Prosthesis Oversizing in Balloon-Expandable Transcatheter Aortic Valve Implantation Is Associated With Contained Rupture of the Aortic Root

Abstract

patients with severe symptomatic aortic stenosis underwent TAVI, of whom 35 patients received a self-expandable prosthesis and 72 patients a balloon-expandable prosthesis. The study population consisted of the 72 consecutive patients with balloon-expandable TAVI, who underwent either Background-To retrospectively investigate the potential cause of contained rupture of the aortic root in balloon-expandable transcatheter aortic valve implantation (TAVI) by means of pre-and postinterventional multislice computed tomography. Methods and Results-Seventy-two patients (mean age 82±7 years, mean aortic valve area 0.69±0.19 cm 2 ) underwent balloon-expandable TAVI using the EdwardsSAPIEN Transcatheter Heart Valve (23 mm, n=19; 26 mm, n=50; 29 mm, n=3). Aortic annulus dimensions were quantified by multislice computed tomography-based cross-sectional area assessment and average diameter calculation (CAAD) before and after TAVI. Post-TAVI multislice computed tomography data sets were available in 65 patients; contained aortic root rupture was diagnosed in 3 patients. Pre-TAVI CAAD was 23.1±1.8 mm; post-TAVI CAAD was 22.9±1.3 mm. Median relative change in CAAD pre-and post-TAVI was −0.5% (interquartile range, 3.6%). Relative increase of 5% to 10% was observed in 4 patients (1 with contained rupture), relative increase >10% in 2 patients, both with contained rupture. Mean relative oversizing, calculated as the relative difference in diameter between pre-TAVI CAAD and nominal diameter of the selected prosthesis, was 9.8%±7.8%. Relative oversizing was significantly higher in patients with contained rupture compared with patients without contained rupture (24.6%±5.4% versus 9.1%±6.6%; P<0.001). Relative oversizing ≥20% occurred in 6 patients (3 with contained rupture). Conclusions-Contained rupture of the aortic root in balloon-expandable TAVI is associated with severe prosthesis oversizing. Multislice computed tomography-based assessment of aortic annulus dimension in conjunction with adapted sizing guidelines may reduce the incidence of severe oversizing. (Circ Cardiovasc Interv. 2012;5:540-548.)

The impact of calcium volume and distribution in aortic root injury related to balloon-expandable transcatheter aortic valve replacement

“…Previous case reports suggest that the left aortic sinus may be the most vulnerable area with regard to aortic root injury possibly because of the lack of supporting cardiac structures in this area. 28,29 However, it may be speculated whether the culprit site is located at the site of calcification or at the aortic wall opposite to the calcification because of THV migration away from hard calcified areas during balloon expansion. If the latter were to hold true, this could potentially explain our findings.…”

SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR)

“…Recent data indicate that imaging of the aortic root and annulus in systole may be preferable over diastole because of the dynamic changes of the annulus and slightly larger annular sizes noted in systole. 10,11 However, it is important to ensure adequate image quality even if systolic imaging is used. Because CT is typically not used to determine the severity of aortic valve stenosis, datasets do not need to cover the entire cardiac cycle, which allows for reduction of radiation exposure.…”

“…These recommendations have typically been used on the basis of echocardiographic measurements, and the use of CT-based measurements without adaptation of the sizing thresholds may lead to the choice of different prosthesis sizes in approximately 25%-45% of cases. 10,11,33 No CT-specific guidelines for prosthesis sizing have been developed and sufficiently validated yet for the balloon-expandable prosthesis. They are more firmly entrenched for the self-expanding prosthesis 34 (Table 7).…”

Extrinsic compression of the left main coronary artery by a contained aortic annular rupture following trans-catheter aortic valve implantation

“…A contained rupture of the aortic root in balloon-expandable TAVI is associated with prosthesis oversizing [3] as well as other predisposing factors such as heavy calcification [4,5]. In our case sizing was correct, however native valve was severely calcified with calcifications extended beyond the annulus to the aorto-mitral continuity as clearly shown by the CTA.…”