Supplement to January/February 2021

EVOLUT™ TAVR CUSP OVERLAP TECHNIQUE

PRECISION & CONTROL

Sponsored by Medtronic
Funding for this supplement provided by Medtronic

EVOLUT™ TAVR CUSP OVERLAP TECHNIQUE

PRECISION & CONTROL
Contents
3 Procedural Optimization to Minimize Interaction With the Left
Ventricular Conduction System During Self-Expanding TAVR
The inception of the cusp overlap technique: rationale and
development.
By Hemal Gada, MD, MBA, and Amit N. Vora, MD, MPH

8 Evolut Commissural Alignment and the Cusp Overlap Technique

Facilitating post-TAVR coronary reaccess while minimizing the risk
of interaction with the conduction system.
By Sophia L. Alexis, MD; Syed Zaid, MD; Sahil Khera, MD;
Parasuram Melarcode Krishnamoorthy, MD; George D. Dangas, MD, PhD;
Samin K. Sharma, MD; Annapoorna Kini, MD; Aditya Sengupta, MD;
and Gilbert H. L. Tang, MD, MSc, MBA

12 Cusp Overlap Deployment Technique—The Manchester

Experience
Technique rationale, clinical outcomes, and practical advice for
implanters.
By Douglas G. W. Fraser, MB BChir, BA, DM,
and Freidoon Keshavarzi, PGRAD, MD

15 Cusp Overlap Technique in TAVR

Visit www.cuspoverlap.com to
learn more about the technique
TAVR implantation optimization—CT analysis and practical aspects
of the cusp overlap technique.
By Xavier Armario, MD; Liesbeth Rosseel, MD;
and Darren Mylotte, MB BCh, MD, PhD

2 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1

 CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

Procedural Optimization to Minimize

Interaction With the Left Ventricular
Conduction System During
Self-Expanding TAVR
The inception of the cusp overlap technique: rationale and development.
By Hemal Gada, MD, MBA, and Amit N. Vora, MD, MPH

T
ranscatheter aortic valve replacement (TAVR) with the
self-expanding, supra-annular CoreValve and Evolut R
bioprostheses (Medtronic) has been associated with
the need for permanent pacemaker implantation (PPI)
in 15.7% to 28.6% of patients within 30 days after the
procedure.1-9 The frequent requirement for PPI has been one
of the main challenges influencing an operator’s willingness
to perform TAVR with this bioprosthesis. We present a novel
method that describes a series of procedural steps designed
to provide a controlled implantation depth and minimize
the interaction of the bioprosthesis with the atrioventricular
(AV) conduction system, potentially reducing the
subsequent clinical sequelae of conduction disturbances.
Traditional deployment of the CoreValve and subsequently
Evolut bioprosthesis had relied upon obtaining a three-cusp
coplanar view and then adjusting the gantry angle, generally
caudal, to eliminate parallax from the capsule marker
band. Subsequently, Piazza and colleagues demonstrated
that the three-cusp technique with marker adjustment
distorted the native anatomy on fluoroscopy.10 Using the
three-cusp technique, the operator often deployed the valve
without a clear representation of the location of the native
annulus relative to the conduction system. The location of
the conduction system was obscured by the radiographic
foreshortening of the left ventricular outflow tract in
noncusp overlap views.

Figure 1. Cusp overlap view. The left panel illustrates the cusp overlap position with the NCC (yellow), RCC (green), and left
coronary sinus (red). The right panel shows the volume rendering of the cusp overlap view showing the commissure of the non- and
right coronary sinus (courtesy James Harvey, MD).

VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 3

CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

A B C

Figure 2. Location of the AV node and basal annular plane. The blue AV node is shown best in the cusp overlap view (A) with an
increased distance from the AV node to the basal annular plane. The three-cusp coplanar view generally requires caudal angulation
to remove the parallax from the marker band and the AV does appear closer to the basal annular plane due to foreshortening of the
LVOT (B). The LAO view shows the AV node with overlaps the RCC and NCC and isolates the LCC (C). The LVOT is also foreshortened
in this view.

To develop a strategy that minimizes the risk of
interaction of the conduction system with the bioprosthesis,
a better understanding of the location of the conduction
system relative to the aortic annulus basal plane was
needed. The noncoronary cusp (NCC), the most inferiorly
oriented cusp in the left ventricular outflow tract (LVOT),
is isolated from the left coronary cusp (LCC) and the right
coronary cusp (RCC) using the cusp overlap technique.
Below the non-right commissure, the membranous septum
houses the conduction system. More ventricular to the
membranous septum, which may be of variable length, these
conduction fibers become more superficial in the muscular
septum. If the transcatheter heart valve (THV) is deployed
below the membranous septum, there is a greater chance
of interaction with the conduction system. Jilaihawi et al
described the variation in PPI rates depending on the length
of the membranous septum and the depth of the THV. Their
series suggested that when a THV is deployed below the
membranous septum, the risk of PPI was increased.4
CUSP OVERLAP METHOD
Our method demonstrates that by isolating the NCC
and overlapping the NCC/RCC commissure along the basal
annular plane, the implantation view can be optimized
during THV deployment. This view can be easily identified
during computed tomography (CT) reconstruction (3Mensio,
Pie Medical Imaging) and contribute to preprocedural case
planning (Figure 1). The cusp overlap view unforeshortens
and elongates the LVOT and accentuates the NCC/
RCC commissure in the center of the fluoroscopic view,
creating an implant that references the conduction
system and separates it from the annular plane. Given the
unforeshortening of the LVOT, there is also a greater distance
between the NCC insertion and the compact AV node
(Figure 2). This fluoroscopic view may lead to a more precise
3-mm implantation depth, thereby minimizing the risk of
interaction with the conduction system.
In addition to the cusp overlap view, several procedural
steps have been embedded in this technique to further
reduce interaction with the conduction system during
TAVR deployment. We now focus on more of a “top-down”
deployment of the THV, starting with the catheter marker
band positioned at the midportion of the pigtail in the
NCC (Figure 3). With retraction of the nitinol capsule, the
inflow of the prosthesis advances across the annulus and
is positioned at 3 mm below the annulus. This maneuver
avoids traumatic advancement of the bioprosthesis into the
ventricle with inflow flaring deeper within the left ventricle,
resulting in subsequent maneuvers to move it more aortic
and interacting with the muscular septum and conduction
system. We also use a stiffer, double-curved, Lunderquist wire
(Cook Medical) in most cases to maintain a wire position
in the non-right commissure and begin the prosthesis
deployment along the posterior aspect of the annular plane.
The stiffer wire may result in more symmetrical deployment
and is especially valuable when deploying larger-sized THVs.
Using the cusp overlap view to maintain a reference to the
native annular plane, the marker band on the THV delivery
catheter does tend to lose parallax when approaching
the valve plane. The loss of parallax of the marker band
is the result of the delivery catheter following the stiff left
ventricular wire that is generally positioned in the NCC/RCC
commissure. This approach may lead to more confidence
in the initial positioning of the THV in relation to the

