Raphe-Type Bicuspid Aortic Valve as a Risk Factor for Transcatheter Aortic Valve Replacement Failure: Improving Outcomes Using the LIRA Method and the Medtronic FX Prosthesis

Figures

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  Figure 5. Angiographic view of a Corevalve Evolut R with “K” shape at deployment and its post-dilatation sequence. (A) Under-expanded Corevalve Evolut R in the presence of leaflet calcification, causing a waist in its inflow portion (red arrow) with a K-shaped appearance at implantation (red circle, magnified view); (B) optimal final result after post-dilatation; (C–F) safe post-dilatation sequence.

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  Figure 6. Angiographic view of a Corevalve Evolut R with “V” shape at deployment and its post-dilatation sequence during a valve-in-valve procedure. Corevalve Evolut R with a V shape at implantation (A) and after post-dilatation (B), before post-dilatation (C), the virtual basal ring (green dotted line) is located at a higher level compared to the inflow portion of the prosthesis (red dotted line); while after post-dilatation (D), upward movement of the prosthesis is observed, with an inversion of the relationship between the VBR (green dotted line) and the inflow portion of the prosthesis (red dotted line), which is displaced upwards; post-dilatation sequence (E–H) shows the upward displacement of the prosthesis, as evidenced by the movement of the proximal balloon marker (red circle) away from the reference point represented by the sternal tie (yellow dashed line).

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  Figure 7. Angiographic view of a Corevalve Evolut R with “Bench” shape at deployment and its post-dilatation sequence in TAV anatomy. Corevalve Evolut R with a Bench shape (A) at deployment due to deep implantation; suboptimal post-dilatation result (B), retaining the same configuration; ineffective post-dilatation sequence (C–G) showing the recoil of the prosthesis and restoration of the Bench shape.

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  Figure 1. Illustration of the application of the LIRA sizing method. The upper central panel reveals the LIRA plane. It is identified as the supra-annular plane that cuts the raphe at its maximum protrusion along the aortic root, where THV anchoring, and sealing are expected to occur during deployment (yellow dotted line in the sagittal view). Notably, this supra-annular plane is not arbitrarily located at a fixed distance above the VBR, as its location differs in each patient according to the level of the raphe. The yellow circle underlines the presence of a calcific raphe between the right and the left cusp. On the left (in the upper panel) in red, the intercommissural distance at the level of the LIRA plane is displayed. Notably, ICD is not measurable at 4 mm (mid panel on the left). The green circle in the lower panel represents the perimeter at VBR. The LIRA sizing method is based on the measurement of the perimeter at the level of the LIRA plane tracing the internal border of the leaflets (yellow continued line). This perimeter predicts the perimeter that will be occupied by the THV after the implantation.

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  Figure 2. Angiographic view: comparison of initial and final position during deployment phase. Patient with type-1 BAV anatomy assessed by CT scan and implanted with a 34 mm Corevalve Evolut FX valve (A). The implantation height was determined using the cusp-overlap projection (B), and the deployment proceeded in a LAO view, ensuring the elimination of prosthesis parallax (B–D). It is important to note that the prosthesis maintains a consistent depth and orientation throughout all deployment phases, as illustrated by the yellow dotted line.

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  Figure 3. Comparison of prosthesis anchoring in tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV). (Panel A): Post-TAVR CT scan of a 34 mm CoreValve Evolut R in a patient with tricuspid aortic valve. The long-axis view (A1) shows adequate expansion of the prosthesis, which appears circular in all planes displayed in the short-axis views: at the VBR (A2), where anchoring occurs through a 360-degree interaction between the prosthesis and the aortic annulus; at sinus plane (A3); at coaptation leaflet plane (A4). (Panel B): Post-TAVR CT scan of a 26 mm Corevalve Evolut R in patient with a bicuspid aortic valve. The long-axis view (B1) reveals that the prosthesis does not fully interact with the LVOT (white star) but instead anchors at the raphe. This observation is confirmed in the short-axis views, where the prosthesis only partially adheres to the VBR (B2), while it anchors at the level of the raphe and is moved towards the opposite commissure (B3). In both B2,B3 short-axis views, the prosthesis has an elliptical shape; however, at the coaptation leaflet plane (B4), it gains a proper circularity, not hampering prosthesis’ performance.

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  Figure 4. Various configurations of prosthesis’ shape at deployment. The implantation depth influences the extent of deformation of the inflow portion (light blue area in the first row: A,C,E) of the prosthesis, resulting in three different configurations: K shape (A,B): the deformation of the landing zone shows a K-shaped neck (A). The green arrows (B) indicate the two opposite and balanced forces (downward toward the LVOT and upward toward the ascending aorta) that ensure the stability of the prosthesis. These forces are generated by the interaction (black arrows) between the prosthetic stent and the aortic valvar complex. V shape (C,D): the deformation of the landing zone shows a V-shaped appearance (C), with the prosthetic diameter being smaller at the level of the prosthetic inflow. In this case (D), the prosthesis is implanted too high, and the VBR (black arrows) generates forces directed mainly upwards (red arrows), increasing the risk of embolization in case of post-dilatation. Bench shape (E,F): the landing zone does not show significant deformations (E), and it is entirely within the left ventricle, creating a direct communication (red arrows) between the prosthetic outflow and…

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  Figure 8. CT and Angiographic view of a Corevalve Evolut FX with a “K” shape at deployment and its post-dilatation sequence in BAV anatomy. Long-axis and short-axis CT scans show a raphe-type BAV where green arrow indicates VBR plane and yellow arrow indicates the LIRA plane (A); angiographic view of a Corevalve Evolut FX with two prevalent points of constraints corresponding to VBR plane (green arrow) and LIRA plane (yellow arrow) before pre-dilatation (B) and after post-dilatation (C); effective post-dilatation sequence (D–G) of a highly constrained prosthesis with persistence of the waist and the K shape (red circle).