1. Difference in angle of orientation of the aortic valve in the annular plane on CTA compared to post valve deployment on fluoroscopy in TAVR patients.
Dr. Krishna Ramaswamy Award
Yash B. Jobanputra, MD, Brandon Jones, MD, Kimi Sato, MD, Arnav Kumar, MD, Samir R. Kapadia, MD, FACC

2. Background
Computed tomography angiography (CTA) is used to predict the size and orientation of transcatheter aortic valve replacement (TAVR) devices in the aortic annulus.
Whether the valve orients itself at the same angle post deployment is not known.
We sought to find the difference in angulation, if any and whether it was significant

3. Methods
Patients undergoing TAVR who had pre-procedural CTA were evaluated.
Each patient had perpendicular left anterior oblique (LAO) cranial and right anterior oblique (RAO) caudal fluoroscopic imaging to determine the orientation of valve deployment after TAVR.
We then determined the predicted angle of orientation at the same LAO/RAO angulations based on pre-TAVR, 3D-CTA reconstruction for each patient and measured differences in the corresponding cranial and caudal angulations.

4. Biplanar Fluoroscopic images after valve implantation

7. Differences in actual and predicted valve orientation comparing pre-TAVR CTA and post-TAVR fluoroscopic imaging
Mean LAO angulation of 300
Predicted angulation based on CTA
annular orientation.
24±9°
Actual angulation on fluoroscopy post valve deployment
Mean RAO angulation of 240
9±4° 00
Predicted angulation based on CTA
annular orientation.
23±12°
We found that the ultimate orientation of the valve after deployment based on perpendicular fluoroscopic projections obtained in the cardiac cath lab were different than the angles we would have predicted based on measurement of the plane parallel to the annular or STJ plane. In general, the annular plane orientation more closely approximated the ultimate orientation of the valve as seen on fluoroscopy than the predicted orientation based on the STJ plane. Furthermore, both the annular and STJ projections overestimated the degree with which the valve would be tilted towards the cradial projection when viewed in an LAO orientation, and underestimated the degree with which the valve would be tilted towards the caudal projection when viewed in an RAO projection. This information is helpful in predicting the ultimate way in which a TAVR device will seat in the annulus. Both findings would suggest that the valve ultimately takes an orientation more tilted towards the left and right coronary cusps than would have been predicted by CTA measurement. This is of special importance when planning procedures in which valve orientation is critical such as individuals with low coronary artery ostia, sino-tubular effacement, or annular measurements at the borderline of the available device sizes.
Actual angulation on fluoroscopy post valve deployment
30±8°

8. Results Actual plane (Fluoroscopic data) Annular plane P value
Predicted caudal projections based on RAO projection (°)
30 ± 8
23 ± 12
< 0.001
Predicted cranial projections based on LAO projection (°)
9 ± 4
24 ± 9
We retrospectively evaluated 60 consecutive patients, mean age 80±9.3 years (63.3% female).
The mean LAO cranial projection by fluoroscopy was 30±100 by 9±40 vs. 24±90 cranial as predicted by CTA at the same LAO angulation (p<0.001).
The mean RAO caudal projection by fluoroscopy was 24±100 by 30±80 vs. 23±120 caudal as predicted by CTA at the same RAO angulation (p<0.001).

9. Conclusion
These findings suggest that the valves in our study take an orientation different than the annular plane.
This orientation is more horizontally and anteriorly tilted (towards the left coronary and right coronary cusps) than would have been predicted by CTA.
This is of special importance when planning procedures in which predicting valve orientation is critical such as for individuals with low coronary ostia or sino-tubular effacement.

10. Thank you