4 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1


A B
Figure 3. Location of the marker band at initial deployment. The marker band is placed at the mid position of the pigtail catheter
that is positioned at the lowest portion of the noncoronary sinus (A). With retraction of the nitinol capsule, the inflow of the Evolut
bioprosthesis advances to a 3-mm position below the annulus (B).
insertion of the NCC and a better assessment at the point
of no-recapture. We also favor sufficient pacing during the
deployment to minimize cardiac output and the occurrence
of premature ventricular contraction burden, allowing for a
stable bioprosthesis deployment. Finally, once we are at 80%
deployment, we rotate the gantry to an LAO projection to
visualize the LCC and ensure that the inflow is not supra-
annular. We aim for an implantation depth of 3 mm, and
no deeper than 5 mm, below the NCC to reduce our risk of
conduction disturbance. We occasionally aim for shallower
deployment in patients at high risk for conduction system
abnormality but recommend recapture for bioprosthesis
positions < 1 or > 5 mm within the ventricle. Once final
positioning is confirmed, we retract the left ventricular wire,
centralize the nose cone, and slowly release the delivery
catheter from the bioprosthesis by the release of the frame
paddles. We are cautious to avoid interaction of the delivery
catheter and the bioprosthesis as the delivery catheter is
retracted into the aorta.
THE UPMC PINNACLE EXPERIENCE WITH
CUSP OVERLAP
After starting with routine use of the cusp overlap
technique in October 2015, we have observed a significant
decline in the post-TAVR PPI rates at our institution, especially
with the Medtronic CoreValve and Evolut platforms. In the
Medtronic Low Risk trial, the rate of PPI 30-days post-TAVR
was 17.4%,2 with wide site-specific variability (Figure 4). Our
VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 5
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
single-center experience utilizing cusp overlap found that
only one (1.5%) in 65 patients required permanent pacing.
As the highest enrolling center in the Evolut low-risk trial, we
attribute this difference to the comprehensive use of the cusp
overlap technique at our institution.
We have also analyzed our experience in 134 patients
without antecedent PPI who underwent placement of
the 34-mm Evolut R THV, which has been shown to be a
predictor of PPI,11 independent of membranous septum
length.4 After preprocedural computed tomography (CT)
planning to determine the optimal cusp overlap projection
angle, we were able to achieve the projected cusp overlap
gantry view on CT reconstruction in 88% of patients, and
a near cusp overlap projection in the remaining patients.
In this series, we obtained an effective 30-day PPI rate of
5.2%.11 In addition, the new-onset left bundle branch block
rate was 10.9%, below contemporary rates previously
published.2 When compared to previous studies (Figure 5),4-9
we believe that the cusp overlap view contributed to the
lower rate of PPI rates in our series. The Optimize PRO study
(NCT04091048) will provide additional insights into the safety
and efficacy of this method in a broader array of patients at
multiple centers.
PROCTORING EXPERIENCE IN ADOPTION OF
CUSP OVERLAP
Prior to the adoption of the cusp overlap technique as the
standard for Medtronic self-expanding THV deployment, we
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
Figure 4. Funnel plot of site-level variability of 30-day post-TAVR PPI rate in the Medtronic Low Risk trial. Each dot represents an
enrolling center and UPMC Pinnacle had the highest enrollment with a PPI rate lower than 2 confidence intervals, using the cusp
overlap technique for all TAVR deployments.
were able to teach the cusp overlap technique successfully to
several international centers, including those in the United
States. A focused didactic experience involving several Latin
American centers was initiated in July 2018.12 There were
eight formal encounters with Latin American physicians,
involving didactics through programmatic lecture, proctored
and presented cases, as well as case observation at our
institution. We analyzed the results of these experiences
extending to October 2019.12 Fourteen implanting physicians
from seven countries performed consecutive procedures
on 114 patients. Each physician implanted only 22.6 ±
10.9 THVs the previous year, with a lifetime experience of
129 ± 110 THVs. Of the 114 patients, 105 (92%) did not
have a prior PPI. In this series, the in-hospital rate of new
PPI post-THV was 5.7%. During the 30-day follow-up that
included 85 patients, no additional patients required a new
permanent pacemaker. These results suggest that the use
of the cusp overlap in lower volume operators resulted in
reduced rates of PPI and may be useful to potentially shorten
the learning curve for this self-expanding bioprosthesis.
OPTIMIZING POSTPROCEDURAL MANAGEMENT
Our institution has focused on optimizing
postprocedural management over the past several years,
which has included an effort to reduce resource utilization
during the hospitalization period. Our institution
6 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1
experienced a reduction in the 2019 TAVR mean length
of stay (LOS) to 1.23 days after 386 TAVR procedures, at
least partially due to a reduction in the need for new PPI
implantation. More specifically, an analysis of 567 TAVR
cases performed at our institution between July 2015 and
June 2018 included 34 patients who required PPI during
their hospital stay. The average cost of PPI was $4,415, but
the patients who went onto receive PPI had a significantly
longer LOS than those who did not (4.49 vs 1.75 days),
resulting in a modified contribution margin differential of
$12,654 per case. Although the reasons for this reduction
in LOS differential were multifactorial, a primary reason
was related to the reduced postprocedural conduction
disturbances and the need for a temporary or permanent
pacemaker. For example, patients who developed
temporary conduction disturbances requiring temporary
pacing were not placed on the “fast track” protocol
and early ambulation. In those patients who required
permanent pacing, usually on postprocedural day 1, an
additional 24-hour period of bed rest was needed, leading
to slower periprocedural recovery and increased resource
utilization to facilitate suitable disposition.
LIMITATIONS AND MITIGATIONS
There are three potential limitations for the cusp overlap
method that will be informed by additional single and

Figure 5. Rate of PPI in the UPMC Pinnacle 34-mm Evolut R series. Using the cusp overlap technique, the lowest reported rate of
30-day PPI with the 34-mm Evolut R was achieved.4-9
multicenter studies, including the Optimize PRO study. One
concern relates to higher implantation of the self-expanding
bioprosthesis with its 13- to 14-mm skirt height that raises
concerns for coronary access. Preprocedural CT planning
can mitigate this risk by assessing the heights of the coronary
arteries and placing the bioprosthesis at a position to allow
coronary access after TAVR.
Another potential limitation of the cusp overlap
technique is the operator’s anxiety that a shallow TAVR
implantation may lead to a higher rate of valve embolism
(“pop-outs”), potentially resulting in increased procedural
complexity and patient morbidity. In our experience, we
have not found this to be the case, and required the use of a
second THV in only one (0.5%) of approximately 200 cases.
In fact, the cusp overlap technique may facilitate a better
understanding of the true THV depth relative to the NCC,
and importantly, the target 3-mm implantation depth in
relation to the NCC is standard for use for all THV platforms.
Because the LVOT is elongated in this particular view, our
assessment of the depth assessment is likely more accurate.
In a non-cusp overlap view, the LVOT is foreshortened,
leading to the false perception that THV is positioned
shallower relative to the NCC insertion. Another reason to
position the THV at a 3-mm implantation depth is that if
postdilation is indicated, there is a buffer for the potential
shortening of the THV during postdilatation.
VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 7
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
A third limitation is the use of a stiff Lunderquist wire.
Our technique supports the use of the double-curved
Lunderquist wire in most ventricular anatomies. We believe
that the stiffer wire provides several advantages, including
biasing the valve toward the posterior aspect of the annular
plane, eliminating parallax in the marker band, increasing
efficiency, and providing a more predictable deployment.
Like all ventricular wires, the possibility of ventricular
perforation is always a consideration. We deploy the
Lunderquist through a pigtail catheter established toward
the apex of the left ventricle. After unsheathing the wire,
there is no forward manipulation, thereby reducing the
possibility of trauma.
INNOVATION AND IMPACT WITHOUT DEVICE
ITERATIONS
Our description of the novel cusp overlap technique
includes both optimization of the CT image reconstruction
to define an ideal implant angle, and simplification of the
procedure to minimize the interaction of the transcatheter
bioprosthesis and the conduction system. The simplified
cusp overlap technique has the potential to enhance clinical
outcomes by focusing on procedural modifications rather
than to rely on new technology or expanded infrastructure
for clinical improvements. In our institution, the cusp
(Continued on page 19)
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

Evolut Commissural Alignment and the

Cusp Overlap Technique
Facilitating post-TAVR coronary reaccess while minimizing the risk of interaction with the
conduction system.
By Sophia L. Alexis, MD; Syed Zaid, MD; Sahil Khera, MD; Parasuram Melarcode Krishnamoorthy, MD;
George D. Dangas, MD, PhD; Samin K. Sharma, MD; Annapoorna Kini, MD; Aditya Sengupta, MD;
and Gilbert H. L. Tang, MD, MSc, MBA

