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BackgroundImpact of commissural alignment (CA) strategies with self-expandable supra-annular transcatheter aortic valves (TAVR) has not been investigated yet.MethodsMulticentric ambispective study including patients who underwent self-expandable TAVR in 7 centers with the Evolut Pro/Pro+ (EP)(Medtronic, USA) and Acurate neo2 (AN2)(Boston Scientific, USA). Comparison of those with CA attempt vs. those with no CA attempt was performed. The degree of commissural misalignment (CMA) was assessed by computed tomography/angiography and 1-year transvalvular gradients/regurgitation evaluated by echocardiography. A matched comparison according to annular dimensions/eccentricity, prosthesis size/type, and baseline left ventricular function and gradients was performed.ResultsA total of 557 patients, mean age 80.7±6.6 years, 61.4% men, and STS score of 4.3±3.1% were analyzed. A CA technique was attempted in 215 patients (38.6%), including 113 patients with AN2 and 102 patients with EP. None/mild CMA was found in 158 (73.5% vs. 43.6% if no CA attempted, pConclusionsThe use of CA strategies significantly reduced the rate of CMA for the self-expandable TAVR devices ACN2 and EP which was associated to lower transvalvular gradients and intra-prosthetic regurgitation progression at 1-year although no criteria of structural deterioration were met at this follow up.Clinicaltrials.org:NCT05097183CONDENSED ABSTRACTCommissural alignment (CA) strategies with Evolut Pro and Acurate neo2 TAVR devices were similarly successful in ¾ of the patients, representing a significant increase compared to traditional implantation. Patients with moderate/severe commissural misalignment (CMA) had a significantly greater progression of both peak and mean gradients and higher rate of new central aortic regurgitation at 1-year, but not a greater proportion of patients with mean gradient above 10mmHg. Hence, even at only 1-year of follow up and despite the lack of formal structural deterioration criteria, some hints suggest a more rapid deterioration if moderate/severe CMA is present after supra-annular TAVR.

We aimed to describe the feasibility and preliminary outcomes of commissural alignment (CA) for the balloon-expandable transcatheter heart valve.The relationship among native commissures and transcatheter aortic valve implantation neocommissures was analyzed in 10 consecutive patients with tricuspid severe aortic stenosis undergoing transcatheter aortic valve implantation after guided implantation based on computed tomography analysis with a self-developed software. CA was predicted by in silico bio-modelling in the 10 patients and the calculated rotation was applied during crimping. Degrees of CA and coronary overlap (CO) were measured through 1-month follow up computed tomography. Transvalvular residual gradients and the rate of paravalvular leak were also analyzed.Mean commissural misalignment was 16.7±8°. Four patients showed mild misalignment but none of them showed a moderate or severe degree of misalignment. The in silico model accurately predicted the final in vivo position with a correlation coefficient of 0.983 (95%CI, 0.966-0.992), P.001. Severe CO with right coronary ostium occurred in 3 patients likely due to ostial eccentricity, and CO was not present with the left coronary artery in any of the patients. Mean transaortic gradient was 6.1±3.3mmHg and there were no moderate-severe paravalvular leaks.Patient-specific rotation during valve crimping based on preprocedural computed tomography is feasible with balloon-expandable devices and is associated with the absence of moderate or severe commissural misalignment and left main CO.

Background: The vast majority of transcatheter valve-in-valve (ViV) mitral procedures have been reported with the SAPIEN family. We aimed to report the preliminary experience with the Myval balloon-expandable device in this setting. Methods: Multicenter retrospective study of high-risk surgical patients with mitral bioprosthesis degeneration undergoing transcatheter ViV implantation with Myval device. Results: A total of 11 patients from five institutions were gathered between 2019 and 2022 (age 68 ± 7.8, 63% women). The peak and mean transvalvular gradients were 27 ± 5 mmHg and 14.7 ± 2.3 mmHg, respectively, and the predicted neo-left ventricular outflow tract (neo-LVOT) area was 183.4 ± 56 mm2 (range: 171 to 221 mm2). The procedures were performed via transfemoral access in all cases (through echocardiography-guided transeptal puncture (81.8% transesophageal, 11.2% intracardiac)). Technical success was achieved in all cases, with no significant residual mitral stenosis in any of them (peak 7.2 ± 2.7 and mean gradient 3.4 ± 1.7 mmHg) and no complications during the procedure. There were no data of LVOT obstruction, migration, or paravalvular leak in any case. Mean hospital stay was 3 days, with one major vascular complication and no stroke. At 6-month follow-up, there was one case with suboptimal anticoagulation presenting an increase in the transmitral gradients (mean 15 mmHg) that normalized after optimization of the anticoagulation, but no other relevant events. Conclusions: Transseptal ViV mitral implantation with the balloon-expandable Myval device was feasible and safe avoiding redo surgery in high-risk patients with bioprosthesis degeneration.

1 Axial. Medicina de Rehabilitacion y Desarrollo Infantil CS. Guadalajara, Jalisco, Mexico. Laboratorio de Mitocondria-Estres Oxidativo & Enfermedad, Centro de Investigacion Biomedica de Occidente (CIBO), Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico. 3 Departamento de Quimica, Centro Universitario de Ciencias Exactas e Ingenierias, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico. 4 Departamento de Readaptacion Cardiovascular, Instituto Cardiovascular de Guadalajara (ICG), Hospital Bernardette, Guadalajara, Jalisco, Mexico.

Laboratorio de Desarrollo-Envejecimiento, Enfermedades Neurodegenerativas, Centro de Investigacion Biomedica de Occidente, Instituto Mexicano del Seguro Social. Sierra Mojada 800, 44243, Guadalajara, Jalisco, Mexico. 2 Centro Universitario de Ciencias de la Salud (CUCS), University of Guadalajara, Guadalajara, Jalisco, Mexico. Asociacion Mexicana de Atrofia Muscular Espinal (AMAME), Guadalajara Jalisco, Mexico. 4 Department of Internal Medicine, University of Iowa Hospital and Clinics, Iowa, USA. Centro Universitario de Ciencias Exactas e Ingenierias, University of Guadalajara, Guadalajara, Jalisco, Mexico.

INTRODUCTIONParagangliomas are neuroendocrine tumors of the autonomic nervous system that arise from neural crest cells. Paragangliomas are typically extra-adrenal, non-functional and can be discovered incidentally, posing diagnostic and therapeutic challenges.PRESENTATION OF CASEWe present the unusual case of a young man who presented with an acute abdomen secondary to small bowel obstruction, and was found to have an incidental left-sided subdiaphragmatic paraganglioma supplied by a branch of the contralateral right renal artery.DISCUSSIONEmergent laparotomy revealed an internal hernia as the source of the small bowel obstruction. Initial attempts to remove an incidental left subdiaphragmatic mass were aborted because of bleeding. Subsequently, after preoperative superselective embolization of the feeding vessel arising from the right renal artery, the mass was successfully resected. Pathology was consistent with a paraganglioma.CONCLUSIONThis report highlights the rarity of the location and blood supply of an incidental left subdiaphragmatic paraganglioma found in the setting of a small bowel obstruction.