A Practical Adjunct for Resolving Valve Sizing Ambiguity in Bicuspid Aortic Valves During Balloon-Expandable TAVR

Q: What is the clinical evidence from this study?

Study design: Editorial. Population: Severe aortic stenosis and type 1 bicuspid aortic valve (n=2). Intervention: Intraprocedural balloon predilatation with contrast injection. Primary outcome: Optimal transcatheter heart valve sizing and expansion.

Q: What does this research mean for the field?

Intraprocedural predilatation with an undersized balloon and contrast injection provides functional feedback that resolves borderline valve sizing ambiguity in bicuspid aortic valve TAVR, where persistent indentation without regurgitation favors selecting the smaller valve size. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Alvin H Y Ko; Angus Shing Fung Chui

doi:10.1016/j.jaccas.2026.109294

August 1, 2026JACC Case ReportsOpen Access

A Practical Adjunct for Resolving Valve Sizing Ambiguity in Bicuspid Aortic Valves During Balloon-Expandable TAVR

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Key result

Balloon predilatation with contrast injection guides optimal transcatheter valve sizing in borderline bicuspid anatomy.

n=2

Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND

Why the study?

Optimal transcatheter heart valve sizing in bicuspid aortic valve anatomy remains challenging due to complex anatomy and borderline measurements despite advanced MDCT imaging.

Key Points

Determine whether intraprocedural undersized balloon predilatation with contrast injection resolves borderline transcatheter heart valve sizing ambiguity in complex bicuspid aortic valve anatomy.
Evaluated 2 patients (N=2) presenting with severe aortic stenosis, tapered type 1 bicuspid aortic valve anatomy, and borderline sizing between consecutive balloon-expandable valve sizes on multidetector computed tomography.
Performed predilatation using a semicompliant balloon 1 size smaller than the smaller candidate valve (22-mm balloon for 23/26-mm dilemma; 18-mm balloon for 20/23-mm dilemma) under angiographic guidance with contrast injection.
In Case 1, despite residual balloon waist indentation without contrast backflow, selection of the larger 26-mm valve resulted in midportion prosthesis underexpansion (21.3-mm diameter) despite postdilatation.
In Case 2, identical balloon indentation without contrast backflow prompted selection of the smaller 20-mm valve, resulting in complete apposition and optimal expansion without paravalvular leak or annular rupture.

PICO

P

Population

2 patients with severe aortic stenosis and type 1 bicuspid aortic valve of tapered morphology and heavy calcification with borderline sizing on multidetector computed tomography.

I

Intervention / Comparator

Intraprocedural balloon predilatation with contrast injection

O

Primary Outcome

Optimal transcatheter heart valve sizing and expansion

Limitations

Small case series (n = 2), meaning the proposed algorithm is hypothesis-generating
Requires validation in larger cohorts with longer term follow-up to assess durability, PVL rates, and hemodynamics
Generalizability to other BAV subtypes, self-expanding valves, or less calcified anatomies remains uncertain
Balloon predilatation carries a small risk of acute aortic regurgitation or hemodynamic instability

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Implication

Should not yet change bicuspid valve sizing practice; leaves open whether intraprocedural balloon testing refines borderline CT decisions.

Abstract

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Discussion

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Cite This Study

Ko et al. (2026) conducted an editorial in Severe aortic stenosis and type 1 bicuspid aortic valve (n=2). Intraprocedural balloon predilatation with contrast injection was evaluated on Optimal transcatheter heart valve sizing and expansion. Intraprocedural balloon predilatation with contrast injection successfully guided optimal balloon-expandable valve sizing when CT measurements were borderline in complex bicuspid aortic valves.

synapsesocial.com/papers/6ad0fcc53afa093ea9acff8d https://doi.org/10.1016/j.jaccas.2026.109294

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A Practical Adjunct for Resolving Valve Sizing Ambiguity in Bicuspid Aortic Valves During Balloon-Expandable TAVR

Key Points

PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

A Practical Adjunct for Resolving Valve Sizing Ambiguity in Bicuspid Aortic Valves During Balloon-Expandable TAVR

Key Points

PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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