A
s transcatheter aortic valve replacement (TAVR) is
now approved in lower-risk, younger patients, lifetime
management of this population is becoming more
important.1-5 In surgical aortic valve replacement
(SAVR), after excision of the native valve leaflets,
commissural alignment of the new prosthesis is guaranteed.
This has been demonstrated by Fuchs et al who studied
SAVR implantation and found that all commissures were
within 30° of native commissures.6 Cardiac surgeons never
intentionally rotate the valve off its native axis nor do they
compromise the depth of annular sutures.
Because the prevalence of significant coronary artery
disease is 40% to 75% in patients with severe aortic
stenosis undergoing TAVR, one must consider the need
for coronary reaccess when placing a TAVR valve.7,8 In one
study of 779 patients undergoing TAVR, 4.7% had acute
coronary syndrome within 1 year after TAVR and 10% did
during a median follow-up of 25 months. These patients
were on average younger than the total population.9,10 Our
group has studied optimal commissural alignment with the
cusp overlap technique using self-expanding Evolut valves
(Medtronic) to decrease likelihood of future coronary
access challenges.
COMMISSURAL ALIGNMENT FOR CORONARY
REACCESS
Barriers to coronary reaccess after TAVR include the
native aortic valve leaflets, the stent frame (whose distal
end extends above the sinotubular junction), and the
commissures if not properly aligned.11 The likelihood of the
frame interfering with coronary reaccess is highest when
there is a small angle to the commissure and short inflow
to ostium distance.10
Ochiai et al studied coronary positioning with
computed tomography (CT) after implantation of
66 Evolut R/Evolut PRO valves from December 2015
to November 2017. Coronary reaccess was considered
unfavorable if the ostium ended up below the
13/14-mm skirt (depending on valve size implanted) or if
the transcatheter heart valve (THV) commissure landed
near the ostium. Results showed that the skirt eclipsed
the left coronary artery (LCA) in 12.8% of cases and the
right coronary artery (RCA) in 3% of cases. The reason for
no immediate hemodynamic collapse was that there was,
on average, 4.2 to 4.8 mm of horizontal distance between
the coronary ostia and the skirt blocking them. Coronary
access was also obscured when the commissural triangle
(up to 26 mm at the posts) blocked the LCA in 22.7%
of cases and the RCA in 21.2%.8 This led to the inability
to selectively engage the coronaries during coronary
angiography or percutaneous coronary intervention
after TAVR.
Similarly, Abdelghani et al looked at 101 patients
from October 2015 to June 2019 who had Evolut R/PRO
C-tab
"Hat" Marker
Figure 1. C-tab loaded 90° clockwise from the “Hat” marker in
the Evolut TAVR system.

8 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1


Figure 2. Flush port orientation on the Evolut delivery catheter
should be pointed away from the operator (in the 3 o’clock
position) on insertion to improve commissural alignment.
Reprinted from JACC: Cardiovascular Interventions, Vol.
13/Issue 9, Tang GHL, Zaid S, Fuchs A, et al. Alignment of
Transcatheter Aortic-Valve Neo-Commissures (ALIGN TAVR)
Impact on Final Valve Orientation and Coronary Artery Overlap,
Pages 1030-1042, 2020, with permission from Elsevier.
implantation with pre- and post-TAVR CTs. They found
that in 10.8% of cases, a commissure was facing the LCA
and in 9.7% of cases it was facing the RCA.10
In our ALIGN-TAVR study, we looked at 245 patients
between March 2016 and September 2019 at five centers
that had Evolut placement. We used the coregistration
technique between fluoroscopy and the coplanar angle
on pre-TAVR CT using 3mensio software (Pie Medical
Imaging).12 Commissural overlap was considered severe if it
was within 20° of the coronary ostium. Evolut orientation
at initial deployment was categorized by the position of
the radiopaque “Hat” marker on the delivery device; it was
either on the outer curve (OC), center front (CF), inner
curve (IC), or center back (CB) of the aorta (Figure 1).
The same four designations were used for the final
C-tab position of the valve. As the study progressed, less
commissural overlap with the coronaries was found when
the “Hat” marker was placed on the OC of the descending
VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 9
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
Figure 3. Results of Evolut “Hat” marker orientation
on coronary overlap after TAVR. Reprinted from JACC:
Cardiovascular Interventions, Vol. 13/Issue 9, Tang GHL, Zaid S,
Fuchs A, et al. Alignment of Transcatheter Aortic-Valve Neo-
Commissures (ALIGN TAVR) Impact on Final Valve Orientation
and Coronary Artery Overlap, Pages 1030-1042, 2020, with
permission from Elsevier.
aorta/annulus.12 This orientation was more common when
the flush port of the delivery catheter was placed at the
3 o’clock position during insertion (versus the 12 o’clock
position), so a change was made at our institution in
March 2019 to implant the next 107 valves this way
(Figure 2). In the overall cohort, having the “Hat” marker at
the OC/CF position conferred significantly less (P < .001)
commissural overlap than the IC/CB positions: 15.7%
versus 66% for the LCA, 7.1% versus 51.1% for the RCA,
2.5% versus 40.4% for both coronaries, and 20.2% versus
76.6% for one or both coronaries (Figure 3).12
CUSP OVERLAP IMPLANT VIEW TO MINIMIZE THE
RISK OF INTERACTION WITH THE CONDUCTION
SYSTEM
To increase the accuracy of implantation depth with
Evolut valves, at our institution we obtain a cusp overlap
view in addition to the three-cusp coplanar view. To do
this, we obtained a more right anterior oblique (RAO)
caudal view to overlap the left and right coronary cusps
and position the “Hat” marker of the Evolut delivery
catheter toward the CF during initial deployment.13 The
valve is then deployed with contact from the non-coronary
cusp to the overlapped left and right cusps, which enables
higher implantation relative to the non-coronary cusp
without valve “pop-out.”13 The approach in our facility
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

A B

C
Figure 4. “Hat” marker in the OC
position (A). Commissural alignment
confirmed on post-TAVR CT (B).
Straightforward coronary access with
commissural alignment (C).

is to optimize overlap without needing another arterial
puncture, one pigtail can be placed in the right coronary
cusp and another pigtail, a 0.035-inch J wire or an 0.018-
inch nitinol wire in the left coronary cusp, which is then
removed once the cusp overlap view is confirmed.13
With improved visualization of the nadir of the
non-coronary cusp using the cusp overlap technique,
permanent pacemaker implantation (PPI) can be reduced.
marker was OC as seen in the left anterior oblique (LAO)
14°/caudal (CAU) 22° image (Figure 4A). The valve was
implanted in the three-cusp view. Commissural alignment
was confirmed on post-TAVR CT (Figure 4B). One week
later, the patient returned with anginal symptoms.
Secondary to commissural alignment, coronary access was
straightforward and no coronary obstruction was identified
in this case (Figure 4C).

CLINICAL EXAMPLES Case 2

Case 1
A 72-year-old man presented with severe aortic stenosis.
He was deemed a low surgical risk and appropriate for
a 29-mm Evolut valve as part of the Evolut low-risk
randomized trial. The delivery catheter was inserted with
the flush port at the 3 o’clock position and the “Hat”
An 81-year-old woman who presented with
symptomatic severe aortic stenosis (AS) had favorable
anatomy for implantation of a 23-mm Evolut Pro.
Fluoroscopic images were obtained in both the three-cusp
view (LAO 0°/CAU 9°) and the RAO cusp-overlap view
(RAO 23°/CAU 26°). The “Hat” marker in the cusp-overlap

A B

Figure 5. Three-cusp and cusp-overlap views. “Hat” marker at the CF position (A). C-tab at the inner curve with ideal
commissural alignment (B).

