Planned and actual valve planes differ in every TAVR patient studied

When cardiologists implant a transcatheter aortic valve, they rely on pre-procedural imaging to plan exactly how the C-arm should be angled for deployment. A new retrospective study reports that, in practice, the plane in which the valve actually ends up differs from the planned implantation plane in every one of the patients analysed.

The study, published in BMC Cardiovascular Disorders as an open-access research article, was led by Erez Marcusohn and colleagues at a single centre. It set out to quantify the angular difference between the plane planned for implantation and the plane of the valve as actually implanted, and to see whether that difference varied by valve type.

The researchers focused on the S-curve, a planning tool derived from pre-procedural CT imaging that guides C-arm angulation so the imaging plane aligns with the aortic annulus. Proper alignment is considered important because misalignment has been associated with complications such as paravalvular leak, coronary obstruction and conduction disturbances. Despite this clinical relevance, the relationship between the native aortic annulus plane and the final orientation of the implanted valve has remained poorly understood.

To address that gap, the team studied 36 patients who underwent transfemoral transcatheter aortic valve replacement (TAVR) and had both pre-procedural and post-procedural CT scans allowing S-curve assessment of the native and implanted valves. For each patient, they calculated the angular difference between the pre-procedure and post-procedure valve planes. They then used linear and logistic regression models with stepwise selection to identify anatomical, echocardiographic and procedural predictors of plane shift, post-implantation aortic insufficiency and pacemaker implantation.

The patients had a median age of 76.2 years, and 27.8% were male. Across the cohort, the median plane difference was 8.23 degrees, with an interquartile range of 5.2 to 12.62 degrees. Notably, the authors report that a plane difference was demonstrated in all patients, meaning no patient’s valve ended up in exactly the planned plane.

Valve type appeared to matter. Medtronic Evolut valves showed a lower plane shift than Edwards Sapien valves, with an estimated difference of −4.37 degrees (95% CI −8.55 to −0.18, p = 0.042). In other words, after adjusting in the regression model, the Evolut platform was associated with a smaller gap between the planned and actual implantation plane than the Sapien platform in this cohort.

The angular difference was also linked to one clinical outcome. Plane shift predicted moderate post-TAVR aortic insufficiency, with an odds ratio of 1.38 per degree (95% CI 1.04–1.83, p = 0.026). The study also examined associations with implantation depth and pacemaker implantation as secondary outcomes, although the abstract reports the significant finding only for moderate aortic insufficiency.

The authors conclude that anatomical and procedural factors influence valve alignment, and they argue that this underscores the need for optimized imaging and deployment strategies to minimize post-TAVR adverse outcomes. Their findings suggest that the discrepancy between planning and deployment is not an occasional event but a systematic feature of current practice, at least at the centre studied.

Several caveats are important when interpreting these results. The analysis included only 36 patients at a single centre, and the study was retrospective, so it can identify associations but cannot establish causation. The reported odds ratio for aortic insufficiency has a confidence interval that sits close to the threshold of statistical significance, and the abstract does not report which specific anatomical predictors reached significance in the stepwise models. In addition, the article was shared as an early-access, peer-reviewed accepted version that remains subject to further edits before the final Version of Record.

Even with those limitations, the study offers a concrete, measurable target for improvement: if the gap between planned and actual valve planes is consistently around eight degrees, refining imaging protocols and deployment techniques to narrow that gap could be a practical route toward reducing post-TAVR aortic insufficiency.

Subject of Research: Angular difference between planned and actual transcatheter aortic valve implantation planes

Article Title: Angular plane difference in transcatheter aortic valve replacement

Article References: Erez, M., Arthur, K., Itay, B., Anees, M., Yael, G. M., & Amir, S. (2026). Angular plane difference in transcatheter aortic valve replacement. BMC Cardiovascular Disorders. https://doi.org/10.1186/s12872-026-06797-3

Image Credits: AI Generated

DOI: 10.1186/s12872-026-06797-3

Keywords: TAVR, transcatheter aortic valve replacement, S-curve, aortic annulus, C-arm angulation, plane difference, aortic insufficiency, paravalvular leak, Medtronic Evolut, Edwards Sapien, CT imaging, pacemaker implantation