Bicuspid Aortic Valve Leaflet Modification Before Transcatheter Aortic Valve Replacement

Figures

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  Figure 1. Examples of Suboptimal vs Optimal Transcatheter Heart Valve Deployment in Calcified Bicuspid Aortic Valve vs Tricuspid Aortic Valve Anatomies (A) Constrained self-expanding TAVR frame within severely calcified bicuspid aortic valve with calcified raphe. (B) Well-expanded self-expanding TAVR valve in calcified tricuspid aortic valve. (C) Constrained balloon-expandable TAVR frame within severely calcified bicuspid aortic valve. (D) Well-expanded balloon-expandable TAVR in calcified tricuspid aortic valve. Left panels: volume rendered (VR) computed tomography (CT) hockey puck, en face views; Middle panels: CT axial views at worst level of TAVR frame under-expansion; Right panels: Virtual Fluoroscopy views derived from CT. LC = left coronary cusp; NC = noncoronary cusp; RC = right coronary cusp; TAVR = transcatheter aortic valve replacement.

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  Central Illustration. Pre-TAVR Bicuspid Aortic Valve Leaflet Modification by Splitting for THV Optimization (Upper row) Calcified raphe of type 1 BAV acts as a rigid and undeflectable construct which limits THV expansion in theory, CT-based simulation model, and ex vivo bench model. (Lower row) Mechanical laceration adjacent to raphe allows deflection of the rigid and calcified raphe (yellow arrows) and results in well-expanded THV. (Table) Study cohort, models studied, and main results. Abbreviations as in Figure 2.

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  Figure 2. Simulated Transcatheter Aortic Valve Replacement Ovality and Opening Area in Bicuspid Aortic Valve Following Leaflet Modification (Single Splits Simulated) (Upper) Hockey puck aortic view of 4 type 1 and 1 type 0 BAV case models generated from patient CTs. All type 1 BAV had calcified raphe and red lines indicate the location of noncalcific simulated split. (Middle panel) Left: Deployed simulated dummy Evolut Pro 29 into split (green mesh) and unsplit (red mesh) type 1 BAV. Right: three-dimensional rendering without and with a single split (raphe indicated with arrow). (Lower) Improved average ovality (dmax/dmin) and average opening area quantified from 3 separate THV heights including the THV annulus plane for the 5 simulated cases. Of note, case 4 with minimal leaflet calcification showed no improvement with split. BAV = bicuspid aortic valve; CT= computed tomography; THV = transcatheter heart valve.

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  Figure 3. Transcatheter Heart Valve Deployment in a Reconstructed Type 0 Bicuspid Aortic Valve Following Leaflet Modification (A) Type 0 BAV reconstructed valve without split. (B) Type 0 BAV reconstructed valve with deployed Evolut R 26 THV after single split on the bench. (C) Type 0 BAV reconstructed valve with 2 center splits on the bench. (D) En face hockey puck view of Evolut R 26 deployed in unsplit and split type 0 bicuspid reconstructed valve. Postdilatation was performed on the unsplit valve to show area and circularity improvement due to splitting relative to the dilatation of the THV. Postdilatation increased area and reduced ellipticity when applied to the unsplit and 2-split cases. All percentages reflect a calculated change relative to the no-split case. Abbreviations as in Figure 2.

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  Figure 4. Self-Expanding Valve Transcatheter Heart Valve Deployment in a Reconstructed Type 1 Bicuspid Aortic Valve Following Leaflet Modification Improved outcomes for a deployed Evolut Pro Plus 23 in a reconstructed type 1 bicuspid aortic valve after splitting. (Upper) Planar perpendicular aortic view of a type 1 bicuspid reconstructed valve from excised bicuspid patient without a split. Raphe is annotated with an arrow. (Lower) Mechanical split in 3 locations relative to the raphe (dotted lines indicate x2 splits adjacent and x1 split opposite) with modified ShortCut platform yields significant increase in opening area (53%) and decrease in ellipticity (−31%) compared to no split THV deployment. Abbreviations as in Figure 2.

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  Figure 5. Balloon-Expandable Valve Transcatheter Heart Valve Deployment in a Reconstructed Type 1 Bicuspid Aortic Valve Following Leaflet Modification Improved outcomes for a deployed Sapien 3 26 mm THV in a reconstructed type 1 bicuspid aortic valve after splitting. (Upper row) Planar perpendicular aortic view of a type 1 bicuspid reconstructed valve from excised bicuspid patient with raphe and 2 planned split lines indicated (dotted lines indicate x1 split adjacent to raphe and x1 split opposite raphe leaflet). Leaflet display images in side view of 1st and 2nd splits after THV deployment. (Lower row) Resulting aortic view of deployed Sapien in nonsplit native valve (left), 1 mechanical split location relative to the raphe (middle), and 2 split locations adjacent and opposite the raphe (right), yield significant increases in opening area (as much as 19.4%) and decrease in ellipticity (as much as −12%) compared to the nonsplit Sapien 3 deployment. Abbreviations as in Figure 2.