title: Aortic Angulation Attenuates Procedural Success Following Self-Expandable But Not Balloon-Expandable TAVR.
abstract: The aim of this study was to evaluate the impact of increased aortic angulation (AA) on acute procedural success following transcatheter aortic valve replacement (TAVR).
  
  
  
  The degree of angulation between the aorta and the heart can make accurate positioning of the bioprosthesis during TAVR more demanding, particularly in instances of an extremely angulated or horizontal aortic root. Nonetheless, there are limited data on the impact of AA on the acute success of TAVR.
  
  
  
  We assessed 582 patients who underwent TAVR at our institute and had contrast computed tomography available for AA evaluation. TAVR endpoints, device success, and adverse events were considered according to the Valve Academic Research Consortium-2 definitions.
  
  
  
  The mean angulation of the aorta was 47.3 ± 8.7°. Patients were therefore divided into 2 groups: AA <48° and AA ≥48°. AA in the 480 patients who underwent balloon-expandable (BE) TAVR did not influence acute procedural success or short-term clinical outcome. In contrast, increased AA among the 102 patients who underwent self-expandable (SE) TAVR was found to significantly attenuate procedural success (area under the curve: 0.73; 95% confidence interval: 0.61 to 0.85; p = 0.008). The numerical cutoff for AA with the highest sum of sensitivity and specificity for device success was ≥48° (sensitivity 85%, specificity 61%). Moreover, patients whose AA was ≥48° were also associated with an increased need for a second valve and post-dilation, had increased fluoroscopy time and increased valve embolization, and had increased post-procedural paravalvular regurgitation greater than or equal to mild following SE TAVR. Major complications at 30 days, including mortality were similar between AA groups. Six-month mortality was also similar between both AA groups.
  
  
  
  Increased aortic root angulation adversely influences acute procedural success following SE but not BE TAVR. Because of these data, BE valves may be preferred when evaluating patients with high AA before TAVR.
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Yigal
authors.initials: Y
authors.lastname: Abramowitz
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Maeno
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Tarun
authors.initials: T
authors.lastname: Chakravarty
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Kazuno
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Takahashi
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Kawamori
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Geeteshwar
authors.initials: G
authors.lastname: Mangat
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Wen
authors.initials: W
authors.lastname: Cheng
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California.
authors.forename: Hasan
authors.initials: H
authors.lastname: Jilaihawi
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, California. Electronic address: Raj.Makkar@cshs.org.
authors.forename: Raj R
authors.initials: RR
authors.lastname: Makkar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000000981:diagnostic imaging*; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000209:etiology; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods*; D063126:Balloon Valvuloplasty / Q000009:adverse effects / Q000401:mortality; D001705:Bioprosthesis; D000072226:Computed Tomography Angiography; D005260:Female; D006350:Heart Valve Prosthesis; D006801:Humans; D008297:Male; D061330:Multidetector Computed Tomography; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016896:Treatment Outcome
keywords: TAVI; TAVR; aortic stenosis; horizontal aorta; transcatheter aortic valve implantation