Transcatheter Treatment of Bicuspid Aortic Valve Disease: Imaging and Interventional Considerations.

Rajiv Das,Rishi Puri

doi:10.3389/fcvm.2018.00091

Rajiv Das, Rishi Puri

Open Access

https://doi.org/10.3389/fcvm.2018.00091

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Abstract

Patients with bicuspid aortic valve disease have systematically been excluded from large randomized clinical trials investigating transcatheter aortic valve implantation (TAVI) due to their younger age, lower surgical risk and complex aortic anatomy. The asymmetric nature of the bicuspid valve orifice often accompanied by heavy regional calcification has led to concerns regarding valve positioning and expansion. Bicuspid aortic valve disease patients are at heightened risk of TAVI-related complications including coronary occlusion, aortic dissection and annular rupture, as well as the known risks of progressive aortopathy in these patients. These unique anatomical characteristics pose challenges for TAVI operators. However, with recent and ongoing refinements in implantation technique, improvements in pre-procedural imaging and iterations in device design, TAVI is emerging as a safe and feasible treatment option in this population. Paravalvular aortic regurgitation and high pacemaker rates have been the Achilles Heel for TAVI in bicuspid valve patients, yet newer generation devices are yielding promising results. Further studies are required before TAVI ultimately emerges as a viable option in low and intermediate surgical-risk patients with bicuspid valve disease. This review comprehensively summarizes the epidemiology, pathology and current evidence for TAVI in patients with bicuspid aortic valve disease. We also outline some practical tips for performing TAVI in these patients.

Highlights

The transcatheter aortic valve implantation (TAVI) revolution for severe tricuspid aortic valve stenosis (AS) is well-recognized as an alternative to surgical aortic valve replacement (SAVR) for severe aortic stenosis
Bicuspid aortic valve (BAV) has largely been excluded from seminal randomized clinical trials involving TAVI. This was due to concerns about (i) valve positioning and expansion due to the asymmetrical nature of the leaflets and heavy calcification leading to severe paravalvular leak (PVL), (ii) aortic annulus rupture and risk of coronary occlusion, (iii) concomitant aortopathy associated with BAV increasing
This review summarizes the evidence for TAVI in bicuspid aortic valve disease, the role of multi-slice computed tomography (MSCT) to aid procedural planning, and technical considerations to undertake when performing TAVI in BAV

Summary

Introduction

The transcatheter aortic valve implantation (TAVI) revolution for severe tricuspid aortic valve stenosis (AS) is well-recognized as an alternative to surgical aortic valve replacement (SAVR) for severe aortic stenosis. This was due to concerns about (i) valve positioning and expansion due to the asymmetrical nature of the leaflets and heavy calcification leading to severe paravalvular leak (PVL), (ii) aortic annulus rupture and risk of coronary occlusion, (iii) concomitant aortopathy associated with BAV increasing This series demonstrated that pre-procedural MSCT imaging can minimize PVL in TAVI for BAV disease by more accurately sizing the annulus.

Results

Conclusion