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Sengupta et al. Vessel Plus 2020;4:40 Vessel Plus
DOI: 10.20517/2574-1209.2020.55

Review Open Access

Current challenges in TAVI: neo-commissural
alignment to mimic more physiologic valve

implantation

Aditya Sengupta , Sophia L. Alexis , Jason C Kovacic , Gilbert H. L. Tang 1
2
1
1
1 Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
2 Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
Correspondence to: Dr. Gilbert H. L. Tang, Department of Cardiovascular Surgery, The Mount Sinai Hospital, 1190 Fifth Avenue,
GP2W, Box 1028, New York, NY 10029, USA. E-mail: gilbert.tang@mountsinai.org

How to cite this article: Sengupta A, Alexis SL, Kovacic JC, Tang GHL. Current Challenges in TAVI: neo-commissural alignment
to mimic more physiologic valve implantation. Vessel Plus 2020;4:40. http://dx.doi.org/10.20517/2574-1209.2020.55

Received: 9 Oct 2020 First Decision: 13 Nov 2020 Revised: 17 Nov 2020 Accepted: 30 Nov 2020 Published: 10 Dec 2020
Academic Editor: Maurizio Taramasso Copy Editor: Cai-Hong Wang Production Editor: Jing Yu

Received: First Decision: Revised: Accepted: Published: x
Abstract
Science Editor: Copy Editor: Production Editor: Jing Yu Commissural alignment during transcatheter aortic valve implantation (TAVI) has important clinical implications as
TAVI expands to younger patients in whom lifetime treatment of aortic valve disease and coronary artery disease is
of particular importance. Numerous studies have shown that lack of commissural alignment may adversely affect
coronary reaccess and the feasibility of redo-TAVI in this patient population. To assess the risk of commissural
misalignment more accurately, we have pioneered and validated the use of a preprocedural imaging protocol that
determines valve orientation using multi-detector computed tomography-fluoroscopy co-registration. Furthermore,
we have shown that a modified delivery system insertion technique during initial valve deployment results in
improved commissural alignment and reduced coronary artery overlap following TAVI with a self-expanding device.
However, numerous unanswered questions remain about the impact of commissural misalignment on balloon-
expandable valve-in-valve TAVI, especially in patients with unfavorable aortic root anatomy. It is imperative that
clinicians consider these anatomic, device-related, and procedure factors, among others, when evaluating patients
for transcatheter therapies.

Keywords: Aortic stenosis, commissural alignment, aortic valve, coronary artery disease

© The Author(s) 2020. 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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