BACKGROUND:Transcatheter aortic valve implantation (TAVI) in patients with small aortic annuli (SAA) is associated with an increased risk of prosthesis-patient mismatch (PPM). AIMS:This study assesses the 30-day performance of the novel balloon-expandable DurAVR transcatheter heart valve (THV), which features a unique single-piece biomimetic leaflet design, in patients with SAA. METHODS:This pooled analysis derived from first-in-human and early feasibility studies includes all patients with SAA (defined as an aortic annular area from 346 mm2 to 452 mm2) treated with the small-sized DurAVR THV. The mean computed tomography (CT)-derived aortic annulus area was 404±37 mm2, with a mean diameter of 22.7±1.0 mm. Outcomes at 30 days, including PPM, were evaluated per Valve Academic Research Consortium 3 criteria, with independent adjudication of clinical events and core laboratory analysis of post-implant transthoracic echocardiograms. RESULTS:Amongst 100 patients (mean age 77.0±7.3 years; 78% female; mean Society of Thoracic Surgeons score 4.7±4.0%) treated with the DurAVR THV, the overall technical success rate was 93%. At 30 days, device success was achieved in 91% of patients, with no reported deaths and a stroke rate of 2%. Echocardiographic haemodynamic assessment showed a mean transprosthetic gradient of 8.2±3.1 mmHg, a mean effective orifice area of 2.2±0.3 cm2, and a Doppler velocity index of 0.60±0.10. The incidence of moderate or greater PPM was 3%, and no patients experienced more than mild paravalvular leak. The rate of new permanent pacemaker implantation was 6%. CONCLUSIONS:In patients with SAA, the DurAVR THV demonstrated promising clinical and echocardiographic outcomes at 30 days. Longer-term follow-up in larger cohorts is needed to confirm these encouraging early results.

Background Frailty is recognized as a determinant of outcomes following valvular interventions; however, data on its prevalence and prognostic impact in patients undergoing isolated tricuspid valve (TV) surgery remain limited. Objective To evaluate the prevalence of frailty and its association with outcomes in patients undergoing isolated TV surgery. Methods Among Medicare beneficiaries aged ≥65 years who underwent isolated TV surgery (2017-2023), frailty was assessed using the Hospital Frailty Risk Score and categorized as low (<5), intermediate (5–15), and high (>15). The primary outcome was all-cause mortality at 1-and 5 years. Secondary outcomes included in-hospital and 30-day mortality, and prolonged hospitalization (≥10 days). Multivariable Cox models assessed associations between frailty and outcomes. Results Among 8,179 patients (mean age 76±7 years, 58% female), 58%, 33%, and 9% were classified as low, intermediate, and high frailty risk. Increasing frailty was associated with higher in-hospital mortality, 30-day mortality, and prolonged hospitalization (all P<0.001). One-year mortality was 12.2% (95%CI 11.3–13.2), 25.8% (95%CI 24.1–27.6), and 35.8% (95%CI 32.4–39.5) across frailty groups, with similar gradients observed at 5 years (all P<0.001). Beyond 1 year, mortality increased more steeply in intermediate- and high-frailty patients. After adjustment, intermediate (HR: 1.18 [95%CI 1.04–1.33]) and high frailty (HR: 1.32 [95%CI 1.11–1.57]) remained independently associated with increased mortality. Conclusions Among Medicare beneficiaries undergoing isolated TV surgery, frailty is common and independently associated with increased perioperative and long-term mortality. Routine frailty assessment may improve risk stratification and inform patient selection, with potential implications for clinical trial design.

