Definition of trAnscatheter heart Valve orIeNtation in biCuspId aortic valve: The DA VINCI pilot study

Abstract

ObjectivesTo assess the impact of conventional transcatheter heart valve (THV) commissural alignment techniques on THV/coronary overlap and coronary access (CA) after transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV).BackgroundSpecific Evolut Pro/Pro + and Acurate Neo2 THV orientations are associated with reduced neo-commissural overlap with coronary ostia in tricuspid aortic anatomy. Whether standard orientation techniques are effective also in the setting of BAV anatomy has not been studied.MethodsThe DA VINCI (Definition of trAnscatheter aortic Valve orIeNtation in biCuspId aortic valve) pilot study is a prospective registry enrolling consecutive patients with severe BAV stenosis undergoing TAVR with last generation supra-annular tall-frame THVs implanted with a cusp overlap view-based commissural alignment. Patients underwent pre- and post-TAVR computed tomography (CT) and coronary angiography. The study endpoint was the rate of favorable THV/coronary overlap, defined as an angle > 40° between the THV commissural post and coronary ostia. Other endpoints were the rates of successful THV alignment with respect to the raphe and of selective CA after TAVR. Moreover, different virtual THV alignment models were tested to identify which one would produce the lower degree of THV/coronary overlap.ResultsThirty-four patients with type 1 BAV with right-left raphe undergoing TAVR (23 with Evolut Pro/Pro + and 11 with Acurate Neo2) were included. At pre-TAVR CT, moderate/severe cusp asymmetry was found in 50% of patients, severe coronary ostia eccentricity was observed in 47.1% for the RCA vs. 8.8% for the LCA (P < 0.007). Correct TVH orientation was achieved in 29 cases. At post-TAVR CT, optimal THV alignment/mild misalignment to the raphe was observed in 86.2%, but a moderate/severe overlap with the coronaries was seen in 13.7% for the RCA and 44.8% for the LCA (P = 0.019). After TAVR, selective RCA cannulation was possible in 82.8% vs. 75.9% for the LCA (P = 0.74), while combined selective CA of both coronaries was possible in less than two-thirds of the patients. Virtual THV alignment in the coronary ostia overlap view assuming a hypothetical circular THV expansion would produce an optimal THV/coronary overlap in almost 90% of cases.ConclusionGiven cusp asymmetry and coronary ostia eccentricity of BAV combined with potential THV asymmetrical expansion, conventional commissural alignment techniques are associated with higher rates of THV misalignment and of moderate/severe neo-commissure overlap with the coronary ostia as compared to tricuspid aortic stenosis, resulting in lower rates of selective CA after TAVR. A modified THV orientation technique based on the coronary ostia overlap view might be preferable in BAV patients.

Unlocking insights in bicuspid aortic valve management in adult patients: the vital role of cardiac imaging

“…Consequently, an obstruction to blood outflow from the left ventricle to the aorta emerges, culminating in heightened pressure gradients across the valve. This obstruction imposes an augmented workload on the heart and can eventually give rise to symptoms such as angina, fatigue, and dyspnea [8].…”

“…Multimodality imaging plays a pivotal role in the diagnosis, follow-up, and surgical management of BAV patients [14]. While TTE serves as a first-line imaging tool for BAV diagnosis and initial assessment, CT and CMR offer superior spatial resolution for evaluating aortic segments and assessing aortic size and morphology [8,37]. Multimodality imaging techniques play a crucial role in diagnosis, follow-up, and treatment planning for BAV patients.…”

“…A study by Kang et al highlighted function and aortopathy, providing insights critical for surgical decision-making [14]. The DA VINCI pilot study focused on optimizing valve orientation in transcatheter aortic valve implantation (TAVI) for BAV patients, aiming to enhance procedural outcomes and longterm results [8].…”

“…Furthermore, some individuals with BAV may eventually display symptoms like chest pain, fatigue, and difficulty breathing [6,8]. These symptoms stem from altered blood flow, valve dysfunction, and potential concurrent cardiovascular conditions.…”

Echocardiography in Simple Congenital Heart Diseases: Guiding Adult Patient Management

“…These findings underscore the relationship between distinct BAV phenotypes and aortic valve dysfunction, revealing BAV-RL and BAV with raphe as prone to aortic regurgitation, while BAV-RN patients are more predisposed to aortic stenosis. [ 13 ]…”