10 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1

 CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

view was in the CF position on cusp-overlap and the
C-tab landed at the inner curve, with ideal commissural
alignment after deployment (Figure 5A, B). Having the
“Hat” marker at the OC position in the three-cusp view or
CF in the RAO cusp-overlap view allows for optimal results.
CONCLUSION
Although the self-expanding Evolut valve has tall
commissural posts, we have found a valve positioning
methodology that lowers risk of coronary obstruction
while reducing the risk of interaction with the conduction
system. This is increasingly important in the lifetime
management of lower-risk and younger patients. By
inserting the flush port away from the operator, we
are able to control the “Hat” marker in the OC/CF
position > 90% of the time to facilitate future coronary
engagement. Using the cusp overlap technique, we bring
precision to valve deployment to achieve the target
implantation depth, providing physicians the tools to
reduce the risk of TAV interaction with the conduction
system.  n
1. Buzzatti N, Romano V, De Backer O, et al. Coronary access after repeated transcatheter aortic valve implantation: a glimpse
into the future. JACC Cardiovasc Imaging. 2020;13:508-515. doi: 10.1016/j.jcmg.2019.06.025
2. Rogers T, Greenspun BC, Weissman G, et al. Feasibility of coronary access and aortic valve reintervention in low-risk TAVR
patients. JACC Cardiovasc Interv. 2020;13:726-735. doi: 10.1016/j.jcin.2020.01.202
3. Alexis SL, Zaid S, Sengupta A, et al. TAVR aortic root orientation: implications for future coronary access and redo TAVR. Ann
Cardiothorac Surg. 2020;9:502-504. doi: 10.21037/ACS-2020-AV-10
4. Khan M, Senguttuvan NB, Krishnamoorthy P, et al. Coronary angiography and percutaneous coronary intervention after
transcatheter aortic valve replacement with Medtronic self-expanding prosthesis: Insights from correlations with computer
tomography. Int J Cardiol. 2020;317:18-24. doi: 10.1016/j.ijcard.2020.05.065
5. Yudi MB, Sharma SK, Tang GH, et al. Coronary angiography and percutaneous coronary intervention after transcatheter aortic
valve replacement. J Am Coll Cardiol. 2018;71:1360-1378. doi: 10.1016/j.jacc.2018.01.057
6. Fuchs A, Kofoed KF, Yoon SH, et al. Commissural alignment of bioprosthetic aortic valve and native aortic valve following
surgical and transcatheter aortic valve replacement and its impact on valvular function and coronary filling. JACC Cardiovasc
Interv. 2018;11:1733-1743. doi: 10.1016/j.jcin.2018.05.043
7. Goel SS, Ige M, Tuzcu EM, et al. Severe aortic stenosis and coronary artery disease- implications for management in
the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol. 2013;62:1-10. doi: 10.1016/j.
jacc.2013.01.096
8. Ochiai T, Chakravarty T, Yoon SH, et al. Coronary access after TAVR. JACC Cardiovasc Interv. 2020;13:693-705. doi: 10.1016/j.
jcin.2020.01.216
9. Vilalta V, Asmarats L, Ferreira-Neto AN, et al. Incidence, clinical characteristics, and impact of acute coronary syndrome
following transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2018;11:2523-2533. doi: 10.1016/j.jcin.2018.09.001
10. Abdelghani M, Landt M, Traboulsi H, et al. Coronary access after TAVR with a self-expanding bioprosthesis: insights from
computed tomography. JACC Cardiovasc Interv. 2020;13:709-722. doi: 10.1016/j.jcin.2020.01.229
11. Tang GHL, Kaneko T, Cavalcante JL. Predicting the feasibility of post-TAVR coronary access and redo TAVR: more unknowns
than knowns. JACC Cardiovasc Interv. 2020;13:736-738. doi: 10.1016/j.jcin.2020.01.222
12. Tang GHL, Zaid S, Fuchs A, et al. Alignment of Transcatheter Aortic-Valve Neo-Commissures (ALIGN TAVR): impact on final
valve orientation and coronary artery overlap. JACC Cardiovasc Interv. 2020;13:1030-1042. doi: 10.1016/j.jcin.2020.02.005
13. Tang GHL, Zaid S, Michev I, et al. “Cusp-overlap” view simplifies fluoroscopy-guided implantation of self-expanding valve in
transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2018;11:1663-1665. doi: 10.1016/j.jcin.2018.03.018

Sophia L. Alexis, MD Parasuram Melarcode Annapoorna Kini, MD

Department of Cardiovascular Krishnamoorthy, MD Division of Cardiology
Surgery Division of Cardiology Mount Sinai Medical Center
Mount Sinai Health System Mount Sinai Medical Center New York, New York
New York, New York New York, New York Disclosures: None.
Disclosures: None. Disclosures: None.
Aditya Sengupta, MD
Syed Zaid, MD George D. Dangas, MD, PhD Department of Cardiovascular Surgery
Division of Cardiology Division of Cardiology Mount Sinai Health System
Westchester Medical Center Mount Sinai Medical Center New York, New York
Valhalla, New York New York, New York Disclosures: None.
Disclosures: None. Disclosures: None.
Gilbert H. L. Tang, MD, MSc, MBA
Sahil Khera, MD Samin K. Sharma, MD Department of Cardiovascular Surgery
Division of Cardiology Division of Cardiology Mount Sinai Health System
Mount Sinai Medical Center Mount Sinai Medical Center New York, New York
New York, New York New York, New York gilbert.tang@mountsinai.org
Disclosures: None. Disclosures: None. Disclosures: Physician proctor for Medtronic
and consultant to Abbott Structural Heart,
Medtronic, and Gore & Associates.

VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 11

CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
Cusp Overlap Deployment Technique—
The Manchester Experience
Technique rationale, clinical outcomes, and practical advice for implanters.
By Douglas G. W. Fraser, MB BChir, BA, DM, and Freidoon Keshavarzi, PGRAD, MD
T
o minimise the risk of interaction with the conduction
system, precise sizing, positioning, and expansion of the
Evolut valve (Medtronic) are required. An ideal valve
position would include a position just below the annular
plane, and coaxial alignment with the left ventricular
outflow tract (LVOT). This would ensure the maximum
expansion diameter within the annulus to minimise the risk
of paravalvular leak, and a high implantation depth would
reduce the chance of compression of the conduction system,
and the subsequent need for a permanent pacemaker.
However, in practice, upward displacement of the valve can
occur during release, due to systolic ejection, valve shortening
during expansion, and melon seeding when the LVOT is
narrow—and if the valve is placed too high at the outset, a
‘pop-out’ can occur. Furthermore, coaxial alignment may be
difficult to achieve due to the differing axes of the ascending
aorta (adopted by the valve) and the LVOT (of which the
annulus is its proximal cross-section).
In practice, the best results are therefore achieved by
minimising the depth of the device below the noncoronary
cusp (the deepest cusp), whilst allowing for a small degree
of upward movement during expansion. This requires
precise positioning, as well as control of the device during
deployment.
JUDGING THE PROSTHESIS DEPTH
Medtronic's previous guidance for placement of the Evolut
valve has been to first align the lowest points of the three
cusps to create an annular plane three-cusp view. From
transfemoral access, the device is often poorly aligned in this
view, meaning that different sides of the expanded valve will
occupy different depths with respect to a line joining the base
of the cusps (the annular plane). It is, therefore, not possible
in this view to be confident that the expanded valve will be
below all three cusps. Medtronic’s guidance has therefore
been to add either caudal angulation (common in the
United Kingdom) or left anterior oblique (LAO) angulation
(common in the United States) to this three-cusp view to
achieve a device plane. Using these device plane projections,
the operator can adjust the device position so that it is below
12 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1
the left and noncoronary cusps. These angulations have the
effect of elevating the right coronary cusp (RCC) above the
remaining left and noncoronary cusps and so, if the device is
deployed below the still visible non-coronary cusp (NCC) and
left coronary cusp (LCC), the operator can then be confident
that the device will deploy below all three cusps, thereby
minimizing the risk of a pop out.
However, the problem with this approach has been
uncertainty regarding the true depth of the valve using
off-annular plane projections. A potential solution was first
proposed by Piazza et al, who realized that the annulus
remained in-plane in a range of views with different relative
cusp positions, described by an S curve, and that the device
plane could similarly be imaged from different angiographic
angles, described by a second S curve. From transfemoral
access, Piazza et al described how these two S curves intersect
in an RAO caudal view in most cases. This view, being the
unique projection in which both the device and annulus are
in-plane, allows the true device depth below the annulus to be
assessed.1
Determining the S curve of the annulus is easily
accomplished using computed tomography (CT) imaging
software, such as 3mensio (Pie Medical Imaging BV) at the
time of procedural planning. However, determining the
S curve of the device requires image analysis at the time of
the procedure and is not routinely available. This led to initial
difficulties adopting this technique.
However, operators realized that the solution could be
estimated by simply choosing an eccentric RAO caudal angle
from the annular S curve generated from the CT data and
that this view not only aligned the device and annular planes
but frequently also overlapped the LCCs and RCCs along the
annular plane, leading to the term cusp overlap view (COV).
Medtronic has now adopted use of this view, in addition to
other procedural tweaks, to create the current procedural
guidance.
MANCHESTER EXPERIENCE
When we transitioned from a Sapien-only centre (Edwards
Lifesciences) to include the Evolut R valve in 2015, we had