Abnormal ascending aortic flow can persist after transcatheter aortic valve replacement (TAVR) and may contribute to aortopathy and incomplete left ventricular mass regression. The DurAVR transcatheter heart valve is designed to reproduce native leaflet shape and restore flow. In a prospective study, patients with symptomatic severe aortic stenosis underwent transthoracic echocardiography and cardiovascular magnetic resonance (CMR) before TAVR with DurAVR and at six months. Post-implant findings were compared with age-, sex-, and haemodynamics-matched controls without aortic valve disease. Ascending aortic flow displacement (FD) and flow reversal ratio (FRR) were quantified using phase-contrast imaging. Haemodynamic correlates of LV mass regression post-DurAVR were explored using multivariable analysis. One hundred and forty-one participants were studied with CMR (aortic stenosis, 60; DurAVR, 46; controls, 35). Thirty-nine patients had paired baseline and 6-month data. Compared to baseline, DurAVR reduced indexed FD (4.0±1.2 to 3.5±0.8 %/cm², P<0.005) and indexed FRR (3.9±1.0 to 2.6±0.7 %/cm², P<0.0001). Post DurAVR, indexed FD was comparable to controls (3.5±0.8 vs 3.5±1.3 %/cm², P=0.81) and indexed FRR approached control values (2.5±0.7 vs 2.2±0.8 %/cm², P=0.06). Left ventricular mass regressed by 18% (P<0.0001). In regression (R2=0.43), left ventricular mass regression was independently associated with the change in the mean transaortic gradient (relative contribution 68%, P=0.005) and change in systolic FRR (relative contribution 26%, P=0.03). DurAVR THV implantation restored ascending aortic flow towards native physiology and was accompanied by left ventricular reverse remodelling at six months. Larger comparative studies should determine whether normalised post-implant flow translates into improved patient outcomes.

Background Transcatheter aortic valve replacement (TAVR) improves symptoms and survival in patients with severe aortic stenosis, yet the incidence and prognostic significance of early postprocedural heart failure (HF) hospitalization remain incompletely characterized. Our objective is to determine the incidence, clinical characteristics, prognostic implications, and predictors of early HF hospitalization after TAVR. Methods Using the Medicare Provider Analysis and Review database, we identified fee‐for‐service beneficiaries ≥65 years who underwent TAVR between January 1, 2017, and November 30, 2021. Early post‐TAVR HF hospitalization was defined as at least 1 HF readmission occurring between 31 and 365 days after the index procedure. Patients were classified according to the presence or absence of HF hospitalization during this period. Cox proportional hazards models were used to evaluate the association with mortality after adjustment for clinical, procedural, and sociodemographic factors. Results Among 233 309 patients undergoing TAVR, 45 502 (19.5%) experienced HF hospitalization within 1 year. Patients with early HF hospitalization had markedly higher mortality compared with those without HF hospitalization, including 1‐year mortality (43.8% versus 3.6%) and 5‐year mortality (80.6% versus 41.0%) (log‐rank P<0.001). After multivariable adjustment, early HF hospitalization was strongly associated with increased mortality (adjusted hazard ratio [HR], 3.17 [95% CI, 3.11–3.22]). The strongest predictors of early HF hospitalization were advanced cardiac damage stage (adjusted‐subdistribution HR, 1.95 [95% CI, 1.88–2.02]) and high‐risk frailty (adjusted‐subdistribution HR, 1.65 [95% CI, 1.58–1.72]), with graded risk across stages. Conclusions Nearly 1 in 5 older adults undergoing TAVR experience early HF hospitalization, which is associated with markedly increased short‐ and long‐term mortality.

Background:Transcatheter aortic valve replacement (TAVR) is an accepted alternative to surgery in many patients with severe aortic stenosis. Clinical trials have evaluated early and late outcomes in selected TAVR patients, but predictors of late mortality have been less well studied in a broadly inclusive, national patient cohort undergoing TAVR. We sought to characterize 5-year outcomes after TAVR in Medicare beneficiaries and to evaluate the incremental predictive value of demographics, comorbidities, procedural factors, frailty, and social vulnerability in determining late mortality risk. Methods:We studied the fee-for-service Centers for Medicare & Medicaid Services MedPAR database that includes patients aged ≥65 years undergoing TAVR between 2017 and 2022. The primary endpoint was 5-year mortality. Sequential multivariable Cox models were constructed, incrementally adjusting for demographics, comorbidities, procedural and hospital characteristics, and frailty and social vulnerability. Model performance was assessed using C-statistics and integrated discrimination improvement (IDI). Results:A total of 371,248 TAVR patients were included in the analysis. The baseline model, including only demographic factors (age, sex, and race), yielded modest model performance (C = 0.589). Inclusion of comorbidities improved the model discrimination substantially (C = 0.684; IDI +6.9%, p < 0.001), and adding hospital and procedural characteristics yielded additional gains (C = 0.695; IDI +0.9%, p < 0.001). The final model integrated frailty and social vulnerability and achieved the highest predictive accuracy (C = 0.705; IDI +1.0%, p < 0.001). Conclusions:In this large national cohort, frailty and social vulnerability significantly improved risk prediction for long-term mortality after TAVR. We conclude that sociodemographic and frailty-related factors are important components for prediction of 5-year mortality after TAVR.

