice overlap with the neo-commissures.