Balloon Sizing-Guided Valve Selection for Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve

Figures

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  Visual Summary. Flowchart of the Balloon Sizing Strategy for Valve Selection for Transcatheter Aortic Valve Replacement in a Bicuspid Aortic Valve Valve size selection for transcatheter aortic valve replacement using a balloon-expandable valve (BEV) in a type 1 bicuspid aortic valve with a tapered configuration, where the choice between valve size X and X + 1 was considered. X and X + 1 represent 2 consecutive valve sizes considered based on multidetector computed tomography findings (eg, X = 20 mm and X + 1 = 23 mm). LV = left ventricle.

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  Figure 1. Short-Axis Views of Each Level of the Aortic Valve Complex and Measurements of Case 1 in Multidetector Computed Tomography (A) Sinotubular junction (STJ) level. (B) Level slightly below the STJ. This case involves a single coronary artery anomaly. The yellow arrow indicates the ostium of the coronary artery originating from the left coronary cusp. (C) Level 4 mm above the annulus. The intercommissural distance (ICD) is 23.4 mm (yellow double arrow). (D) The annular level. A type 1 bicuspid aortic valve with right-noncoronary cusp fusion and calcification of the raphe and leaflets is observed. The mean annulus perimeter-derived diameter is 24.8 mm, indicating a tapered configuration. (E) Left ventricular outflow tract (LVOT) level. Calcification extends from the annulus into the LVOT. (F) Each measurement of the aortic valve complex in multidetector computed tomography.

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  Figure 2. Intraoperative Angiography Findings of Case 1 (A) In the coplanar view, a 22-mm balloon shows residual indentation (yellow arrows) during predilatation. (B) Aortography during predilatation reveals no contrast backflow into the left ventricle. (C and D) Final angiography demonstrates inadequate expansion of a 26-mm valve.

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  Figure 3. Postoperative Multidetector Computed Tomography Short-Axis Views of Each Level of the Implanted 26-mm Valve in Case 1 (A) At the level of the inflow edge of the valve, the valve is completely apposed to the left ventricular outflow tract. (B) The midportion of the valve is insufficiently expanded and has a diameter of 21.3 mm (yellow double arrow) compared with the native annular diameter of 24.8 mm. (C) At the level of the outflow edge of the valve, the valve is perfectly apposed to the sinotubular junction. THV = transcatheter heart valve.

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  Figure 4. Short-Axis Views of Each Level of the Aortic Valve Complex and Measurements of Case 2 in Multidetector Computed Tomography (A) Sinotubular junction level (STJ). (B) The level slightly below the STJ. The yellow arrow indicates the ostium of the left coronary artery. (C) Level 4 mm above the annulus. The intercommissural distance (ICD) is 21.8 mm (yellow double arrow). (D) Annular level. A type 1 bicuspid aortic valve with right-left coronary cusp fusion and calcification of the raphe and leaflets is observed. The mean annulus perimeter-derived diameter is 22.6 mm, indicating a tapered configuration. (E) The level of the left ventricular outflow tract. (F) Each measurement of the aortic valve complex in multidetector computed tomography.

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  Figure 5. Intraoperative Angiography Findings of Case 2 (A) In the coplanar view, an 18-mm balloon shows residual indentation (yellow arrows) during predilatation. (B) Aortography during predilatation reveals little contrast backflow into the left ventricle. (C and D) Final angiography demonstrates adequate expansion of a 20-mm valve without complications such as aortic rupture.

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  Figure 6. Postoperative Multidetector Computed Tomography Short-Axis Views of Each Level of the Implanted 20-mm Valve in Case 2 (A) The level of the inflow edge of the valve. (B) The midportion of the valve. The valve is sufficiently expanded and has a diameter of 21.0 mm (yellow double arrow) compared with the native annular diameter of 22.6 mm. (C) The level of the outflow edge of the valve. The entire valve is apposed to the native aortic valve complex. THV = transcatheter heart valve.