CT Imaging Prior to TAVR in Bicuspid Aortic Valve Stenosis May Help Stratify Risk of Complications

Patients who had cardiac computed tomography (CT) prior to intervention had favorable outcomes with transcatheter aortic valve implantation (TAVI) for treatment of bicuspid aortic valve aortic stenosis, according to research published in JACC: Cardiovascular Imaging.

Hasan Jilaihawi, MD, of Cedars-Sinai Heart Institute in Los Angeles, and colleagues sought to evaluate TAVI in bicuspid aortic valve aortic stenosis, particularly focusing on TAVI-directed bicuspid aortic valve imaging morphological classification. As the researchers explained, “bicuspid aortic valve disease is the commonest congenital cardiac abnormality in humans and is a significant risk factor for premature aortic valve disease, most commonly aortic stenosis.” They hypothesized that imaging prior to TAVI would identify morphological subtypes and therefore stratify risk of complications.

Dr Jilaihawi and colleagues studied 130 consecutive patients (total number of TAVI cases=5130) with severe native aortic stenosis, along with their bicuspid aortic valve leaflet morphology. Patients were gathered from 14 centers in Canada, China, France, Hong Kong, Italy, Germany, and the United States. SAPIEN, SAPIEN XT, and SAPIEN 3 (Edwards Lifesciences) and Corevalve (Medtronic, Inc.) were among the devices implanted.

Acute procedural, peri-procedural, and 30-day outcomes were reported on the basis of VARC-2 (Valve Academic Research Consortium) criteria. Prior to discharge, transthoracic echocardiography was used to determine paravalvular aortic regurgitation and central aortic regurgitation.

In terms of morphological subtypes, bicommissural vs tricommissural bicuspid aortic valve aortic stenosis occurred in 68.9% of patients treated in North America, 88.9% in Europe, and 95.5% in Asia (P=.003). In bicommissural bicuspids, non-raphe type bicuspid aortic valve aortic stenosis occurred in 11.9% of patients in North America, 9.4% in Europe, and 61.9% in Asia (P<.001), vs raphe-type

Overall mortality rates and cerebrovascular events were favorable and similar between subsets (3.8% and 3.2%, respectively). The rate for new permanent pacemaker was high (26.2%) and occurred more often with coronary cusp fusion. However, there was a significantly higher post-dilatation with self-expanding prostheses vs balloon-expandable prostheses (28.8% vs 10.1%; P=.011). That being said, there were no significant differences in end points, including 30-day mortality (2.9% vs 5.0%, respectively; P=.66) and new permanent pacemaker implantation (25.5% vs 26.9%, respectively; P=.83).

Paravalvular aortic regurgitation that was at least moderate in 18.1% overall, but lower in patients with pre-procedural CT (11.5%). It could be predicted by intercommissural distance for bicommissural bicuspids (odds ratio [OR]: 1.37; 95% confidence interval [CI]: 1.02-1.84; P=.036) and a lack of baseline CT for annular measurement (OR: 3.03; 95% CI: 1.20-7.69; P=.018).

In tri-leaflet aortic valve disease, the need for new permanent pacemaker has varied among different devices (3.4% with SAPIEN 3 and 22.2% with Corevalve, for example), but these ranges were not seen in bicuspid aortic valve disease. Instead, the rates were consistently high.

Given the relatively favorable clinical outcomes and complication rates, the authors recommended that “CT-guide assessment should be an integral part of procedural planning, but is especially important given the heterogeneity of BAV [bicuspid aortic valve] morphological phenotypes that has significant potential to influence outcome.”

Disclosures: Dr Jilaihawi is a consultant to Edwards Lifesciences, St Jude Medical, and Venus Medtech. Dr Makkar has received grants from Edwards Lifesciences and personal fees from St Jude Medical and Medtronic.

Reference

Jilaihawi H, Chen M, Webb J, et al. A bicuspid aortic valve imaging classification for the transcatheter aortic valve implantation era. JACC Cardiovasc Imag. 2016. doi: 10.1016/j.jcmg.2015.12.022.