Three-Cusp View Orientation in TAVI: Evaluating LOA Versus Non-LOA Impact on Outcomes With Contemporary Valve Prostheses.

Background: Optimal projection views during transcatheter aortic valve implantation (TAVI) procedures are critical for procedural success and patient outcomes.

Aims: This study investigated the influence of 3-cusp view orientation-line of alignment (LOA) versus non-LOA-on procedural outcomes in patients undergoing TAVI with contemporary transcatheter heart valves.

Methods: This retrospective analysis included 421 consecutive patients with severe symptomatic aortic stenosis who underwent transfemoral TAVI at a single center between March 2019 and December 2023. Patients received either SAPIEN 3 (n = 140) or CoreValve Evolut R/PRO (n = 281) prostheses and were classified as having either LOA (n = 312, 74.1%) or non-LOA (n = 109, 25.9%) projection based on pre-procedural computed tomography. Primary endpoints included device success according to VARC-2 criteria, post-procedural aortic regurgitation, and 30-day clinical outcomes. Multivariate logistic regression analyses were performed to identify independent predictors of device success, post-procedural hemodynamics, and the need for permanent pacemaker implantation.

Results: Non-LOA patients had larger annulus dimensions (461.37 ± 83.52 vs. 441.16 ± 80.83 mm², p = 0.03), higher calcium burden (3072.26 ± 1524.36 vs. 2646.0 ± 1189.11 AU, p = 0.01), and required more contrast (179.99 ± 67.12 vs. 161.94 ± 64.7 ml, p = 0.01). Multivariate analysis revealed that aortic valve calcium score was the only independent predictor of device success (p = 0.018), while LOA orientation showed no significant association (p = 0.971). Valve type was the primary determinant of post-procedural hemodynamics (SAPIEN 3 superior, p = 0.025), and prior bundle branch block was the strongest pacemaker predictor (p = 0.005). Device success (94.81% vs. 95.88%, p = 0.86) and safety outcomes were comparable between groups.

Conclusions: While LOA orientation creates anatomical differences, it doesn't change fundamental treatment decisions-calcium burden and valve type remain the primary determinants of outcomes. LOA status should inform procedural planning through enhanced contrast management and risk-stratified surveillance, without compromising fundamental treatment decisions. Contemporary TAVI procedures demonstrate excellent safety and efficacy across both types of projections.