**9.3 Commissural alignment**

ALIGN TAVR was a study done in 2020 which was the first complete evaluation of the importance of commissural alignment in TAVR. The study compared the effect of the initial deployment orientation of the 483 SAPIEN 3, 100 ACURATE-neo, and 245 Evolut transcatheter heart valves on the final orientation of commissural alignment. 828 patients from 5 centers were studied who had undergone the TAVR procedure from March 2016 to September 2019. The patient's pre-TAVR computed tomography (CT) imaging and procedure fluoroscopy were studied. The pre-TAVR CT had coplanar fluoroscopic views added to it to help determine the commissural alignment. The severe overlap in between the coronary arteries and neocommisural posts were defined as 0° to 20° apart. The different types of valves were classified differently. The Evolut and ACURATE-neo deployment commissural post were defined as center back (CB), center front (CF), inner curve (IC), and outer curve (OC). The Sapien 2 valve had commissural post at clock position 3, 6, 9, and 12. This study showed that valve alignment can be optimized. The SAPIEN 3's orientation did not have an impact on alignment. While ACURATE-neo commissural post showed less coronary artery overlap at the CB or IC in deployment versus in CF or OC. The Evoult "Hat"

had less overlap at OC or CF at initial deployment versus IC or CB. This study showed the significance of optimizing valve alignments in order to avoid coronary artery overlap [49].
