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

ABSTRACT 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.