Supra‐annular structure assessment for self‐expanding transcatheter heart valve size selection in patients with bicuspid aortic valve

Abstract

ObjectivesTo explore assessment of supra‐annular structure for self‐expanding transcatheter heart valve (THV) size selection in patients with bicuspid aortic stenosis (AS).BackgroundAnnulus‐based device selection from CT measurement is the standard sizing strategy for tricuspid aortic valve before transcatheter aortic valve replacement (TAVR). Because of supra‐annular deformity, device selection for bicuspid AS has not been systemically studied.MethodsTwelve patients with bicuspid AS who underwent TAVR with self‐expanding THVs were included in this study. To assess supra‐annular structure, sequential balloon aortic valvuloplasty was performed in every 2 mm increments until waist sign occurred with less than mild regurgitation. Procedural results and 30 day follow‐up outcomes were analyzed.ResultsSeven patients (58.3%) with 18 mm; three patients (25%) with sequential 18 mm, 20 mm; and only two patients (16.7%) with sequential 18 mm, 20 mm, and 22 mm balloon sizing were performed, respectively. According to the results of supra‐annular assessment, a smaller device size (91.7%) was selected in all but one patient compared with annulus based sizing strategy, and the outcomes were satisfactory with 100% procedural success. No mortality and 1 minor stroke were observed at 30 d follow‐up. The percentage of NYHA III/IV decreased from 83.3% (9/12) to 16.7% (2/12). No new permanent pacemaker implantation and no moderate or severe paravalvular leakage were found.ConclusionsA supra‐annular structure based sizing strategy is feasible for TAVR in patients with bicuspid AS.

Location of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Zone III Using External Landmark Without Fluoroscopy: A CTA-based Retrospective Study

“…Subjects whose images accompanied by vascular malformation, poor contrast enhancement, and history of aortic surgery were precluded. Before CT scanning, 70 ml contrast agent iohexol (Omnipaque 370 mg I/ml, GE Healthcare, Shanghai, China) and 60 ml 0.9% saline were injected into the middle elbow vein by a dual-head power injector (Mallinckrodt, American) at a ow rate of 4 ml/s [11]. A 128-slice dual-energy CT scanner (SOMATOM De nition Flash, Siemens Medical Solutions, Germany) was utilized for the scanning during the arterial phase.…”

Transcatheter aortic valve replacement for bicuspid aortic valve stenosis

“…Angiography of the ascending aorta during balloon valvuloplasty can help verify whether an adequate seal is achievable and aid in selecting an appropriately sized prosthesis. Liu et al 10 performed sequential balloon aortic valvuloplasty before TAVR with a self-expanding valve in 12 patients. Of these, 11 (91.7%) received a smaller device than they would have with multidetector computed tomographyguided annulus measurement.…”

TAVR technique tries to go higher than bicuspid valve hurdles

“…Indeed, a various combination of large and elliptical annulus shapes, asymmetric leaflets, extensive calcifications, and aortic root deformation is often present in old BAV patients. In such context, Liu et al report their experience in BAV patients with an original technique based on a balloon valvuloplasty‐based sizing allowing for self‐expandable prostheses size selection and implantation planning. Applying this algorithm, the authors implanted (often undersized) self‐expandable prostheses at supra‐annular level and obtained very interesting procedural results in unselected BAV.…”

“…In conclusion, despite these promising reports , both the specific technical challenges (rough sizing technique, difficulties in valve deployment, uncertain prosthesis stability) and the unproven long‐term efficacy do represent major issues for the systematic adoption of this technique in unselected BAV patients. Cautiously, the selection of supra‐annular self‐expandable prostheses implantation technique represents a valuable alternative to be considered in selected BAV patients with adverse anatomic features (which are anticipated to limit the chance of success for standard TAVR techniques).…”