Background The incidence and clinical importance of bioprosthetic valve dysfunction (BVD) in patients undergoing supra-annular, self-expanding transcatheter aortic valve replacement (TAVR) or surgery is not well understood. Objectives The purpose of this study was to evaluate the 5-year incidence and clinical outcomes of BVD in patients undergoing CoreValve/Evolut TAVR or surgery. Methods This post hoc analysis pooled data from the U.S. High Risk Pivotal (n = 726) and SURTAVI (n = 1,618) randomized controlled trials (RCTs), the Extreme Risk Pivotal trial (n = 608), and CoreValve Continued Access Study (n = 2,654). The primary endpoint was the incidence of BVD through 5 years from the RCTs. The association of BVD with 5-year clinical outcomes was evaluated in the pooled RCT and non-RCT populations. Results Of 5,606 patients evaluated, 3,070 (54.8%) were men, and the mean age was 82.2 ± 7.4 years. A total of 2,344 RCT patients, including 1,227 who received TAVR and 1,117 who received surgery, and 3,262 non-RCT TAVR patients were included. The rate of BVD was lower in RCT patients undergoing CoreValve/Evolut TAVR compared with surgery (9.7% vs 15.3%; subdistribution HR: 0.57; 95% CI: 0.45-0.73; P < 0.001). In the pooled RCT and non-RCT cohort, BVD was associated with increased 5-year all-cause mortality (HR: 1.49; 95% CI: 1.32-1.68; P < 0.001), cardiovascular mortality (HR: 1.76; 95% CI: 1.52-2.03; P < 0.001), and hospitalization for valve disease or worsening heart failure (HR: 1.48; 95% CI: 1.23-1.78; P < 0.001). Conclusions Five-year valve performance was significantly better after CoreValve/Evolut TAVR compared with surgery. Development of BVD in TAVR and surgery patients was associated with worsened 5-year clinical outcomes. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement, NCT01240902; Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI], NCT01586910; Safety and Efficacy Continued Access Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in Very High Risk Subjects and High Risk Subjects Who Need Aortic Valve Replacement, NCT01531374)

BACKGROUND:Mitral valve intervention improves clinical outcomes in selected patients with severe mitral regurgitation; less is known about the use trends and long-term outcomes of different mitral intervention strategies in real-world patients. OBJECTIVES:The aim of this study was to describe use trends in mitral valve intervention and identify factors contributing to 5-year mortality in elderly patients. METHODS:The fee-for-service Centers for Medicare and Medicaid Services claims database was used to identify patients ≥65 years of age hospitalized for surgical or transcatheter mitral valve intervention between January 1, 2017, and December 31, 2022. The primary outcome was 5-year mortality. RESULTS:There were 172,478 mitral valve interventions identified over the 5-year period. The number of mitral valve interventions, indexed per 100,000 Medicare Part A beneficiaries, increased by 9.2% over this period. The incidence of surgery declined by 15.7% whereas transcatheter edge-to-edge repair (M-TEER) increased by 94.8% and transcatheter mitral valve replacement (TMVR) increased by 100%. In-hospital mortality rates were 6.9% for surgery, 4.0% for TMVR, and 1.5% for M-TEER. Five-year mortality was 39.5% after surgery, 55.1% after TMVR, and 61.9% after M-TEER. Among patients at low frailty risk, 5-year mortality rates were 24.4%, 45.8%, and 52.2% for surgery, TMVR, and M-TEER, respectively; among patients at intermediate frailty risk, they were 44.8%, 62.2%, and 70.7%, respectively; among those at high frailty risk, they were 57.8%, 74.2%, and 80.6%, respectively. Quartiles of social vulnerability were incrementally associated with higher mortality. CONCLUSIONS:Mitral valve interventions in elderly patients are increasing over time, driven by transcatheter therapies. Five-year mortality varied by type of intervention and was significantly influenced by frailty and social vulnerability.

