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Avvedimento et al. Mini-invasive Surg 2022;6:24 https://dx.doi.org/10.20517/2574-1225.2021.143 Page 3 of 11

Figure 1. Graphical representation of commissural alignment and different degrees of commissural misalignment following TAVI. THV:
transcatheter heart valve; L-R: left-right; N-L: non-coronary-left; NRL: non-coronary-right.

commissural alignment after TAVI may have an impact on THV’s hemodynamics and durability. In a sub-
analysis of the Low Risk TAVR trial, commissural misalignment has been associated with a higher rate of
[7,8]
hypo-attenuated leaflet thickening (40% vs. 28%; P = 0.25) .
Coronary re-access after TAVI
The feasibility of coronary angiography and/or percutaneous coronary intervention (PCI) after TAVI was
not a focus in early RCTs of high-risk and inoperable patients. The expansion of TAVI indications has
undoubtedly raised the point of repeat coronary angiography and PCI due to the progressive nature of
coronary artery disease and acute coronary syndromes.

In a large cohort of high-risk patients (n = 1936) enrolled in the SOURCE 3 registry treated with balloon-
expandable THVs, coronary angiography was required in 3.5% of patients up to three years after TAVI, and
PCI was deemed successful up to 97% of cases even in the acute setting of ST-segment elevation myocardial
infarction and cardiogenic shock . However, despite the advancement in THV design and procedural
[9]
refinements, there is still a non-negligible risk of difficult coronary engagement after TAVI. Different
factors could affect coronary re-access, including interactions between the THV and native aortic valve
leaflets, being the risk of severe overlap as high as 51.4% [9,10] . Traditionally, anatomical factors, such as
coronary height and STJ height and width, have been considered impactful on the ability to traverse a THV
to access the coronary ostia. Moreover, THV design and its position during deployment strongly influence
coronary re-engagement after TAVI. In the Reobtain Coronary Ostia Cannulation Beyond Transcatheter
Aortic Valve Stent (RE-ACCESS) study, among 300 patients enrolled, unsuccessful coronary cannulation
following TAVR was observed in 7.7% of cases. In this analysis, the use of self-expandable supra-annular
THVs (Evolut R/PRO THVs) was associated with a higher risk of unsuccessful coronary re-access after
TAVI, due to supra-annular position above the coronary ostia, the asymmetrical skirt, and closed-cell frame
design. Conversely, balloon-expandable valves with their features (low-frame height, large-cell frame design,
and sub-coronary implantation) facilitate coronary cannulation even when implanted in a higher
position . In line with this evidence, in a post-implantation computer tomography (CT) analysis, Ochiai
[11]
and colleagues demonstrated that the incidence of CT features of unfavorable coronary access (coronary
ostium located below the skirt or in front of the THV commissural posts above the skirt) occurred more
frequently in the Evolut R/Evolut PRO group than the SAPIEN 3 group (left coronary artery (LCA) 34.8%
[12]
and right coronary artery (RCA) 25.8% vs. LCA 15.7% and RCA 8.1%, respectively) .