Impact of Noncoaxial Transcatheter Aortic Valve Implantation on Clinical Outcomes.

Background
Noncoaxial placement of transcatheter heart valves (THVs) relative to the native aortic annulus is occasionally detected on fluoroscopy after transcatheter aortic valve replacement (TAVR).Objectives
This study aimed to evaluate the impact of noncoaxial TAVR deployment on clinical outcomes.Methods
We retrospectively evaluated consecutive patients undergoing transfemoral TAVR in the Bern transcatheter aortic valve implantation registry. Coaxiality between the native annulus and the THV was measured using the 3-cusp view on fluoroscopic images and was defined as the angle between a line intersecting the lower points of native cusps and a line intersecting the lower hinge points of the prosthesis frame. Patients were categorized according to tertiles of coaxiality.Results
Among 2,025 patients (mean age 81.6 ± 6.5 years, mean Society of Thoracic Surgeons Predicted Risk of Mortality 4.2% ± 3.3%) undergoing TAVR with contemporary devices between February 2014 and June 2023, the mean axial angulation of the device relative to the native annulus was 4.1°. According to Valve Academic Research Consortium-3 criteria, patients in the highest tertile of THV axial angle (range, 4.8-21.7°) had reduced device early safety (56.2% vs 82.7%; aHR: 0.67; 95% CI: 0.59-0.76; P < 0.001) and higher rates of stage-2 bioprosthetic valve failure at 1-year follow-up (1.5% vs 0.7%; HR: 3.47; 95% CI: 1.26-9.54; P = 0.016), compared to those with coaxial valve positioning (range, 0.1-3.0). Left ventricle outflow tract calcium volume, predilatation, and valve type were independent predictors of noncoaxial valve implantation.Conclusions
Noncoaxial THV deployment is associated with impaired valve early safety and increased risk of bioprosthetic valve failure 1 year after TAVR.