Defining optimal fluoroscopic projection for TAVI with self-expanding device: Concordance between the “double-S curve” and “cusp-overlap” methods - The 67th Annual Conference of the Israel Heart Society

Jeremy Ben-Shoshan ^1,2 Hind Alosaimi ¹ Pascal Thériault Lauzier ¹ Michele Pighi ³ Pavel Overtchook ¹ Giuseppe Martucci ¹ Marco Spaziano ¹ Ariel Finkelstein ² Hemal Gada ⁴ Nicolo Piazza ¹

¹McGill University Health Center, McGill University, Montreal, QC, Canada
²Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
³Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
⁴PinnacleHealth Cardiovascular Institute, Wormleysburg, Pennsylvania, USA

Background - Transcatheter aortic valve implantation (TAVI) with self-expandable device requires the aortic annulus and delivery catheter to appear perpendicular on fluoroscopy. We use a logistic model, the “double-S curve”, for intraprocedural determination of optimal projection for TAVI. Recently, a novel “cusp-overlap” technique, consisting of overlapping of the left and right coronary cusps, was suggested as TAVI opimal projection. Herein, we assess the concordance between views generated by the cusp-overlap and double-S curve methods.

Methods - We included 100 consecutive patients with severe native aortic valve stenosis undergoing TAVI with self-expanding device planned by pre-procedural multidetector computerized tomography (MDCT). Optimal projection for TAVI was determined by the double S-curve model as a view in which both the aortic valve annulus and delivery catheter appear perpendicular on fluoroscopy. Optimal projection according to the cusp-overlap technique was also assessed by MDCT and concordance between methods was evaluated in vertical (CRA/CAU) and horizontal (LAO/RAO) axes.

Results - TAVI using the double-S curve model was associated with high procedural success rate (98%), low complications rate and absence of moderate or severe paravalvular leak. The double-S curve and cusp-overlap methods provided comparable views located in the RAO/CAU quadrant in 82% and 87% of patients, respectively (RAO 14.7±15.2 vs 12.9±12.5, p=0.36 and CAU 27.0±9.4 vs 26.9±10.4, p=0.9 respectively). The two methods correlated significantly in both horizontal and vertical axes (Pearson`s r = 0.54 and 0.58, respectively, p<0.001). Per-patient variance between the two methods occurred mostly on the horizontal rather than vertical axis (10.6±8.3 and 7.0±5.9, respectively, p<0.001).

Conclusions - The double S-curve is a reliable model for definition of optimal projection for TAVI with self-expandable device and is associated with satisfying outcomes. The cusp-overlap technique provides projections comparable to the double-S curve model and its application might preclude intraprocedural imaging processing or substantial C-arm adjustments.