Coronary artery disease (CAD) is the leading cause of heart failure with reduced ejection fraction (HFrEF). Coronary artery bypass grafting (CABG) improves long-term mortality in HFrEF. Percutaneous coronary intervention (PCI) is often performed as an alternative to CABG in patients at high surgical risk. However, in patients with HFrEF and limited myocardial reserve, PCI may result in haemodynamic instability, increasing risk and precluding optimal revascularisation. Mechanical circulatory support (MCS) during high-risk PCI may enhance haemodynamic stability during the procedure and enable complete revascularisation. We thus performed the PROTECT IV trial to determine whether PCI with routine use of the Impella CP microaxial flow pump improves early and late outcomes in patients with HFrEF and complex CAD compared with PCI with or without use of an intra-aortic balloon pump (IABP). PROTECT IV is a prospective, multicentre, randomised, parallel-controlled, open-label, superiority trial with an adaptive design. Patients with complex CAD and left ventricular ejection fraction ≤40% (n=1,252) deemed at excessive surgical risk for bypass grafting by the Heart Team will be randomised in a 1:1 ratio to PCI with Impella CP versus PCI with or without an IABP. The primary endpoint is the composite of all-cause death, stroke, myocardial infarction, unplanned clinically driven revascularisation, durable left ventricular assist device implant or heart transplant, or other hospitalisation for cardiovascular causes at 3-year follow-up, with at least 1-year follow-up in all patients. Prespecified substudies will evaluate the impact of MCS on renal function, the procedural role of right heart catheterisation, and the utility of myocardial viability assessment. The PROTECT IV trial will determine whether routine MCS with Impella CP during high-risk PCI improves the prognosis of patients with complex CAD and HFrEF.

•LBBB is the most common TAVI-induced conduction abnormality.•Strain imaging can assist with determining the etiology of heart failure after TAVI.•Strain imaging can help predict response to CRT.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) is an alternative to surgery in patients with severe aortic stenosis, but data are limited on younger, low-risk patients. This analysis compares outcomes in low-surgical-risk patients aged <75 years receiving TAVR versus surgery. METHODS:The Evolut Low Risk Trial randomized 1414 low-risk patients to treatment with a supra-annular, self-expanding TAVR or surgery. We compared rates of all-cause mortality or disabling stroke, associated clinical outcomes, and bioprosthetic valve performance at 3 years between TAVR and surgery patients aged <75 years. RESULTS:In patients <75 years, 352 were randomized to TAVR and 351 to surgery. Mean age was 69.1±4.0 years (minimum 51 and maximum 74); Society of Thoracic Surgeons Predicted Risk of Mortality was 1.7±0.6%. At 3 years, all-cause mortality or disabling stroke for TAVR was 5.7% and 8.0% for surgery (P=0.241). Although there was no difference between TAVR and surgery in all-cause mortality, the incidence of disabling stroke was lower with TAVR (0.6%) than surgery (2.9%; P=0.019), while surgery was associated with a lower incidence of pacemaker implantation (7.1%) compared with TAVR (21.0%; P<0.001). Valve reintervention rates (TAVR 1.5%, surgery 1.5%, P=0.962) were low in both groups. Valve performance was significantly better with TAVR than surgery with lower mean aortic gradients (P<0.001) and lower rates of severe prosthesis-patient mismatch (P<0.001). Rates of valve thrombosis and endocarditis were similar between groups. There were no significant differences in rates of residual ≥moderate paravalvular regurgitation. CONCLUSIONS:Low-risk patients <75 years treated with supra-annular, self-expanding TAVR had comparable 3-year all-cause mortality and lower disabling stroke compared with patients treated with surgery. There was significantly better valve performance in patients treated with TAVR. REGISTRATION:URL: https://clinicaltrials.gov; Unique identifier: NCT02701283.