Figure 1. Single-centre experience (N = 487). Trend toward
lower pacemaker (P = .13) and left bundle branch block (LBBB)
rates using Evolut R in comparison to Sapien 3 valves.
been used to only implanting in the three-cusp annular plane
view (as per Edwards Lifesciences instructions for use). We,
therefore, felt uncomfortable coming off the annular plane
and were attracted to ways to visualise both the valve and
annulus in plane. After experimentation with RAO caudal
annular projections predicted by the CT analysis, we similarly
adopted the cusp overlap view as a convenient place to start.
We were pleased by how often the cusp overlap technique
aligned both the annulus and device and were struck by the
low rate of pacemaker implantation, trending to be lower than
our Sapien experience (N = 487; Evolut, 4.6%; Sapien 3, 8%
pacemaker at 30 days) and the low rates of perivalvular leak
(Figure 1).2,3
In the lab, we have found that the COV has been a very
workable view with both RAO and caudal angulations < 30°
in roughly 80% of cases. In the remaining cases, we have found
that a less extreme view derived from the CT annular S curve
in between the three-cusp and cusp overlap views works well
with good device alignment.
Furthermore, as the COV puts the lowest point of the
NCC lateral to the valve, rather than behind the valve (as in
the three-cusp view and modifications) visualisation of its
position is further simplified (Figure 2). With the pigtail firmly
at the base of this cusp, the device can be easily adjusted
relative to the base of the pigtail. We have also been confident
that when the valve is below the NCC in the COV it will
be below all three cusps in almost all cases. As Medtronic
now recommends, we aim to place the valve at a target
implantation depth of 3 mm, with a range of 1 to 5 mm;
shallower implantations may lead to pop-outs during
postdilation, whereas deeper implants increase the pacemaker
rates. This cusp overlap technique has allowed us to greatly
simplify deployment (Figure 2).
The effect of caudal and LAO angulation off the annular
plane has been further examined in a modeling study.3 This
study showed that the valve was elevated above the annular
plane in a similar way with respect to the RCC whenever
VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 13
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
A B C
Figure 2. Valve ring level with the annulus (red line) in three-
cusp view but valve not in plane (valve ring oval shape) (A).
Following LAO angulation, valve in plane but now looks high
relative to the pigtail and a line joining NCC and LCC (B). Valve
at optimal height (blue line) 3 mm below the annular plane (red
line) (C).
caudal or LAO angulation was applied (Figure 3). We've
calculated that each 10° of caudal or LAO angulation off the
MANCHESTER CUSP OVERLAP TECHNIQUE
PROCEDURAL STEPS
1. Image in three-cusp view to verify S curve angles
from CT. Apply any difference from CT angle to all
subsequent views.
2. Switch to COV. With the pigtail at the base of the
NCC, slowly unsheath the valve (up to a point before
annular contact) while keeping the base of the valve
approximately 1 mm horizontally below the base of
the pigtail. This will be approximately 3 mm below the
annular plane, defined as the line joining the base of the
NCC and LCC.
3. We then deploy the valve to 80% in the cusp overlap
view, under rapid pacing to reduce cardiac output
and minimize the likelihood of movement. During
deployment aim to keep the valve 1 mm horizontally
below the base of the pigtail held at the base of the
NCC. Check valve depth below a line joining the NCC
and LCC at 80%—aiming for 2-4 mm below this line.
Consider recapture if < 1 or > 5 mm.
4. Assess expansion and depth below the LCC in this view.
5. Check in the LAO cranial view to judge tension on
the valve before release, with the aim of a mid aortic
position. Check device below LCC, risk of coronary
obstruction, degree of aortic regurgitation in this view.
Check degree of valve expansion in both views.
6. Do not release unless a good position is achieved.
Recapture and reposition the valve, if necessary, to
obtain an optimal position.
CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
Figure 3. In the three-cusp annular plane view the valve is not
in plane. However, in the RAO caudal views, both the valve and
the device are in plane. The sheath is withdrawn, exposing the
valve level with the base of the pigtail. Further withdrawal,
flaring of the valve with its base 3 mm below the annular plane,
is then followed by deployment to 80% (double arrow) under
rapid ventricular pacing, and then subsequent release.
annular plane, raised the valve an average of 1 to 1.5 mm,
above a line joining the bases of the NCC and LCC. In practice,
this effect means that a device that is, in reality, 3 mm below
the annular plane may appear to be above the annular plane
if 20° to 30° caudal or LAO is used to align the device. The
operator response to this would likely be to advance the
device distally by up to 4 to 5 mm, leading to a 7- to 8-mm
depth on the NCC and perhaps a 12-mm depth on the LCC,
when in fact the position was already optimal and would
have deployed at 3 and 7 mm, respectively. This effect may be
significantly more pronounced with large annuli. This effect is
also readily visible in the lab.
EXPERIENCE WITH CUSP OVERLAP TECHNIQUE IN
THE UNITED KINGDOM
National data from the United Kingdom show significantly
higher pacemaker rates (16%-18%) for the Evolut valve
compared to those for the balloon-expandable Sapien valve
(6%-8%).4 Currently, approximately one-third (16 of 46
centers) across the United Kingdom are using the cusp overlap
technique, with most centers having started within the last 6
to 12 months and not all operators in these centers adopting
the technique. Anecdotally we believe that the current
adoption of the cusp overlap technique is low in the United
Kingdom, but this is very likely to change in light of the recent
(and ongoing) data and increased awareness of the technique.
ADDITIONAL RECOMMENDATIONS
Those new to the Evolut valve can follow the simplified
scheme described previously, which allows rapid deployment
with accurate results and is especially useful when
hemodynamics are compromised during placement. It is
recommended to start flaring the valve above the annulus
and, once partially flared, advance to the desired position.
14 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1
This minimises interaction with the conduction system and
helps sit the frame in the optimum position. If the LVOT size
Is smaller than the annulus, some forward pressure can be
applied to fix the valve in place.
For experienced implanters used to implanting at 0 to
1 mm in the caudal or LAO off annular views, it is important
to be aware that the valve will look lower in the RAO caudal
view and that 1 to 2 mm is the minimum depth in this view.
Additional observations include the annular plane being more
vertical in the COV, and that, following expansion, the valve
may look more constrained as this view approximates more
closely to the short diameter of the LVOT.
SUMMARY
LAO and caudal angulation from the three-cusp view leads
to the valve looking higher In a similar way to the RCC. Failure
to recognize this effect can contribute to a deep implantation.
Using the cusp overlap technique (COT) the true depth of
the device beneath the annular plane is seen by aligning both
the annulus and the prosthesis in the same view. Deployment
from 0% to 80% can be performed without moving from the
COV, and a target 3-mm placement below the annular plane
usually equates to 1 mm below a pigtail placed at the base
of the NCC in this view. It is advised to consider recapture
if the device is < 1 or > 5 mm below the NCC in this view.
Following this, it is important to check in the LAO cranial view
with the device aligned before final release. This technique
simplifies deployment, has been associated with a reduction of
pacemaker rates, and is now recommended by Medtronic.  n
1. Piazza N. Obtaining the correct depth of implant using the FluoroCT Double S curve. Presented at PCR London Valves 2015.
2. Pisaniello A, Makki H, Daniels M, et al. Low rates of permanent pacing are observed following self-expanding transcatheter
aortic valve replacement using an annular plane projection for deployment. Circ Int. 2020 (expected publication Jan-Feb 2021).
3. Fraser D. Achieving single digit pacemaker rates in contemporary practice—Experience from Manchester, UK. Presented at
PCR London Valves 2019.
4. Ludman P. National data extracted from BCIS dataset: http://www.bcis.org.uk/wp-content/uploads/2018/11/TAVI-slide-
deck-to-2017-data-15-11-2018.pdf. Accessed January 8, 2021.
Douglas G. W. Fraser, MB BChir, BA, DM
Manchester Heart Centre
Manchester Royal Infirmary
Manchester University NHS Foundation Trust
University of Manchester
Manchester, United Kingdom
douglas.fraser@mft.nhs.uk
Disclosures: Proctor for Medtronic.
Freidoon Keshavarzi, PGRAD, MD
Manchester Heart Centre
Manchester Royal Infirmary
Manchester University NHS Foundation Trust
University of Manchester
Manchester, United Kingdom
Disclosures: None.
 CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

