TAVR: Angle Matters for CoreValve Outcomes

A high degree of aortic angulation is linked to poor procedural success when using self-expandable transcatheter aortic valve replacement (TAVR) devices, a single-center study showed.

Patients receiving the Sapien line of balloon-expandable TAVR devices had no reported adverse events associated with having more than the mean 47.3 degrees of angulation between the aorta and the heart, Raj Makkar, MD, of Cedars-Sinai Heart Institute in Los Angeles, and colleagues also reported online in JACC: Cardiovascular Imaging.

However, patients who had increased angulation (48 degrees or higher) and got a self-expandable TAVR device -- namely CoreValve -- had less procedural success (AUC 0.73, 95% CI 0.61-0.85).

The numerical cut-off of 48 degrees for angle between the aorta and heart had a high sensitivity (85%) and specificity (61%) in predicting successful device implantation.

Rates of major complications and death after self-expandable device placement were similar between lower- and higher-angle groups. Six-month mortality also no different. But there were other risks associated with high angulation in CoreValve patients, who were more likely to:

• Need a second valve (21.7% versus 3.6% for their lower-angle peers, P=0.01)
• Need postdilatation (47.8% versus 14.3%, P<0.001)
• Undergo longer fluoroscopy (26.8 min versus 19.1 min, P=0.03)
• Have valve embolization (8.7% versus 0%, P=0.04)
• Show postprocedural paravalvular regurgitation (63% versus 34%, P=0.02)

Extremely angulated or horizontal aortic roots make for difficult positioning of the bioprosthesis during TAVR, the authors suggested.

"In extreme aortic angulation cases of self-expandable implantations it may be useful to mount a snare catheter onto the delivery system and advance both together. This technique allows the snare catheter to be placed anywhere along the delivery system for applying traction as it navigates through the aortic arch and root. The operator can apply a constant flexion force on the delivery system through the proximal end of the snare catheter thereby aligning it toward the center of the annulus."

Makkar's retrospective study included 582 patients who had TAVR and contrast CT data available. All were high-risk for valve surgery and had been assessed with coronary angiography and transthoracic echocardiography.

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