Mitral regurgitation is the most common valvular disease and is estimated to affect over 5 million Americans. Real-world data collection contributes to safety and effectiveness evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, and clinical best practice research. We aimed to establish a minimum core data set in mitral interventions to promote efficient, reusable real-world data collection for all of these purposes. Two expert task forces separately evaluated and reconciled a list of candidate elements derived from: 1) 2 ongoing transcatheter mitral trials; and 2) a systemic literature review of high-impact mitral trials and U.S multicenter, multidevice registries. From 703 unique data elements considered, unanimous consensus agreement was achieved on 127 “core” data elements, with the most common reasons for exclusion from the minimum core data set being burden or difficulty in accurate assessment (41.2%), duplicative information (25.0%), and low likelihood of affecting outcomes (19.6%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established and implemented into the national Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapies Registry 127 interoperable, reusable core data elements to support more efficient, consistent, and informative transcatheter mitral device evidence for regulatory submissions, safety surveillance, best practice development, and hospital quality assessments.

Aim Transfemoral Trans-catheter Aortic Valve Replacement (TF-TAVR) is a safe and effective therapy compared with surgical aortic valve replacement (SAVR) in patients across all risk profiles using balloon-expandable valves (BEV) and self-expanding valves (SEV). Our aim was to compare safety and efficacy of BEV vs. SEV in high-risk patients undergoing TF-TAVR. Methods and results We searched PubMed, EMBASE, Clinicaltrials.gov , Scopus, and Web of sciences for studies on patients with severe aortic stenosis undergoing TAVR. Primary outcome was 30-day all-cause mortality. Secondary outcomes defined by Valve Academic Research Consortium 2 (VARC-2) criteria were also examined. Six studies with 2,935 patients (1,439 to BEV and 1,496 to SEV) were included. BEV was associated with lower risk of all-cause mortality (2.2% vs. 4.5%; RR: 0.51; 95% CI: 0.31–0.82; p < 0.006) and cardiovascular mortality [(2.5% vs. 4.3%; RR: 0.54; 95% CI: 0.32–0.90; p = 0.01) at 30 days compared with SEV. Implantation of more than one valve per procedure (0.78% vs. 5.11%; RR: 0.15; 95% CI: 0.07–0.31; p < 0.00001), and moderate/severe AR/PVL (2.5% vs. 9.01%; RR: 0.3; 95% CI: 0.17–0.48); p < 0.00001) were also lower in the BEV arm. Conclusion BEV TAVR is associated with reduced all-cause mortality (High level of GRADE evidence), cardiovascular mortality (very low level) at 30 days compared with SEV TAVR in high surgical risk patients. Data are necessary to determine if the difference in outcomes persists in longer-term and if the same effects are seen in lower-risk patients. Systematic Review Registration identifier, CRD42020181190.

Optimal timing for aortic valve replacement in symptomatic patients with less than severe aortic stenosis (AS) is not well defined. There is limited information on the benefit of valve replacement in these patients. Symptomatic patients with less than severe AS, defined as a mean aortic gradient ≥20 and <40 mm Hg, peak aortic velocity >3 and <4 m/s, and aortic valve area >1.0 and <1.5 cm2, enrolled in the Society for Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry and who underwent attempted supra-annular, self-expanding transcatheter aortic valve replacement (TAVR) were reviewed. Site-reported valve hemodynamics, clinical events, and quality of life metrics were analyzed at 30 days and 1 year after the procedure. A total of 1,067 patients with attempted TAVR (mean age 78.4 ± 8.4 years; Society for Thoracic Surgery score 4.7 ± 3.4%) were found to have symptoms but less than severe AS. From baseline to postprocedure, mean gradient decreased (29.9 ± 4.9 vs 8.4 ± 4.8 mm Hg, p <0.001), and aortic valve area increased (1.2 ± 0.1 vs 2.2 ± 0.7 cm2, p <0.001). Clinical events included 30-day and 1-year all-cause mortality (1.5% and 9.6%), stroke (2.2% and 3.3%), and new pacemaker implantation (18.1% and 20.9%). There were statistically significant improvements in the New York Heart Association functional class and Kansas City Cardiomyopathy Questionnaire at 30 days and 1 year. In conclusion, patients with symptomatic but less than severe AS who underwent supra-annular, self-expanding TAVR experienced improved valve hemodynamics and quality of life measures 1 year after the procedure. Randomized studies of TAVR versus a control arm in symptomatic patients with less than severe AS are ongoing.

