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Avvedimento et al. Mini-invasive Surg 2022;6:24 Mini-invasive Surgery
DOI: 10.20517/2574-1225.2021.143

Review Open Access

Commissural alignment in TAVI: a new frontier to

facilitate coronary reaccess and Redo TAVI

1
Marisa Avvedimento , Gilbert H. L Tang 2
1
Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples 80131, Italy.
2
Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY 10029, USA.
Correspondence to: Dr. Marisa Avvedimento, Department of Advanced Biomedical Sciences, University of Naples Federico II,
Via Sergio Pansini, 5, Naples 80131, Italy.

How to cite this article: Avvedimento M, Tang GHL. Commissural alignment in TAVI: a new frontier to facilitate coronary
reaccess and Redo TAVI. Mini-invasive Surg 2022;6:24. https://dx.doi.org/10.20517/2574-1225.2021.143

Received: 26 Nov 2021 First Decision: 7 Feb 2022 Revised: 23 Feb 2022 Accepted: 7 Mar 2021 Published: 22 Apr 2022

Academic Editors: Andrea Scotti Copy Editor: Tiantian Shi Production Editor: Tiantian Shi

Abstract
As transcatheter aortic valve implantation (TAVI) expands to younger and low-risk patients with longer life
expectancies, the need for post-TAVI coronary access and reintervention for failing transcatheter heart valve
(THV) is expected to increase. Commissural alignment in TAVI may facilitate subsequent coronary access,
avoiding severe overlap with the THV commissures, and potentially redo-TAVI. The ability to traverse a THV to
access the coronary ostia is related to anatomic factors (coronary height and sino-tubular junction (STJ) height and
width) and valve-related features. Furthermore, recent evidence suggests that commissural alignment after TAVI
may have an impact on THV’s hemodynamics and durability. Several studies have provided technique
modifications to obtain commissural alignment with available self-expanding TAVI devices. However, future efforts
should aim to refine THV and delivery system designs to make neo-commissural alignment easier and safer. An
individualized decision-making approach is recommended in device selection when considering future coronary
access and redo-TAVI to facilitate the lifetime management of patients with aortic valve and coronary artery
disease. This review aims to provide an overview of available evidence for neo-commissural alignment and
strategies to achieve more anatomic valve implantation further.

Keywords: Aortic stenosis, transcatheter aortic valve implantation, TAVI, commissural alignment, redo-TAVI

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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