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Background: Redo-transcatheter aortic valve replacement (TAVR) can pin the index transcatheter heart valve leaflets open leading to sinus sequestration and restricting coronary access. The impact of initial implant depth and commissural alignment on redo-TAVR feasibility is unclear. We sought to determine the feasibility of redo-TAVR and coronary access after SAPIEN 3 (S3) TAVR stratified by implant depth and commissural alignment., Methods: Consecutive patients with native valve aortic stenosis were evaluated using multidetector computed tomography. S3 TAVR simulations were done at 3 implant depths, sizing per manufacturer recommendation and assuming nominal expansion in all cases. Redo-TAVR was deemed unfeasible based on valve-to-sinotubular junction distance and valve-to-sinus height <2 mm, while the neoskirt plane of the S3 transcatheter heart valve estimated coronary access feasibility., Results: Overall, 1900 patients (mean age, 80.2±8 years; STS-PROM [Society of Thoracic Surgeons Predicted Risk of Operative Mortality], 3.4%) were included. Redo-TAVR feasibility reduced significantly at shallower initial S3 implant depths (2.3% at 80:20 versus 27.5% at 100:0, P <0.001). Larger S3 sizes reduced redo-TAVR feasibility, but only in patients with a 100:0 implant ( P <0.001). Commissural alignment would render redo-TAVR feasible in all patients, assuming the utilization of leaflet modification techniques to reduce the neoskirt height. Coronary access following TAV-in-TAV was affected by both index S3 implant depth and size., Conclusions: This study highlights the critical impact of implant depth, commissural alignment, and transcatheter heart valve size in predicting redo-TAVR feasibility. These findings highlight the necessity for individualized preprocedural planning, considering both immediate results and long-term prospects for reintervention as TAVR is increasingly utilized in younger patients with aortic stenosis., Competing Interests: Dr Koshy is supported by a postdoctoral scholarship from the Heart Foundation of Australia. Dr Khera is a speaker for Medtronic and Zoll Medical; a proctor for Medtronic; and a consultant for Terumo, Medtronic, Abbott, and Boston Scientific. Dr Tang is a physician proctor for Medtronic; a consultant for Medtronic, Abbott Structural Heart, and NeoChord; a physician advisory board member for Abbott Structural Heart, Boston Scientific, and JenaValve; and receives speaker’s honoraria from Siemens Healthineers. The other authors report no conflicts.

Objectives: To compare outcomes in Sapien 3 Ultra (S3U) transcatheter aortic valve replacement (TAVR) with extreme annular undersizing (EAU) versus nominal annular sizing (NAS)., Background: The Edwards S3U valve has reduced paravalvular leak (PVL) in TAVR but outcomes remain unknown in extremely undersized anatomy. Implanting a smaller S3U valve may facilitate future redo-TAVR but risk compromising hemodynamics., Methods: From December 2019 to July 2021, 366 patients with native aortic stenosis underwent S3U TAVR. Patients with EAU (annular areas >430 mm 2 for 23 mm or >546 mm 2 for 26 mm) were compared to NAS (338-430 mm 2 for 23 mm or 430-546 mm 2 for 26 mm). In-hospital and 30-day outcomes, and redo-TAVR feasibility were determined., Results: There were 79 (21.6%) EAU patients, with more bicuspid (p = 0.0014) and ≥moderate annular/left ventricular outflow tract calcification (p < 0.001). The EAU group had less annular oversizing than NAS group (23 mm: -8.2 ± 2.6% vs. 4.0 ± 7.0%, p < 0.001; 26 mm: -8.9 ± 2.2% vs. 6.7 ± 6.9%, p < 0.001), more balloon overfilling (71.3% vs. 11.6%, p < 0.001), and postdilatation (15.0% vs. 5.8%, p = 0.016). No differences were found in in-hospital or 30-day mortality and stroke (p > 0.05). Mild PVL (13.4% EAU vs. 11.5% NAS, p = 0.56) and mean gradients (23 mm: 13.0 ± 4.5 vs. 14.1 ± 5.4 mmHg, p = 0.40; 26 mm: 11.4 ± 4.1 vs. 11.5 ± 3.9 mmHg, p = 1.0) were similar at 30 days. Had the EAU group undergone NAS with the larger Sapien 3/S3U, by computed tomography analysis simulating 80:20 or 90:10 target implant depth, 33.3%-60.9% (vs. 4.3%-23.2%) would not be feasible for redo-TAVR due to high risk of coronary obstruction., Conclusions: In this first report of EAU with S3U TAVR, similar excellent short-term outcomes can be achieved compared to NAS, and may preserve future redo-TAVR option., (© 2022 Wiley Periodicals LLC.)

Despite current valve guidelines recommending both transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively) in patients with symptomatic severe aortic stenosis (AS), TAVR has recently become the preferred treatment over SAVR, driven by its minimal invasiveness, faster recovery and earlier improvement in quality of life. However, several limitations and unresolved issues remain with TAVR, including stroke, conduction system disorder, durability, bicuspid anatomy, coronary reaccess and lifetime management with aortic valve reintervention. Our review aims to highlight the above issues and discuss them in depth, to demonstrate the complementary role of TAVR and SAVR in the treatment of AS., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve replacement (TAVR) has become the treatment option for symptomatic severe aortic stenosis patients across all risk profiles. Despite remarkable advancements in technology and operator experience, the occurrence of periprocedural stroke remains a significant concern, predominantly attributed to thromboembolic events in the immediate postprocedural period. To optimize patient outcomes, various strategies have been developed to minimize the risk of stroke, encompassing comprehensive preprocedural planning, effective management of comorbidities, utilization of cerebral embolic protection devices, and tailored medical therapy. This comprehensive review summarizes the currently available strategies for mitigating periprocedural stroke post‑TAVR and provides insights into future directions. [ABSTRACT FROM AUTHOR]