Figure 4. Coronary access according to valve design and implantation depth.

Coronary engagement after previous SAPIEN 3 (A) implantation is commonly feasible with standard catheters, and the access route may be least impaired (green arrow); engagement across the stent frame (red arrow) may become necessary only in the case of high THV positioning or low coronary take-off. Potential access routes for the ACURATE neo valve (B) may be via the stabilisation arches (red arrow) or from outside the valve frame (dotted green arrow). The common access route in tall-frame valves ([C] Portico/Navitor; [D] Evolut) is across the uncovered stent struts above the leaflet plane (red arrows), whereas, especially in patients with a wide sinotubular junction or sinus of Valsalva, an access route from outside the valve frame (dotted green arrows) may be an alternative. The lower leaflet position and the larger cells of the Portico/Navitor THV stent frame may facilitate coronary catheterisation in comparison with the Evolut platform. Regardless of the THV type, correct commissural alignment of the prosthesis will usually facilitate coronary access. THV: transcatheter heart valve