Cusp Overlap Technique in TAVR

TAVR implantation optimization—CT analysis and practical aspects of the cusp overlap technique.
By Xavier Armario, MD; Liesbeth Rosseel, MD; and Darren Mylotte, MB BCh, MD, PhD

T
ranscatheter aortic valve replacement (TAVR) is a crest of the interventricular septum within the interleaflet
safe and effective alternative to surgical aortic valve triangle separating the NCC and RCC. Kawashima et al
replacement for the treatment of symptomatic described three variants of bundle of His anatomy: (1) the
severe aortic valve stenosis across all surgical bundle courses within the right half of the MS in 50%
risk categories.1-7 In 2007, when TAVR was first of cases, (2) within the left half of the MS in 30%, and
commercialized in Europe, such a statement would have (3) coursing on to the MS just under the endocardium in
not seemed possible for a nascent technology that was 20%.11 The latter two anatomic variances would increase
plagued by high rates of three important complications: the risk of new conduction disturbances during TAVR.
postprocedural paravalvular leak, vascular complications,
and new permanent pacemaker implantation (PPI). A
Progressive iterations of transcatheter heart valve (THV)
design, preprocedural planning, and implantation
technique have seen these complications become less
frequent. Higher rates of new PPI have been the most
challenging issues to address due to the anchoring
mechanism of most THV technology (radial force) and
the proximity of the implantation site to the cardiac
conduction system. Current rates of new PPI range from
2% to 36% depending on the THV design and the patient
population studied.8 Although the clinical impact of new
PPI after TAVR has been somewhat controversial, meta-
analyses have suggested an increased risk of all-cause
mortality at 1 year in patients receiving a new permanent
pacemaker.9 Certainly, the requirement for PPI is B
associated with longer hospital stay and increased costs.10
The cusp overlap implantation technique has the
potential to lower the risk of interaction with the
conduction system by providing a more accurate
assessment of THV depth. In this article, we review the
rationale and practicalities of using this technique.

THE IMPORTANCE OF IMPLANTATION DEPTH

The proximity of the aortic valve and the cardiac
conduction system explains the occurrence of new
conduction disturbances with TAVR (Figure 1). The
conduction system continues from the atrioventricular
node toward the bundle of His and then splits into the
left and right bundle branches. Located caudal to the
commissure between the right (RCC) and noncoronary
cusps (NCC), the bundle of His emerges at the surface of
the interventricular membranous septum (MS), with the
left bundle branch emerging and traversing the superficial
Figure 1. The aortic valve and conduction system. AA,
ascending aorta; BH, bundle of His; LBB, left bundle branch;
LCC, left coronary cusp; LV, left ventricle; MS, interventricular
membranous septum; NCC, noncoronary cusp; RA, right atrium;
RBB, right bundle branch; RCC, right coronary cusp, RV, right
ventricle.

VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 15

CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

Figure 2. Double S-curve and chamber anatomy. The double-S curve gives a fluoroscopic projection where the aortic annulus is
aligned and the delivery catheter parallax is removed. This fluoroscopic view corresponds to the point where the aortic annulus
S-curve (yellow curve) and the delivery catheter S-curve (blue curve) cross and is usually obtained in an RAO-caudal view. The LAO-
cranial view corresponds to a four-chamber view where the LVOT is foreshortened, while the RAO-caudal view corresponds to a
3-chamber view where the LVOT is elongated. AA, ascending aorta; CAU, caudal; CRA, cranial; LAO, left anterior oblique; LA, left
atrium; LV, left ventricle; LVOT, left ventricular outflow tract; RAO, right anterior oblique.

The depth at which a THV is implanted in the left
ventricular outflow tract (LVOT) has been consistently
associated with the requirement for new PPI for both
balloon- and self-expandable THVs.12,13 This is axiomatic
because the deeper the THV is implanted the greater the
risk of contact between the THV and the conduction
tissue. Such interaction induces either direct or indirect
(localized edema, hematoma, etc.) injury to the conduction
tissue. A shallower THV implantation in the LVOT is
therefore among the simplest ways to reduce new PPI
rates. It is, however, important to implant the THV at a
sufficient depth to avoid pop-up of the valve into the aorta
and to ensure anchoring and sealing. Each valve has specific
guidance regarding implantation depth; for example, the
recommended Evolut TAV (Medtronic) implantation
depth is 3 mm depth below the aortic annulus. Because
a few millimeters in implantation depth can make a big
difference for PPI rates, accurate imaging of the aortic
root during valve implantation is crucial to achieving the
correct implantation depth and a low PPI rate. Recently,
Jilaihawi et al described the Minimizing Depth According
to the membranous Septum (MIDAS) approach for
the deployment of self-expandable THVs, aiming for an
implantation depth of less than the MS length, which in
their experience reduced the incidence of new conduction
disturbances and requirement of new PPI.14
S-CURVES, DOUBLE S-CURVE, AND CHAMBER
ANATOMY
Device implantation is optimally performed in an
angiographic projection that is perpendicular to the
virtual plane of the aortic annulus and has parallax
removed from the delivery system. In other words, it is
recommended to implant in an angiographic view where
there is no foreshortening of either the patient’s anatomy
or the delivery system. Traditionally, with self-expandable
devices that have a marker band at the distal tip of the
delivery capsule, it was uncommon to have both the
anatomy and device in plane together, and hence, there
were two options: (1) implant in an angiographic view
where the anatomy was in the correct imaging plane
and accept that the device was not perfectly aligned, or
(2) implant in an angiographic view where the device is
in-plane and accept that the anatomy was not perfectly
aligned. Neither of these implantation techniques is ideal
because the presence of parallax in either the anatomy
or the device renders the relationship between them
(implant depth) unclear.
To address this problem, Piazza and Thériault-Lauzier
developed the double S-curve implantation technique
using bespoke multislice CT (MSCT) software (FluoroCT).
Using this software program, the operator could construct
the S-curve of the annular plane in the usual way and then

