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Sengupta et al. Vessel Plus 2020;4:40 I http://dx.doi.org/10.20517/2574-1209.2020.55 Page 5 of 7

Figure 2. Optimization of commissural alignment with the evolut system

CONCLUSION
Achieving neo-commissural alignment during initial TAVI has important clinical implications for
future coronary reaccess and aortic valve reintervention, especially in younger patients in whom lifetime
treatment of aortic valve and coronary artery disease must be taken into consideration. Although we have
shown that a modified delivery system insertion technique during initial valve deployment results in better
commissural alignment and less coronary overlap following self-expanding TAVI, further studies are
needed to affirm the reproducibility of this strategy. Additionally, 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 TAVI.

Commissural alignment is particularly important for facilitating coronary reaccess following implantation
of the Evolut system since this supra-annular valve extends above the sinotubular junction and coronary
ostia. The Evolut valve has a unique “Hat” marker that can be oriented during initial deployment in one of
four positions: anterior or posterior in the center of the deployment device (center front or center back)