# Commissural Misalignment Following Valve‐in‐Valve Transcatheter Aortic Valve Implantation

## TL;DR

This study examines how commissural misalignment affects outcomes in patients undergoing valve-in-valve transcatheter aortic valve implantation for failed surgical valves.

## Contribution

The study provides new insights into the impact of commissural misalignment on clinical and hemodynamic outcomes in ViV-TAVI procedures.

## Key findings

- Commissural misalignment was associated with reduced technical success due to increased coronary obstruction.
- Mid-term survival was comparable between patients with and without commissural misalignment.
- Device success was not significantly different between groups despite higher residual valve gradients.

## Abstract

Data on commissural misalignment (CMA) during valve‐in‐valve transcatheter aortic valve implantation (ViV‐TAVI) for valve failure after surgical aortic valve replacement (SAVR) is scarce.

To study the impact of CMA on clinical and hemodynamic outcomes following ViV‐TAVI for failed SAVR.

Data of patients who underwent ViV‐TAVI for failed SAVR valves at two institutions (Heart Center Leipzig at Leipzig University, Leipzig, Germany; Cedars‐Sinai Smidt Heart Institute, Los Angeles, USA) were retrospectively collected and compared regarding the existence of CMA. Outcomes of interest included Valve Academic Research Consortium (VARC)‐3‐based clinical endpoints, Computed Tomography‐based hypoattenuated leaflet thickening (HALT), hemodynamic outcome, and mid‐term all‐cause mortality.

Of the 687 patients who underwent ViV‐TAVI, post‐procedural CT of sufficient quality to measure commissural alignment was available in 180 patients (47.8% females, mean age 78.0 years). Self‐expanding TAVI valves were used in 49.2% of the cases. CMA was found in 35 individuals (19.4%) and was associated with reduced VARC‐3‐based technical success (80% vs. 93%, p = 0.03), driven by increased rates of coronary obstruction (17.1% vs. 5.6%, p = 0.03). The incidence of HALT was 31.7%, without differences in patients with and without CMA. VARC‐3‐based device success was 62.9%, driven by an incidence of residual mean valve gradient (≥ 20 mmHg) of 35.4%, without differences between groups. Midterm survival after a mean of 747 days was 84.6% and comparable between groups.

For patients undergoing ViV‐TAVI for failed SAVR, technical success is reduced for cases of CMA due to higher odds of coronary obstruction, without differences in mid‐term survival.