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

Figures

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  Figure 1. Altered right-handed helical aortic flow patterns in patients with bicuspid aortic valve disease. Patients with right and non-coronary cusp fusion BAV had higher wall shear stress patterns in the ascending aorta [Reproduced with permission from the Bissell et al. (32)].

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  Figure 2. The Sievers and Schmidtke classification system for bicuspid aortic valve [Adapted from Sievers et al. (33)].

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  Figure 3. Computer Tomography Imaging of bicuspid aortic valve. (A) Sievers Type 1 Raphe-type bicuspid aortic valve (BAV) with mixed cusp fusion (left-right). (B) Large bulky cusps measuring 16.9 mm maximum diameter. (C) Asymmetric large annulus. (D) Low lying coronary ostia at 11 mm combined with large bulky leaflets indicate a risk of coronary occlusion during TAVI.

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  Figure 4. (A) Transeptal puncture and positioning of hydrophilic wire and Judkins Right in the left ventricle. (B) Anterograde crossing of the aortic valve and wire changed for exchange wire. (C) Amplatz Goose Neck Snare used to snare the exchange wire. (D) Exchange wire then externalized via the left femoral artery [Adapted with permission from the Rodríguez-Olivares et al. (75)].

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  Figure 5. MSCT imaging of bicuspid aortic valve. (A) Annulus measurement with minimum diameter of 17 mm and maximum diameter of 24 mm and area of 325 mm2. (B) Cross-sectional view taken 4 mm above the level of the annulus. The valve is a Type 0 Sievers BAV with no raphe. (C) Distance to coronary ostia >10 mm. (D) The distance from the aortic annulus to the mitral valve ring measures 10.1 mm acceptable for TAVI implantation.

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  Figure 6. Implantation of SAPIEN 3 in patient with bicuspid aortic valve with previous mitral valve replacement. (A) Aortogram for root alignment with pigtail catheter in the right coronary cusp. (B) Balloon sizing with 20 mm balloon touching hinge points with simultaneous aortogram showing filling of coronary arteries. (C) Successful deployment of 23 mm SAPIEN 3 valve with no paravalvular leakage.

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  Figure 7. MSCT imaging of the aortic annulus post TAVI implantation with 23 mm Edwards Sapien Valve. (A) shows circular deployment of the transcatheter heart valve. (B) Left ventricular outflow tract view showing bi-leaflet mitral valve prosthesis and TAVI valve post deployment. (C) Volume rendered imaging confirming there is no interaction between the base of the TAVI valve and mitral valve prosthesis.

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  Figure 8. Transcatheter aortic valve replacement in bicuspid aortic valve. (A) Sievers Type 1 bicuspid valve with partial raphe between the right and left cusps. Large annulus with perimeter measuring 98.1 mm and an intercommisural distance of 28.9 mm. (B) “Hockey puck” view of the bicuspid valve shows partial raphe between left and cusps. (C) Balloon valvuloplasty with 25 mm balloon for sizing prior to TAVI implantation. Yellow arrow shows leak of contrast into left ventricle during simultaneous aortogram indicating inadequate seal. (D) 34 mm Evolute R deployed at leaflet tips with no paravalvular leak.