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OBJECTIVE: Current implantation techniques do not allow for controlling the rotation of the SAPIEN™ prosthesis during transcatheter aortic valve implantation (TAVI) which might be beneficial regarding optimal physiological valve performance and optimal coronary flow and avoidance of the fully covered commissural stent-part in front of the coronary ostia. This new stent-design of SAPIEN XT™ allows for identification of the commissures during fluoroscopy using maximal magnification. Therefore it facilitates intraoperative anatomically-correct positioning of the valve. Aim of this study was to proof the concept of DynaCT guided anatomical rotation of the SAPIEN XT™ valve during transapical-AVI (TA-AVI).
METHODS: Intraoperatively, an automatically segmented DynaCT was performed using the Siemens Syngo Aortic ValveGuide™ software prototype (Fig. 1A). Comapared to Edwards SAPIEN™ commusiures of SAPIEN XT™ could be identified with high quality fluoroscopic systems. Prior to standard transapical implantation one radiopaque stent-commissure of the crimped SAPIEN™ prosthesis (Fig. 1B) was aligned with the left/right native aortic valve commissure visualized by the DynaCT. Final rotational orientation of the valve after implantation was assessed by transesophageal echocardiography (Fig. 1C).
RESULTS: Feasibility of anatomical rotation was evaluated in 9 patients scheduled for TA-AVI by a heart team. Mean logistic EuroSCORE and STS-score were 23.7±4.9% and 8.6±2.1%, mean aortic gradient improved from 46.0±21.9 to 9.6±3.1 mmHg and there was no death within 30-days. All valves were implanted successfully with none/trival paravalvular regurgitation in six, mild (1+) in two and moderate (2+) in one patient.Optimal anatomically rotation could be achieved in 5 patients, minor rotational deviation (<10°) in 3 and moderate (10°-20°) in 1 patient.
CONCLUSIONS: DynaCT guided anatomical rotation of the SAPIEN™ valve is feasible during TA-AVI avoiding implantation of the fully covered commissural stent-part in front of the coronary ostia which might reduce the risk of coronary obstruction. In addition the technique provides the potential benefit of physiological valve position.