title: DynaCT-guided anatomical rotation of the SAPIEN XT valve during transapical aortic valve implantation: proof of concept.
abstract: BACKGROUND
  Transcatheter aortic valve implantation (T-AVI) by using the Edwards SAPIEN (Edwards Lifesciences LLC, Irvine, California, United States) prosthesis is currently being performed by the implantation of valved stent into the aortic annulus without respecting the native commissural (rotational) orientation. Anatomical orientation may, however, be beneficial regarding optimal physiological valve performance, optimal coronary flow, and avoidance of the fully covered commissural stent part in front of the coronary ostia. With the recently introduced SAPIEN XT, transcatheter valve identification of the commissures during fluoroscopy is feasible. The aim of this study was to evaluate the concept of Dynamic-CT (DynaCT)-guided anatomical rotation of the SAPIEN XT valve during transapical-AVI (TA-AVI).
  
  
  METHODS
  Intraoperatively, an automatically segmented DynaCT was performed using the Siemens Syngo Aortic ValveGuide (Siemens AG, Forchheim, Germany) software prototype. Commissures of SAPIEN XT could be identified with a high-quality fluoroscopic system. Before standard TA implantation, one radiopaque stent commissure of the crimped SAPIEN XT prosthesis was aligned with the native aortic valve commissure visualized by DynaCT. Resulting rotational orientation of the valve after implantation was assessed by transesophageal echocardiography.
  
  
  RESULTS
  Feasibility of anatomical rotation was evaluated in 10 patients scheduled for TA-AVI by an interdisciplinary heart team. Mean logistic EuroSCOREs and Society of Thoracic Surgeons scores were 23.7 ± 4.9% and 8.6 ± 2.1%, mean aortic gradient improved from 46.0 ± 21.9 to 9.6 ± 3.1 mm Hg, and there was no death within 30 days. All valves were implanted successfully with none or trivial paravalvular regurgitation in seven patients, mild (1 + ) in two patients, and moderate (2 + ) in one patient. An optimal anatomical position could be achieved in six patients, minor rotational deviation (< 10 degrees) in three patients, and moderate deviation (10 to 20 degrees) in one patient only.
  
  
  CONCLUSIONS
  DynaCT-guided anatomical rotation of the SAPIEN XT valve is feasible during TA-AVI, avoiding implantation of the fully covered commissural posts in front of the coronary ostia. This might reduce the risk of coronary obstruction. In addition, the technique provides the potential benefit of physiological valve position and performance.
authors.affiliation: Department of Cardiac Surgery, Kerckhoff-Klinik, Heart Center, Bad Nauheim, Hessen, Germany. j.blumenstein@kerckhoff-klinik.de
authors.forename: Johannes M
authors.initials: JM
authors.lastname: Blumenstein
authors.forename: Arnaud
authors.initials: A
authors.lastname: Van Linden
authors.forename: Helge
authors.initials: H
authors.lastname: Moellmann
authors.forename: Joerg
authors.initials: J
authors.lastname: Seeburger
authors.forename: Ardawan
authors.initials: A
authors.lastname: Rastan
authors.forename: Won-Keung
authors.initials: WK
authors.lastname: Kim
authors.forename: Friedrich W
authors.initials: FW
authors.lastname: Mohr
authors.forename: Joerg
authors.initials: J
authors.lastname: Kempfert
authors.forename: Thomas
authors.initials: T
authors.lastname: Walther
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology; D001022:Aortic Valve Insufficiency / Q000209:etiology; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation*; D017548:Echocardiography, Transesophageal; D005240:Feasibility Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D006801:Humans; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D011857:Radiographic Image Interpretation, Computer-Assisted; D015641:Radiography, Interventional; D012984:Software; D013813:Therapy, Computer-Assisted; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome