Incidence and Predictors for Recurrence of Ventricular Arrhythmia Presenting During Acute Myocarditis: A Multicenter Study.

BACKGROUND: Management of acute myocarditis (AM) patients experiencing ventricular arrhythmia (VA) during acute illness is controversial, especially regarding early implantable cardioverter-defibrillator (ICD) implantation. OBJECTIVES: The purpose of this study was to evaluate the prevalence of and find predictors for long-term sustained VA recurrence and overall mortality among AM patients with VA. METHODS: This was a multicenter retrospective analysis of AM patients (verified by cardiac magnetic resonance imaging or myocardial biopsy) with documented VA during the acute illness ("initial VA"). Patients with history of myocardial infarction, heart failure, or VA were excluded. The study endpoint was a composite of sustained VA and overall mortality during follow-up. RESULTS: The study included 69 AM patients with initial VA: sustained monomorphic ventricular tachycardia (MMVT) (n = 25), sustained polymorphic ventricular tachycardia (VT)/ventricular fibrillation (n = 13), and nonsustained VT (n = 31). Age was 44 ± 13 years, and 23 of 69 (33.3%) were women. During median follow-up of 5.5 years, 27 of 69 (39%) patients reached the composite endpoint including sustained VA (n = 24) and death (n = 11). Initial MMVT, predischarge left ventricular dysfunction (left ventricular ejection fraction <50%), and anteroseptal delayed enhancement on cardiac magnetic resonance imaging were significantly associated with the composite endpoint. On multivariable analysis, initial MMVT (HR: 5.17; 95% CI: 1.81-14.6; P = 0.001) and predischarge LV dysfunction (HR: 4.57; 95% CI: 1.83-11.5; P = 0.005) were independently associated with the composite endpoint. Using these 2 predictors, we could delineate subgroups with low (∼4%), medium (∼42%), and high (∼82%) 10-year incidence of composite endpoint. CONCLUSIONS: AM patients presenting with VA have high incidence of sustained VA recurrence and mortality posthospitalization. Initial MMVT and predischarge LV dysfunction are independently associated with VA recurrence and mortality. Implantable cardioverter-defibrillator implantation may be considered in such high-risk patients.

Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction: A Randomized Clinical Trial.

Importance: Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking. Objective: To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI. Design, Setting, and Participants: This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis. Intervention: Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI. Main Outcomes and Measures: A needle-to-balloon time of 10 minutes or less. Results: A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality. Conclusions and Relevance: In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT05415085.

Thyroid dysfunction and mortality in cardiovascular hospitalized patients.

Background: Thyroid dysfunction (TD) is associated with increased cardiovascular morbidity and mortality. Early detection may influence the clinical management. Objective: To determine the prevalence, predictors, and prognostic value of TD among hospitalized cardiac patients. Methods: A retrospective analysis of a 12-year database consisting of nonselectively adult patients admitted to a Cardiology Department and who were all screened for serum thyroid-stimulation-hormone (TSH) levels . Statistical analysis of demographic and clinical characteristics, mortality and length of hospital stay (LOS) was performed. Results: A total of 14369 patients were included in the study; mean age was 67 years, 38.3% females. 1465 patients (10.2%) had TD. The most frequent type of TD was mildly elevated TSH (5.4%) followed by mildly reduced TSH (2.1%), markedly elevated TSH (1.5%), and markedly reduced TSH (1.2%). Female gender, history of hypothyroidism, heart failure, atrial fibrillation, renal failure and amiodarone use were significantly associated with TD. During follow-up 2975 (20.7%) patients died. There was increased mortality in the mildly reduced TSH subgroup (hazard ratio [HR] =1.44), markedly elevated TSH subgroup (HR=1.40) and mildly elevated TSH subgroup (HR=1.27). LOS was longer for patients with TD; the longest stay was observed in the markedly elevated TSH subgroup (odds ratio=1.69). Conclusion: The prevalence of TD in hospitalized cardiac patients is 10.2%. TD is associated with an increased mortality rate and LOS. Consequently, routine screening for thyroid function in this population is advisable, particularly for selected high-risk subgroups. Future studies are needed to determine whether optimizing thyroid function can improve survival in these patients.

Administration of Intravenous Furosemide in Patients with Acute Infection: Patient Characteristics and Impact on In-Hospital Outcome.

Intravenous (IV) fluid is frequently used to treat patients who have been admitted with an acute infection; among these patients, some will experience pulmonary congestion and will need diuretic treatment. Consecutive admissions to the Internal Medicine Department of patients with an acute infection were included. Patients were divided based on IV furosemide treatment within 48 h after admission. A total of 3556 admissions were included: In 1096 (30.8%), furosemide was administered after ≥48 h, and in 2639 (74.2%), IV fluid was administered within <48 h. Mean age was 77.2 ± 15.8 years, and 1802 (50.7%) admissions were females. In a multivariable analysis, older age (OR 1.01 [95% CI, 1.00-1.01]), male gender (OR 0.74 [95% CI, 0.63-0.86]), any cardiovascular disease (OR 1.51 [95% CI, 1.23-1.85]), congestive heart failure (CHF) (OR 2.81 [95% CI, 2.33-3.39), hypertension (OR 1.42 [95% CI, 1.22-1.67]), respiratory infection (OR 1.38 [95% CI, 1.17-1.63]), and any IV fluid administration (OR 3.37 [95% CI, 2.80-4.06]) were independently associated with furosemide treatment >48 h after hospital admission. In-hospital mortality was higher in patients with furosemide treatment (15.9% vs. 6.8%, p < 0.001). Treatment with furosemide in patients admitted with an infection was found to be associated with prolonged hospital stay and increased in-hospital mortality.

Mean Platelet Volume as a Predictor of Coronary Artery Disease Severity and its Association With Coronary Artery Calcification.

Coronary calcium score (CCS) is a highly sensitive marker for estimating coronary artery calcification (CAC) and detecting coronary artery disease (CAD). Mean platelet volume (MPV (is a platelet indicator that represent platelet stimulation and production. The aim of the current study was to examine the association between MPV values and CAC. We examined 290 patients who underwent coronary computerized tomography (CT) exam between the years 2017 and 2020 in a tertiary care medical center. Only patients evaluated for chest pain were included. The Multi-Ethnic Study of Atherosclerosis (MESA) CAC calculator was used to categorize patients CCS by age, gender, and ethnicity to CAC severity percentiles (<50, 50-74, 75-89, ≥90). Thereafter, the association between CAC percentile and MPV on admission was evaluated. Out of 290 patients, 251 (87%) met the inclusion and exclusion criteria. There was a strong association between higher MPV and higher CAC percentile (P = .009). The 90th CAC percentile was associated with the highest prevalence of diabetes mellitus (DM), hypertension, dyslipidemia, and statin therapy (P = .002, .003, .001, and .001, respectively). In a multivariate analysis (including age, gender, DM, hypertension, statin therapy, and low-density lipoprotein level) MPV was found to be an independent predictor of CAC percentile (OR 1.55-2.65, P < .001). Higher MPV was found to be an independent predictor for CAC severity. These findings could further help clinicians detect patients at risk for CAD using a simple and routine blood test.

Cryoballoon-Induced Circumferential Pulmonary Vein Fibrosis, Assessed by Late Gadolinium-Enhancement Cardiac Magnetic Resonance Imaging, and Its Correlation with Clinical Atrial Fibrillation Recurrence.

BACKGROUND: Prior studies evaluating post-atrial fibrillation (AF) ablation pulmonary vein (PV) ostial gaps via magnetic resonance imaging (MRI) have shown circumferential PV fibrosis in a minority of patients, and their correlation with AF recurrence was weak. These studies were mostly based on radio-frequency AF ablations. AIM: We aimed to assess cryoballoon ablation-induced PV fibrosis via MRI and its correlation with AF recurrence. METHODS AND RESULTS: This was a prospective study of consecutive patients with symptomatic AF who underwent pre- and post-ablation MRI to assess baseline and ablation-induced fibrosis, respectively. Post-ablation PV gaps were assessed by new semi-quantitative visual analysis assisted by computerized ADAS analysis. AF recurrence monitored via multiple ECGs and event monitoring at 6 and 12 months post ablation. Nineteen patients with 80 PVs were included, age 56 ± 11, with paroxysmal and persistent AF in 17/19 and 2/19 patients, respectively. Baseline MRI showed minimal LA fibrosis. All patients underwent successful cryoballoon PV electrical isolation. Post-ablation MRI revealed circumferential PV fibrosis among 63/80 (78.8%) PVs and partial fibrosis with major gaps among 17/80 (21.2%) PVs. AF recurred within one year in 5/9 (55.5%) patients with partial PV fibrosis, while no AF recurred among the 10 patients in whom all PVs had circumferential fibrosis (p < 0.01). Similarly, there were significantly more PVs without circumferential fibrosis (due to major gaps) among patients with AF recurrence as compared with patients without AF recurrence (42.9% vs. 13.5%; p < 0.01). CONCLUSION: Cryoballoon AF ablation results in circumferential PV fibrosis in the majority of PVs, as assessed by a new clinically relevant MRI-LGE analysis. Significant correlation was found between major PV gaps on post-ablation MRI and AF recurrence, suggesting that MRI might have the ability to predict AF recurrence.

Nonagenarians admission and prognosis in a tertiary center intensive coronary care unit - a prospective study.

BACKGROUND: With increasing life expectancy, the prevalence of nonagenarians with cardiovascular disease is steadily growing. However, this population is underrepresented in randomized trials and thus poorly defined, with little quality evidence to support and guide optimal management. The aim of the present study was to evaluate the clinical management, therapeutic approach, and outcomes of nonagenarians admitted to a tertiary care center intensive coronary care unit (ICCU). METHODS: We prospectively collected all patients admitted to a tertiary care center ICCU between July 2019 - July 2022 and compared nonagenarians to all other patients. The primary outcome was in-hospital mortality. RESULTS: A total of 3807 patients were included in the study. Of them 178 (4.7%) were nonagenarians and 93 (52%) females. Each year the prevalence of nonagenarians has increased from 4.0% to 2019, to 4.2% in 2020, 4.6% in 2021 and 5.3% in 2022. Admission causes differed between groups, including a lower rate of acute coronary syndromes (27% vs. 48.6%, p < 0.001) and a higher rate of septic shock (4.5% vs. 1.2%, p < 0.001) in nonagenarians. Nonagenarians had more comorbidities, such as hypertension, renal failure, and atrial fibrillation (82% vs. 59.6%, 23% vs. 12.9%, 30.3% vs. 14.4% p < 0.001, respectively). Coronary intervention was the main treatment approach, although an invasive strategy was less frequent in nonagenarians in comparison to younger subjects. In-hospital mortality rate was 2-fold higher in the nonagenarians (5.6% vs. 2.5%, p = 0.025). CONCLUSION: With increasing life expectancy, the prevalence of nonagenarians in ICCU's is expected to increase. Although nonagenarian patients had more comorbidities and higher in-hospital mortality, they generally have good outcomes after admission to the ICCU. Hence, further studies to create evidence-based practices and to support and guide optimal management in these patients are warranted.

First-in-Human Dedicated Leaflet Splitting Device for Prevention of Coronary Obstruction in Transcatheter Aortic Valve Replacement.

BACKGROUND: Coronary artery obstruction is a life-threatening complication of transcatheter aortic valve replacement (TAVR) procedures. Current preventive strategies are suboptimal. OBJECTIVES: The aim of this study was to describe bench testing and clinical experience with a novel device that splits valve leaflets that are at risk for causing coronary obstruction after TAVR, allowing normal coronary flow. METHODS: The ShortCut device was initially tested in vitro and preclinically in a porcine model for functionality and safety. The device was subsequently offered to patients at elevated risk for coronary obstruction. Risk for coronary obstruction was based on computed tomography-based anatomical characteristics. Procedure success was determined as patient survival at 30 days with a functioning new valve, without stroke or coronary obstruction. RESULTS: Following a successful completion of bench testing and preclinical trial, the device was used in 8 patients with failed bioprosthetic valves (median age 81 years; IQR: 72-85 years; 37.5% man) at 2 medical centers. A total of 11 leaflets were split: 5 patients (63.5%) were considered at risk for left main obstruction alone, and 3 patients (37.5%) were at risk for double coronary obstruction. All patients underwent successful TAVR without evidence of coronary obstruction. All patients were discharged from the hospital in good clinical condition, and no adverse neurologic events were noted. Procedure success was 100%. CONCLUSIONS: Evaluation of the first dedicated transcatheter leaflet-splitting device shows that the device can successfully split degenerated bioprosthetic valve leaflets. The procedure was safe and successfully prevented coronary obstruction in patients at risk for this complication following TAVR.

The Added Value of a High CT Coronary Artery Calcium Score in the Management of Patients Presenting with Acute Chest Pain vs. Stable Chest Pain.

Background: Contrast computerized tomography (CT) scan is occasionally aborted due to a high coronary artery calcium score (CACS). For the same CACS in our clinical practice, we observed a higher occurrence of severe coronary artery disease (CAD) in patients with acute chest pain (ACP) compared to patients with stable chest pain (SCP). Since it is known that ACP differs in many ways from SCP, the aim of this study was to compare the predictive value of a high CACS for the diagnosis of severe CAD between ACP and SCP patients. Methods: This single center observational retrospective study included consecutive patients who underwent cardiac CT for chest pain and were found to have a CACS of >200 Agatston units. Patients were divided into two groups, ACP and SCP. Severe CAD was defined as ≥70% stenosis on coronary CT angiography or invasive coronary angiography. Baseline characteristics and final diagnosis of severe CAD were compared. Results: The cohort included 220 patients, 106 with ACP and 114 with SCP. ACP patients had higher severe CAD rates (60.4% vs. 36.8%; p < 0.001). On multivariate analysis including cardiac risk factors, CACS > 400 au (OR = 2.34 95% CI [1.32−4.15]; p = 0.004) and ACP (OR = 2.54 95% CI [1.45−4.45]; p = 0.001) were independent predictors of severe CAD. The addition of the clinical setting of ACP added significant incremental predictive value for severe stenosis. Conclusion: A high CACS is more associated with severe CAD in patients presenting with ACP than SCP. The findings suggest that the CACS could impact the management of patients during the scan.

[RECOMMENDATIONS FOR CHANGING CARDIOVASCULAR SCREENING OF ATHLETES WHO ARE REQUIRED FOR PRE-PARTICIPATION SCREENING UNDER THE SPORTS LAW - A POSITION PAPER ON BEHALF OF THE ISRAEL HEART SOCIETY].

INTRODUCTION: For many years routine screening of athletes in Israel includes frequently performed ECGs and exercise tests that overload the system with questionable benefits. The purpose of the current document is to reevaluate the need for pre-participation testing and establish new evidence-based guidelines. It should be noted that our proposal for a change of approach relates only to subjects whose health questionnaire is normal, who do not have a family history of sudden and unexpected death at an early age, or a family history of hereditary heart disease and whose physical examination from a cardiovascular point of view is normal.

Anatomical accuracy of the KODEX-EPD novel 3D mapping system of the left atrium during pulmonary vein isolation: A correlation with computer tomography imaging.

BACKGROUND: A novel 3D mapping system (KODEX-EPD, EPD Solutions) enables catheter localization and real-time 3D cardiac mapping. OBJECTIVE: To evaluate left atrium (LA) anatomical mapping accuracy created by the KODEX-EPD system during pulmonary vein isolation (PVI) compared with gold standard computed tomography (CT) images acquired from the same patients before the procedure. METHODS: In 15 consecutive patients who underwent PVI, 3D mapping of the LA was created on the KODEX-EPD system using the Achieve catheter. Pulmonary vein (PV), posterior wall, and appendage anatomy and diameters, were compared to the CT 3D reconstruction measured on the CARTO 3 system. Measurements were done independently by two physicians in each method. Linear correlation and agreement between CT and EPD measurements were assessed by Spearman correlation and Bland-Altman plot. RESULTS: Mean LA mapping time was 7.7 ± 3.6 min. Very high interobserver correlation was found for both EPD and CT measurements (Spearman r = .9). High correlation (r = .75) was found between CT and EPD measurements. Bland-Altman plot method revealed that measurements assessed by EPD were slightly higher than those assessed by CT. Mean difference was 3.5 mm, p < .01. In 2 (13.5%) patients each, disagreement regarding the presence of a left common PV and a right middle accessory vein anatomy was seen. CONCLUSION: The new KODEX-EPD mapping system allows quick and accurate mapping of the LA with high correlation to CT imaging. Some differences in left common and accessory right middle vein anatomy were seen.

The Association of Alanine Aminotransferase Levels With Myocardial Perfusion Imaging and Cardiovascular Morbidity.

INTRODUCTION: Studies suggest that non-alcoholic fatty liver disease (NAFLD) is associated with an independent risk of cardiovascular disease (CVD). We utilized a large cohort of patients undergoing myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) to determine the association between alanine aminotransferase (ALT) as a surrogate marker for presumed NAFLD, and the presence of myocardial ischemia and mortality. METHODS: We retrospectively assessed SPECT-MPI results and medical records of individuals evaluated between 1997 and 2008. We excluded patients with known non-NAFLD liver diseases, ALT values <17 or >340 U/L and absent liver tests. Elevated ALT cases were classified as presumed NAFLD. The primary endpoint was abnormal SPECT-MPI. Secondary endpoints included cardiac death, acute myocardial infarction and all-cause mortality. RESULTS: Of 26,034 patients who underwent SPECT-MPI, 11,324 met inclusion criteria. 1635 (14.4%) patients had elevated ALT. SPECT-MPI results did not differ significantly between subjects with elevated ALT and controls. Elevated ALT was associated with increased risk for the composite endpoint of cardiac death or acute myocardial infarction at 5-year follow-up (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.01-1.67) and in all-cause mortality (HR 1.27, CI 1.02-1.58) but only in patients with normal SPECT-MPI. CONCLUSIONS: The long-term mortality of patients with abnormal SPECT-MPI is not modulated by ALT, likely reflecting an already high risk and established CVD. However, patients with normal SPECT-MPI are at increased risk for a future cardiac event if they have an elevated ALT level, suggesting an important role for NAFLD in earlier stages of CVD.

Loss of left ventricular rotation is a significant determinant of functional mitral regurgitation.

AIM: To evaluate insufficient rotational movement of the left ventricle (LV) as a potential novel mechanism for functional regurgitation of the mitral valve (FMR). METHODS AND RESULTS: We compared reference subjects and patients with LV dysfunction (LVD, ejection fraction EF < 50%) with and without FMR (regurgitant volume RVol>10 ml). Subjects without structural mitral valve pathology undergoing cardiac MRI were evaluated. Delayed enhancement, global LV remodeling parameters, systolic twist and torsion were measured (using manual and novel automated cardiac MRI tissue-tracking). The study included 117 subjects with mean ± SD age 50.4 ± 17.8 years, of which 30.8% were female. Compared to subjects with LVD without FMR (n = 31), those with FMR (n = 37) had similar clinical characteristics, diagnoses, delayed enhancement, EF, and longitudinal strain. Subjects with FMR had significantly larger left ventricles (EDVi:136.6 ± 41.8 vs 97.5 ± 26.2 ml/m, p < 0.0001) with wider separation between papillary muscles (21.1 ± 7.6 vs 17.2 ± 5.7 mm, p = 0.023). Notably, they had lower apical (p < 0.0001) but not basal rotation and lower peak systolic twist (3.1 ± 2.4° vs 5.5 ± 2.5°, p < 0.0001) and torsion (0.56 ± 0.38°/cm vs 0.88 ± 0.52°/cm, p = 0.004). In a multivariate model for RVol including age, gender, twist, LV end-diastolic volume, sphericity index and separation between papillary muscles, only gender, volume and twist were significant. Twist was the most powerful correlate (beta -2.23, CI -3.26 to -1.23 p < 0.001). In patients with FMR, peak systolic twist negatively correlates with RVol (r = -0.73, p < 0.0001). CONCLUSION: Reduced rotational systolic LV motion is significantly and independently associated with RVol among patients with FMR, suggesting a novel pathophysiological mechanism and a potential therapeutic target.

Predictors of Hypoxemia and Related Adverse Outcomes in Patients Hospitalized with COVID-19: A Double-Center Retrospective Study.

Hypoxemia is a hallmark of coronavirus disease 2019 (COVID-19) severity. We sought to determine predictors of hypoxemia and related adverse outcomes among patients hospitalized with COVID-19 in the two largest hospitals in Jerusalem, Israel, from 9 March through 16 July 2020. Patients were categorized as those who developed reduced (<94%) vs. preserved (≥94%) arterial oxygen saturation (SpO2) within the first 48 h after arrival to the emergency department. Overall, 492 hospitalized patients with COVID-19 were retrospectively analyzed. Patients with reduced SpO2 were significantly older, had more comorbidities, higher body surface area (BSA) and body mass index (BMI), lower lymphocyte counts, impaired renal function, and elevated liver enzymes, c-reactive protein (CRP), and D-dimer levels as compared to those with preserved SpO2. In the multivariable regression analysis, older age (odds ratio (OR) 1.02 per year, p < 0.001), higher BSA (OR 1.16 per 0.10 m2, p = 0.003) or BMI (OR 1.05 per 1 kg/m2, p = 0.011), lower lymphocyte counts (OR 1.72 per 1 × 103/µL decrease, p = 0.002), and elevated CRP (1.11 per 1 mg/dL increase, p < 0.001) were found to be independent predictors of low SpO2. Severe hypoxemia requiring ventilatory support, older age, and pre-existing comorbidities, including underlying renal dysfunction and heart failure, were found to be significantly associated with in-hospital mortality. These findings suggest that assessment of predictors of hypoxemia early at the time of hospitalization with COVID-19 may be helpful in risk stratification and management.

Distribution of C-arm projections in native and bioprosthetic aortic valves cusps: Implication for BASILICA procedures.

OBJECTIVES: We sought to document aortic cusps fluoroscopic projections and their distributions using leaflet alignment which is a novel concept to optimize visualization of leaflets and for guiding BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent coronary artery obstruction) and determine whether these projections were feasible in catheter laboratory. BACKGROUND: Optimal fluoroscopic projections of aortic valve cusps have not been well described. METHODS: A total of 128 pre-transcatheter aortic valve replacement (pre-TAVR) computed tomographies (CT) (72 native valves and 56 bioprosthetic surgical valves) were analyzed. Using CT software (3Mensio, Pie medical imaging, the Netherlands), leaflet alignment was performed and the feasibility of these angles, which were defined as rate of obtainable with efforts (within LAO/RAO of 85° and CRA/CAU of 50°) were evaluated. RESULTS: High feasibility was seen in right coronary cusp (RCC) front view (100%) and left coronary cusp (LCC) side view (99.2%), followed by noncoronary cusp side view (95.3%). In contrast, low feasibility of RCC side view (7.8%) and LCC front view (47.6%) was observed. No statistical differences were seen between the distribution of native valves and bioprosthetic surgical valves. With patient/table tilt of 20°LAO and 10°CRA, the feasibility of RCC side view and LCC front view increased to 43.7 and 85.2%, respectively. CONCLUSION: Distributions of each cusp's leaflet alignment follows "sigmoid curve" which can provide better understanding of aortic valve cusp orientation in TAVR and BASILICA. RCC side view used in right cusp BASILICA is commonly unachievable in catheter laboratory and may improve with patient/table tilt.