16 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1

 CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

A B C D E F

G H I J K L

Figure 3. Cusp overlap technique. Traditional three-cusp view where all three cusps are visible, generally corresponding to an LAO-
CRA view (A-C). In this view, the NCC (yellow dot) is on the left side, the RCC (green dot) is in the middle, and the LCC (red dot) is on
the right side. THV positioning, deployment, and final assessment under a 3-cusp view (D-F). New 2-cusp view where the LCC and
the RCC are overlapped and the NCC is isolated, generally corresponding to an RAO-CAU view (G-I). In this view, the NCC (yellow
dot) remains on the left side while the RCC (green dot) and the LCC (red dot) are overlapped on the right side. THV positioning,
deployment, and final assessment under a 2-cusp view (J-L). CAU, caudal; CRA, cranial; LAO, left anterior oblique; LCC, left coronary
cusp; NCC, non-coronary cusp; RAO, right anterior oblique; RCC, right coronary cusp; THV, transcatheter heart valve.

construct the S-curve of the delivery catheter once it was
sitting in the aortic root of the patient during the TAVR
procedure. The software generates the delivery catheter
S-curve once a left anterior oblique (LAO) and a right
anterior oblique (RAO) projection (> 20º separation) with
the delivery catheter in-plane are input into the system
(Figure 2). The junction of the aortic annulus S-curve
and the delivery catheter S-curve gives the angiographic
projection where both the anatomy and delivery catheter
are simultaneously in-plane. Thus, in this angiographic view,
the distance between the base of the NCC (pigtail catheter)
and the bottom of the THV (the implant depth) can be
trusted to be accurate because there is no foreshortening
of either structure. Importantly, in 90% of cases, the
junction of these two S-curves (hence the title of double
S-curve technique) was in an RAO-caudal projection, with
the remaining cases being either an anteroposterior-caudal
or a shallow LAO-caudal projection.15,16
Further understanding of the fluoroscopic anatomy of
the heart, described as chamber anatomy, reveals why
the RAO-caudal implantation view removes parallax
from both the anatomy and the delivery catheter: in
this projection, the heart is imaged in a three-chamber
view (echocardiographic nomenclature) with the LVOT
elongated (no foreshortening). On the other hand, in an
LAO-cranial view, the heart is imaged in a four-chamber
view with the LVOT foreshortened (Figure 2). Thus, if
a catheter is placed in the LVOT, it is foreshortened in
the LAO-cranial projection but not in the RAO-caudal
projection. If the LAO-cranial view is used for THV
implantation, the delivery catheter appears to be closer
to the anatomy (represented by the NCC pigtail) than
it actually is, and therefore, the depth of implantation
appears to be less than it actually is. This does not
occur if the RAO-caudal projection is used for THV
implantation.17
Although the double-S technique was used successfully
in several centers, the requirement for dedicated MSCT
software and the time required to generate the S-curve
of the delivery catheter in the LVOT during TAVR meant
that widespread adoption of the double-S implantation
technique did not occur.
CUSP OVERLAP TECHNIQUE
Because the double-S curve implantation view occurs
in the RAO-caudal projection in 90% of cases, a “modified
double-S” can be achieved by simply selecting an RAO-
caudal implantation view from the annular S-curve and
then adjusting this angle slightly during the procedure (if
required) to ensure that the marker band at the base of the
delivery catheter is in-plane.
More recently, Gada and colleagues recognized that
in the RAO-caudal implant view, the RCC and the left
coronary cusp (LCC) are superimposed on MSCT, leaving
the NCC isolated. This two-cusp view, or cusp overlap
view, is distinct from the traditional three-cusp view that is
found usually in an LAO-cranial projection (Figure 3). This
important observation affords TAVR operators the ability

VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 17

CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic
Figure 4. Beam projections and radiation exposure in
transradial and transfemoral approaches during coronary
angiography. Reproduced with permission from Tarighatnia A,
et al. Anatol J Cardiol. 2017;18:298-303.
to efficiently and simply identify a suitable RAO-caudal
implantation view without the need for dedicated MSCT
software. The technique is performed by overlapping the
RCC and LCC (cusp overlap view) and isolating the NCC
while riding along the annular S-curve on the pre-TAVR
MSCT.18 Similar to the double S-curve view, the cusp
overlap view occurs in the RAO-caudal projection in the
majority of cases.
CUSP OVERLAP TECHNIQUE: ADVANTAGES AND
LIMITATIONS
The cusp overlap view, therefore, provides the correct
implantation plane for assessment of THV deployment
depth at the level of the NCC. There are also other
advantages of deploying in this view: (1) the position of
the wire in the left ventricle and the amount of tension on
the wire can be easily assessed; (2) the delivery catheter
appears vertical and thus implantation appears more
straightforward; (3) the short axis of the aortic annulus is
imaged in this plane, and therefore maximal constraint of
the THV is best appreciated in this view; and (4) operators
receive less radiation in an RAO projection (Figure 4).
There are, however, two important drawbacks of the
cusp overlap implantation view. First, the amount of
tension and position of the delivery catheter on the inner
or outer curvature of the aorta cannot be assessed in an
RAO-caudal view. Hence, we recommend that once depth
assessment is made in the cusp overlap view and the valve
is deployed prior to the point of no recapture, an LAO
projection (on the S-curve) be used to assess the delivery
catheter position and final release. Second, infrequently,
and particularly in the vertical annulus or in obese
patients, the amount of RAO-caudal angulation required
18 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1
can be uncomfortable for the operator or lead to image
degradation, respectively. In such cases, a less extreme
RAO-caudal projection on the S-curve, situated between
the cusp overlap view and the three-cusp view, should be
considered as an alternative.
CUSP OVERLAP TECHNIQUE IN DAILY PRACTICE
While the transition from a traditional three-cusp view
to the cusp overlap view for THV implantation is relatively
straightforward, it can require several cases to become
familiar with the technique. During this transition, we
would suggest that operators start with patients with
straightforward anatomy and good renal function so
that additional aortography can be performed during
implantation if required. In our daily practice with self-
expanding THV, we will identify the cusp overlap view
and an LAO-cranial view before starting the case. We
then place the delivery system across the stenotic aortic
valve. At this point, we perform our first aortography to
assess the selected implantation view and initial device
depth. A careful deployment of the THV, which starts
at mid pigtail, is performed with occasional 3 to 5 mL
contrast injections until annular contact on the left side is
achieved. We then proceed to the point of no recapture,
80% of THV deployment, and assess implantation depth
in the cusp overlap view before moving the C-arm to the
predefined LAO-cranial view to assess depth on the LCC
and the amount of tension in the delivery system, before
performing final release.
CONCLUSION
The cusp overlap implantation technique has the
potential to lower the risk of interaction with the
conduction system. In an RAO-caudal view, identified
simply using the cusp overlap technique, the relationship
between the native anatomy and delivery catheter can be
accurately determined and thus the true implant depth
assessed. Large, prospective studies are being performed
to confirm the risks and benefits of this new implant
strategy.  n
1. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot
undergo surgery. N Engl J Med. 2010;363:1597-1607. doi: 10.1056/NEJMoa1008232
2. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J
Med. 2011;364:2187-2198. doi: 10.1056/NEJMoa1103510
3. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl
J Med. 2014;370(19):1790-1798. doi: 10.1056/NEJMoa1400590
4. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.
N Engl J Med. 2016;374:1609-1620. doi: 10.1056/NEJMoa1514616
5. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk
patients. N Engl J Med. 2017;376:1321-1331. doi: 10.1056/NEJMoa1700456
6. Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in
low-risk patients. N Engl J Med. 2019;380:1695-1705. doi: 10.1056/NEJMoa1814052
7. Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk
patients. N Engl J Med. 2019;380:1706-1715. doi: 10.1056/NEJMoa1816885
8. van Rosendael PJ, Delgado V, Bax JJ. Pacemaker implantation rate after transcatheter aortic valve implantation with early
and new-generation devices: a systematic review. Eur Heart J. 2018;39:2003-2013. doi: 10.1093/eurheartj/ehx785
 CUSP OVERLAP TECHNIQUE
Funding for this supplement provided by Medtronic

