Sealing Behaviour in Transcatheter Bicuspid and Tricuspid Aortic Valves Replacement through Patient-Specific Computational Modeling

BACKGROUND Patient-specific computer simulation of transcatheter aortic valve replacement (TAVR) can provide unique insights in device-patient interaction. The aim of this study was to compare transcatheter aortic valve sealing behaviour in patients with bicuspid aortic valves (BAV) and tricuspid aortic valves (TAV) through patient-specific computational modeling. METHODS Patient-specific computer simulation was retrospectively performed with FEops HEARTguide for patients who underwent TAVR using the Venus A-Valve. Simulation output was compared with postprocedural computed tomography and echocardiography to validate the accuracy of the simulation. Sealing behaviour was analysed based on the predicted device-patient interaction by quantifying the distance between the transcatheter heart valve (THV) skirt and the surrounding anatomical regions. Skirt malapposition was defined by a distance larger than 1mm. RESULTS In total, 43 patients were included in the study. Predicted and observed THV frame deformation showed good correlation (R 2 ≥ 0.90) for all analysed measurements (maximum diameter, minimum diameter, area and perimeter). The amount of predicted THV skirt malapposition was strongly linked with the echocardiographic grading of paravalvular leakage (PVL). More THV skirt malapposition was observed for BAV cases when compared to TAV cases (22.7% vs 15.5%, p < 0.05). A detailed analysis of skirt malapposition showed a higher degree of malapposition in the interleaflet triangles section for BAV cases as compared to TAV patients (11.1% vs 5.8%, p < 0.05). CONCLUSIONS Patient-specific computer simulation of TAVR can accurately predict the behaviour of the self-expanding Venus A-Valve. BAV patients are associated with more malapposition of the THV skirt as compared to TAV patients, and this is mainly driven by more malapposition in the interleaflet triangle region. Key messages What is already known on this subject? Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) is becoming increasingly important due to expanding indications towards younger patients, as well as to geographic growth of the therapy. Patient-specific computational modeling of TAVR based on pre-procedural computed tomography (CT) has emerged as a promising technology capable of accurately predicting device-anatomy interaction, as well as paravalvular leakage and the risk on TAVR-induced conduction abnormalities for both tricuspid aortic valve (TAV) and BAV patients. What might this study add? BAV patients are associated with more malapposition of the transcatheter heart valve (THV) skirt as compared to TAV patients, and this is mainly driven by more malapposition in the interleaflet triangle region. More cases and studies are needed to confirm the results and related malapposition of the THV skirt to clinical echo-based paravalvular leakage grading. How might this impact on clinical practice? Patient-specific computational modeling of TAVR based on pre-procedural CT might be performed in BAV patients. Transcatheter heart valve size and ideal implanted depth could be recommended to reduce the malapposition and potential paravalvular leakage.