# Left-right commissural aortic root enlargement facilitates valve-in-valve transcatheter aortic valve implantation: A computed tomographic analysis

## TL;DR

Enlarging the aortic root at the left-right commissure may reduce the risk of coronary obstruction during future valve-in-valve TAVI procedures.

## Contribution

This study provides CT-based evidence that left-right commissural aortic root enlargement is a safe and effective strategy for future valve-in-valve TAVI.

## Key findings

- 85% of valves used in patients with LR ARE were 23 or 25 mm, indicating significant upsizing.
- 94% of patients would be safe for VinV TAVI with self-expanding valves, and 77% with balloon-expandable valves.

## Abstract

Aortic root enlargement (ARE) at the left-right (LR) commissure may mitigate risk of coronary obstruction during future valve-in-valve (VinV) transcatheter aortic valve implantation (TAVI) by creating space for blood flow behind the LR surgical valve strut into the adjacent sinuses. We analyzed computed tomography (CT) scans after LR ARE to determine theoretical candidacy for future VinV TAVI.

All patients undergoing LR ARE and bioprosthetic surgical aortic valve replacement (SAVR) between February 2023 and November 2024 were reviewed retrospectively. Postoperative CT scans were analyzed, modeling for both balloon-expandable (BEV) and self-expanding (SEV) valves. Risk of coronary obstruction was based on virtual transcatheter valve to coronary (VTC) and sinotubular junction (VTSTJ) distances, and measurements of the LR ARE patch.

There were 32 patients (62% female, 44% inpatient) who had LR ARE with bioprosthetic SAVR, including 22% with a concomitant Y ARE. There was no 30-day mortality or stroke. Postoperative mean gradient was 5.5 mm Hg. Overall, 85% of valves were 23 or 25 mm, representing upsizing by 1.7 ± 0.7 sizes. The patch was 26.2 ± 4.7 mm tall, with 6.2 ± 2.4 mm of space behind the LR strut. If a SEV were used, 94% would be safe for VinV TAVI with low risk of coronary obstruction; if balloon inflation were needed during TAVI (such as for BEV), 77% could have safe VinV TAVI.

In this CT analysis, LR ARE carried low risk of coronary obstruction for future VinV TAVI and may benefit patients undergoing bioprosthetic SAVR.