9. Faroux L, Chen S, Muntané-Carol G, et al. Clinical impact of conduction disturbances in transcatheter aortic valve
replacement recipients: a systematic review and meta-analysis. Eur Heart J. 2020;41:2771-2781. doi: 10.1093/
eurheartj/ehz924
10. Fadahunsi OO, Olowoyeye A, Ukaigwe A, et al. Incidence, predictors, and outcomes of permanent pacemaker
implantation following transcatheter aortic valve replacement: analysis from the U.S. Society of Thoracic
Surgeons/American College of Cardiology TVT registry. JACC Cardiovasc Interv. 2016;9:2189-2199. doi: 10.1016/j.
jcin.2016.07.026
11. Kawashima T, Sato F. Visualizing anatomical evidences on atrioventricular conduction system for TAVI. Int J Cardiol.
2014;174:1-6. doi: 10.1016/j.ijcard.2014.04.003
12. De Torres-Alba F, Kaleschke G, Diller GP, et al. Changes in the pacemaker rate after transition from Edwards SAPIEN
XT to SAPIEN 3 transcatheter aortic valve implantation: the critical role of valve implantation height. JACC Cardiovasc
Interv. 2016;9:805-813. doi: 10.1016/j.jcin.2015.12.023
13. Gomes B, Geis NA, Chorianopoulos E, et al. Improvements of procedural results with a new-generation
self-expanding transfemoral aortic valve prosthesis in comparison to the old-generation device. J Interv Cardiol.
2017;30:72-78. doi: 10.1111/joic.12356
14. Jilaihawi H, Zhao Z, Du R, et al. Minimizing permanent pacemaker following repositionable self-expanding
transcatheter aortic valve replacement. J Am Coll Cardiovasc Interv. 2019;12:1796-1807. doi: 10.1016/j.
jcin.2019.05.056
15. Thériault-Lauzier P, Andalib A, Martucci G, et al. Fluoroscopic anatomy of left-sided heart structures for
transcatheter interventions: insight from multislice computed tomography. JACC Cardiovasc Interv. 2014;7:947-957.
doi: 10.1016/j.jcin.2014.06.002
16. Thériault-Lauzier P, Spaziano M, Vaquerizo B, et al. Computed tomography for structural heart disease and
interventions. Interv Cardiol. 2015;10:149-154. doi: 10.15420/ICR.2015.10.03.149
17. Piazza N, Mylotte D, Theriault Lauzier P. Fluoroscopic "heart chamber" anatomy - the case for imaging modality-
independent terminology. EuroIntervention. 2016;18;12:Y9-Y15. doi: 10.4244/EIJV12SYA3
18. Tang GHL, Zaid S, Michev I, et al. "Cusp-overlap" view simplifies fluoroscopy-guided implantation of self-
expanding valve in transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2018;11:1663-1665. doi: 10.1016/j.
jcin.2018.03.018
Xavier Armario, MD
Department of Cardiology
Galway University Hospital
Galway, Ireland
Disclosures: None.
(Continued from page 7)
overlap technique has been associated with reproducibly
low PPI rates and improved clinical outcomes through
what we believe is a rational, evidence-based, and intuitive
approach that is supported by sound principles in anatomy
and pathophysiology.  n
1. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk
patients. N Engl J Med. 2017;376:1321-1331. doi: 10.1056/NEJMoa1700456
2. Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk
patients. N Engl J Med. 2019;380:1706-1715. doi: 10.1056/NEJMoa1816885
3. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J
Med. 2014;370:1790-1798. doi: 10.1056/NEJMoa1400590
4. Jilaihawi H, Zhao Z, Du R, et al. Minimizing permanent pacemaker following repositionable self-expanding transcatheter
aortic valve replacement. JACC Cardiovasc Interv. 2019;12:1796-1807. doi: 10.1016/j.jcin.2019.05.056
5. Eitan A, Witt J, Stripling J, et al. Performance of the Evolut-R 34 mm versus Sapien-3 29 mm in transcatheter aortic valve
replacement patients with larger annuli: early outcome results of Evolut-R 34 mm as compared with Sapien-3 29 mm in
patients with annuli >/=26 mm. Catheter Cardiovasc Interv. 2018;92:1374-1379. doi: 10.1002/ccd.27588
6. Tang GHL, Reardon MJ, Kodali SK, et al. Comparison of clinical and echocardiographic outcomes after transcatheter aortic
valve implantation with 31-mm CoreValve versus 34-mm Evolut R bioprostheses from the STS/ACC TVT Registry. Am J Cardiol.
2019;124:1091-1098. doi: 10.1016/j.amjcard.2019.07.010
7. Dowling C, Firoozi S, Doyle N, et al. Initial experience of a large, self-expanding, and fully recapturable transcatheter aortic
valve: the UK & Ireland Implanters’ registry. Catheter Cardiovasc Interv. 2019;93:751-757. doi: 10.1002/ccd.27934
8. Kuhn C, Frerker C, Meyer AK, et al. Transcatheter aortic valve implantation with the 34 mm self-expanding CoreValve
Evolut R: initial experience in 101 patients from a multicentre registry. EuroIntervention. 2018;14:e301-e305. doi: 10.4244/
EIJ-D-17-01153
9. Harnath A, Gomes B, Herwig V, et al. First experience with the 34 mm self-expanding Evolut R in a multicentre registry.
EuroIntervention. 2018;14:e298-e300. doi: 10.4244/EIJ-D-18-00137
10. Piazza N, Mylotte D, Theriault Lauzier P. Fluoroscopic “heart chamber” anatomy - the case for imaging modality-
independent terminology. EuroIntervention. 2016;12:Y9-Y15. doi: 10.4244/EIJV12SYA3
11. Gada H, Vora A, Siddique S, et al. TCT CONNECT-473 Reduction of rates of permanent pacemaker implantation with 34-mm
Evolut R using cusp overlap technique. J Am Coll Cardiol. 2020;76 (17 suppl S):B196.
12. Gada H, Vora A, Millan-Iturbe O, et al. TCT CONNECT-473 Reproducibility of cusp overlap technique to reduce permanent
pacemaker implantation with Evolut: the Latin American experience. J Am Coll Cardiol. 2020;76:B202.

Liesbeth Rosseel, MD Hemal Gada, MD, MBA

Department of Cardiology President, Heart and Vascular Institute
Galway University Hospital Medical Director, Structural Heart Program
Galway, Ireland UPMC Pinnacle Heart and Vascular Institute
Disclosures: None. Harrisburg, Pennsylvania
gadah@upmc.edu
Darren Mylotte, MB BCh, MD, PhD Disclosures: Consultant to Medtronic, Boston Scientific
Department of Cardiology Corporation, Abbott Vascular, and Bard.
Galway University Hospital
National University of Ireland Galway Amit N. Vora, MD, MPH
Galway, Ireland Associate Director, Structural Heart Program
darren.mylotte@nuigalway.ie UPMC Pinnacle Heart and Vascular Institute
Disclosures: Consultant for Medtronic, Boston Harrisburg, Pennsylvania
Scientific, and Microport. Disclosures: Consultant to Medtronic.

VOL. 15, NO. 1 JANUARY/FEBRUARY 2021 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY 19

CUSP OVERLAP TECHNIQUE
Funding for this supplement providedVISIT
by Medtronic
WWW.CUSPOVERLAP.COM TO LEARN MORE ABOUT THE TECHNIQUE

UC202111562 EN
20 SUPPLEMENT TO CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2021 VOL. 15, NO. 1