BACKGROUND:Randomized data comparing outcomes of transcatheter aortic valve replacement (TAVR) with surgery in low-surgical risk patients at time points beyond 2 years is limited. This presents an unknown for physicians striving to educate patients as part of a shared decision-making process. OBJECTIVES:The authors evaluated 3-year clinical and echocardiographic outcomes from the Evolut Low Risk trial. METHODS:Low-risk patients were randomized to TAVR with a self-expanding, supra-annular valve or surgery. The primary endpoint of all-cause mortality or disabling stroke and several secondary endpoints were assessed at 3 years. RESULTS:There were 1,414 attempted implantations (730 TAVR; 684 surgery). Patients had a mean age of 74 years and 35% were women. At 3 years, the primary endpoint occurred in 7.4% of TAVR patients and 10.4% of surgery patients (HR: 0.70; 95% CI: 0.49-1.00; P = 0.051). The difference between treatment arms for all-cause mortality or disabling stroke remained broadly consistent over time: -1.8% at year 1; -2.0% at year 2; and -2.9% at year 3. The incidence of mild paravalvular regurgitation (20.3% TAVR vs 2.5% surgery) and pacemaker placement (23.2% TAVR vs 9.1% surgery; P < 0.001) were lower in the surgery group. Rates of moderate or greater paravalvular regurgitation for both groups were <1% and not significantly different. Patients who underwent TAVR had significantly improved valve hemodynamics (mean gradient 9.1 mm Hg TAVR vs 12.1 mm Hg surgery; P < 0.001) at 3 years. CONCLUSIONS:Within the Evolut Low Risk study, TAVR at 3 years showed durable benefits compared with surgery with respect to all-cause mortality or disabling stroke. (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients; NCT02701283).

Over the past two decades, transcatheter aortic valve implantation (TAVI) has been established as an alternative to aortic valve replacement in symptomatic patients with severe aortic stenosis. Within these clinical studies are high-level randomized clinical trials that have informed Society guidelines. The purpose of this chapter is to describe nine randomized clinical trials and one single-arm study that help address the evidence base for TAVI in clinical practice. The clinical trials of interest are described in detail, as are the background and clinical questions raised by these trials. These large-scale, randomized clinical trials have established that TAVI is superior to medical therapy in patients who are not candidates for surgery and is a suitable alternative to surgery in patients who are high, intermediate, and low risk for surgery. Additional clinical trials are ongoing to evaluate the future of TAVI in patients with aortic valve disease. TAVI is now well established as an alternative to surgery in patients with symptomatic aortic valve stenosis.

BACKGROUND: Coronary accessibility following redo–transcatheter aortic valve replacement (redo-TAVR) is increasingly important, particularly in younger low-risk patients. This study aimed to predict coronary accessibility after simulated Sapien-3 balloon-expandable valve implantation within an Evolut supra-annular, self-expanding valve using pre-TAVR computed tomography (CT) imaging. METHODS: A total of 219 pre-TAVR CT scans from the Evolut Low-Risk CT substudy were analyzed. Virtual Evolut and Sapien-3 valves were sized using CT-based diameters. Two initial Evolut implant depths were analyzed, 3 and 5 mm. Coronary accessibility was evaluated for 2 Sapien-3 in Evolut implant positions: Sapien-3 outflow at Evolut node 4 and Evolut node 5. RESULTS: With a 3-mm initial Evolut implant depth, suitable coronary access was predicted in 84% of patients with the Sapien-3 outflow at Evolut node 4, and in 31% of cases with the Sapien-3 outflow at Evolut node 5 ( P <0.001). Coronary accessibility improved with a 5-mm Evolut implant depth: 97% at node 4 and 65% at node 5 ( P <0.001). When comparing 3- to 5-mm Evolut implant depth, sinus sequestration was the lowest with Sapien-3 outflow at Evolut node 4 (13% versus 2%; P <0.001), and the highest at Evolut node 5 (61% versus 32%; P <0.001). CONCLUSIONS: Coronary accessibility after Sapien-3 in Evolut redo-TAVR relates to the initial Evolut implant depth, the Sapien-3 outflow position within the Evolut, and the native annular anatomy. This CT-based quantitative analysis may provide useful information to inform and refine individualized preprocedural CT planning of the initial TAVR and guide lifetime management for future coronary access after redo-TAVR. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02701283.