The first large, consecutive evaluation of commissural alignment using a dedicated patient-specific implant technique found it safe and effectively achievable in a majority of patients, with minimal impact on procedural duration. Christopher Meduri, MD, MPH, of Karolinska University Hospital, Stockholm, presented these findings Tuesday at EuroPCR 2022. Meduri and colleagues performed a registry study of 170 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the Acurate Neo2 at Karolinska University Hospital using a dedicated patient-specific implant technique. The effectiveness was evaluated with degree of misalignment based on pre-specified computed tomography (CT) angles as none (0-15°), mild (16-30°), moderate (31-45°) and severe (45-60°). The safety endpoints were stroke or transient ischemic attack (TIA), both procedural and at 30 days; mortality; and additional complications. Fluoroscopic time stamps WERE used to document the duration of time required for alignment. patients undergoing TAVR had a dedicated implant technique used to attempt commissural alignment using both left-to-right (L-R) overlap and three-cusp view. The Karolinska Alignment technique’s initial step is valve insertion into sheath with port down at the 6 o’ clock position and advancing of the marker to top of the pigtail. The second step consists of two stages: a) confirming one of the wings of the valve sits on the inner curve (2:1, aligned) in L-R overlap view, and b) swinging the fluoroscopic forearm to the three-cusp view without rotating the valve with a goal of achieving a symmetric view of the wings (equally spaced from each other, 1:1:1). If the valve is not aligned upfront and alignment is noted to be 2:1, then clockwise rotation is performed, and if wings are aligned in a 1:2 setting, then counterclockwise rotation is commenced. Lastly, once alignment is achieved, the valve is deployed in the three-cusp view. Of 170 patients, 167 (98.2%) were analyzed for alignment, and the study demonstrated that 97% of patients had no significant misalignment (none [80%], mild [17%], moderate [1.2%] and severe [1.8%]). The average alignment time was 92.1 seconds. The authors also performed an analysis of initial rotations with the flushport at the 6 o’clock position and reported that between 20% and 46% of valves were initially misaligned with flushport alone, and only 25% of cases were optimally aligned without rotation. One third of the cases required clockwise rotation, and two thirds needed counterclockwise rotation. All patients were analyzed for safety and linked to the Swedish TAVR registry (SWENTRY) for 30-day outcomes. The rate of in-hospital death was 1.2%, stroke/TIA was 1.2%, and major complications 1.8%. At 30 days, the death rate was 1.8%, while the stroke/TIA rate remained 1.2%. Meduri concluded that this dedicated-patient-specific implant technique for commissural alignment was effectively achieved in 97% of patients undergoing TAVR with the Acurate Neo2 valve, with no appearance of safety concerns, despite small manipulations in ascending aorta and low sentinel use. In response to a panelist’s question, Meduri stressed the importance of commissural alignment and said it should be uniformly advocated for all patients undergoing TAVR. He stated that whether it improves the sinus washout or offers better long-term durability is unknown and needs to be further investigated.