Impact of aortic landing zone geometry on TAVI implantation depth: Comparison between ACURATE neo2 and Portico/Evolut

Background During transcatheter aortic valve implantation (TAVI), increased aortic angulation can affect the final implantation depth of self-expandable (SE) devices due to the interaction between the high stent frame and the targeted aortic landing zone (LZ). We herein sought to investigate the behaviour of the ACURATE neo2, a SE device with a unique release mechanism, in relation to patient-specific angulation and curvature of the aortic LZ. Methods The mismatch between the intended and the final implantation depth (δH) was compared between patients treated with ACURATE neo2 (Acurate, n=106) and Evolut/Portico (n=101) SE devices. To do so, curvature (κ LZ,tot) and angulation (α LZ,Dist) were calculated based on the three-dimensional aortic LZ centerline available from pre-TAVI CT. Results The Acurate and Evolut/Portico groups showed a negligible difference (p=0.09) for δH averaged between non-coronary (NCC) and left coronary cusp (LCC). However, when splitting both δH NCC and δH LCC values into two subgroups based on κ LZ,tot and α LZ,Dist median values, δH significantly increased on LCC compared with NCC in Evolut/Portico patients with high LZ curvature (κ LZ,tot >0.123/mm, p=0.016) and high LZ distal angulation (α LZ,Dist >28.5°, p=0.012). No statistically significant differences arose within the Acurate group. Conclusions Among SE devices, the ACURATE neo2 was the least affected by the curvature and angulation of the LZ anatomy, leading to a more predictable and symmetrical implantation depth. The clinical impact of this finding on TAVI outcomes in patients with an angulated aortic LZ warrants further investigation in larger studies.