Aortic Valve (TAVR/TAVI)JACCFriday, August 28, 2026

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

1 min read·By E. Nolan Beckett, MD·Source: JACC. Asia

Key Numbers

54.7%

14.3%

29.9%

12.4%

From The Valve Wire

The anatomy-tailored alignment technique — repositioning the Evolut FX "Hat" marker to center-back in the cusp-overlap view at the descending aorta before deployment — cut median commissural misalignment from 20.3° to 14.5° and halved moderate/severe misalignment (14.3% vs 29.9%, P = 0.013) across 172 consecutive TAVR cases.

Coronary overlap ≤20° also dropped from 28.4% to 12.4%.

Post-procedural CT confirmed alignment per ALIGN-TAVR Consortium criteria.

This is a single-center, non-randomized comparison of sequential cohorts, which invites operator learning-curve confounding: the tailored group came second.

Source Abstract

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.

Authors: Tominaga T, Ichibori Y, Narui S, Higuchi R, Mori N et al.

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