Figure 7. Implantation steps to obtain commissural alignment with different type of THVs.

The figure shows the suggested rotation of the delivery system at the time of insertion (A, B, C), the expected fluoroscopic view of radiopaque markers in the RL cusp overlap view when the THV is still crimped (D, E, F) and the final fluoroscopic view after valve deployment in the same RL cusp overlap view (G, H, I) when implanting different THVs pursuing commissural alignment. If, before valve deployment, the fluoroscopic view is different from expected in the cusp overlap view, the operator should slowly torque the delivery catheter clockwise in order to obtain the desired orientation. Even if a gentle torque could be attempted with the THV at the level of the aortic valve, with the CoreValve platform, it is advisable to perform this manoeuvre only in the descending aorta to facilitate torquing force transmission through the delivery system. CF: central front; LAO: left anterior oblique; OC: outer curve; THV: transcatheter heart valve. Adapted with permission from79.