Anatomical predictors of conduction damage after transcatheter implantation of the aortic valve

Figures

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  Figure 1. Measurements using multiplanar reconstruction images. (A) Virtual dissection images of the aortic root and membranous septum viewed from the right anterior oblique and caudal direction, showing the concept of the measurements. Actual measurements were all performed using multiplanar reconstruction images (B–F). The membranous septum (yellow–green area) is located inferior to the interleaflet triangle (yellow area) between the right (R) and non-coronary (N) aortic sinuses, interposed by the inner heart curvature. The black line (B) corresponds to the plane of the virtual basal ring represented in panel B. The white line corresponds to the orthogonal plane bisecting the interleaflet triangle between the R and N, as shown in panel C. (B) The width of the membranous septum (a) was determined from the plane of the virtual basal ring. (C) The height of the membranous septum (b) was measured from the crest of the muscular ventricular septum and the inner heart curvature. The inferior distance (c) was determined from the plane of the virtual basal ring (black line) to the crest of the muscular ventricular septum. (D) The angle of rotation of the root was defined as the angle between the…

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  Figure 2. Membranous septum and the proximal left bundle branch. The left panel shows a virtual dissection reconstructed similar to the echocardiographic parasternal long-axis image. The white star indicates the membranous septum. With known knowledge (right panel) concerning the location of the left bundle branch (RED) ramifying from the branching portion of the bundle of His24 26 in the antero-inferior margin of the membranous septum (black-dotted area, superimposed on the original image of Tawara26), such combined images help the interventionists appreciate the danger zone during transcatheter aortic valve implantation. Note that, when described in attitudinally appropriate terminology, the so-called ‘anterior’ and ‘posterior’ fascicles of the left bundle are more appropriate referred to as the superior and inferior fascicles respectively.27 R, right coronary aortic sinus; N, non-coronary aortic sinus.

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  Figure 3. Representative cases with and without conduction damage after transcatheter aortic valve implantation superior panels demonstrate a case with left bundle branch block after implantation of Sapien 3. The virtual basal ring plane (white-dotted line) is located inferior to the membranous septum (white star), and the valve is implanted relatively deeper to the virtual basal ring. Inferior panels demonstrate a case without conduction damage after implantation of Sapien 3. The virtual basal ring plane (white-dotted line) is located superior to the membranous septum (white star), and the valve is implanted approximately at the level of the virtual basal ring. Significant distance is noted between the inferior edge of the valve and the crest of the muscular ventricular septum, where the proximal left bundle branch ramifies from the branching portion of the bundle of His (compare to figure 2). R, right coronary aortic sinus; N, non-coronary aortic sinus.