Optimization of Commissural Alignment Using an Anatomy-Tailored Method for a Supra-Annular Self-Expanding Transcatheter Heart Valve.

BACKGROUND: The conventional commissural alignment for a supra-annular self-expanding valve positions the delivery catheter flush port at the 3 o'clock orientation, with confirmation of the "Hat" marker on the outer curve at the descending aorta during transcatheter aortic valve replacement. However, tailoring the "Hat" marker position according to native valve anatomy may further optimize commissural alignment. OBJECTIVES: This study evaluated the effectiveness of a novel anatomy-tailored method compared with the conventional technique. METHODS: We analyzed 172 consecutive patients who underwent transcatheter aortic valve replacement with supra-annular self-expanding valve (Evolut FX) and postprocedural contrast-enhanced computed tomography between March 2023 and February 2025. In the anatomy-tailored approach, a single additional step was incorporated into the conventional method: the "Hat" marker was repositioned to the center back in the cusp-overlap view at the descending aorta. The aim was to align the "Hat" marker to the center-front position during valve deployment. Commissural misalignment (CMA) was evaluated according to the ALIGN-TAVR (Alignment of Transcatheter Aortic-Valve Neo-Commissures) Consortium criteria. RESULTS: The mean age was 84.5 ± 5.1 years, with 54.7% (94 of 172) male patients. Of 172 patients, 67 underwent the conventional method and 105 the anatomy-tailored method. The anatomy-tailored method yielded smaller CMA angles (14.5° [IQR: 9.8-24.1] vs 20.3° [IQR: 11.0-30.6], P = 0.031) and fewer cases of moderate/severe (>30°) CMA (14.3% [15 of 105] vs 29.9% [20 of 67], P = 0.013). Coronary overlap ≤20° (either or both) was also reduced (12.4% [13 of 105] vs 28.4% [19 of 67], P = 0.009). CONCLUSIONS: The novel and easy anatomy-tailored alignment technique improved commissural alignment compared with the conventional method. Enhanced commissural alignment was associated with better coronary alignment.