Catheterization and Cardiovascular Interventions 86:E88–E98 (2015)
VALVULAR AND STRUCTURAL HEART DISEASES Original Studies Aortic Annulus and Root Characteristics in Severe Aortic Stenosis due to Bicuspid Aortic Valve and Tricuspid Aortic Valves: Implications for Transcatheter Aortic Valve Therapies Femi Philip, MD, Nadine Nadar Faza, MD, Paul Schoenhagen, MD, Milind Y. Desai, MD, E. Murat Tuzcu, MD, Lars G. Svensson, MD, and Samir R. Kapadia,* MD Background: Patients with severe aortic stenosis due to BAV are excluded from transcatheter aortic valve replacement (TAVR) due to concern for asymmetric expansion and valve dysfunction. We sought to characterize the aortic root and annulus in bicuspid aortic valve (BAV) and tricuspid aortic valves (TAV). Methods and Results: We identified patients with severe AS who underwent multi-detector computed tomographic (MDCT) imaging prior to surgical aortic valve replacement (SAVR, n 5 200) for BAV and TAVR (n 5 200) for TAV from 2010 to 2013. The presence of a BAV was confirmed on surgical and pathological review. Annulus measurements of the basal ring (short- and long-axis, area-derived diameter), coronary ostia height, sinus area (SA), sino-tubular junction area (STJ), calcification and eccentricity index (EI, 1-short axis/long axis) were made. Patients with TAV were older (78.8 years vs. 57.8 years, P 5 0.04) than those with BAV. The aortic annulus area (5.21 6 2.1 cm2 vs. 4.63 6 2.0 cm2, P 5 0.0001), sinus of Valsalva diameter (3.7 6 0.9 cm vs. 3.1 6 0.1 cm, P 5 0.001) and ascending aorta diameter (3.5 6 0.7 cm vs. 2.97 6 0.6 cm, P 5 0.001) were significantly larger with BAV. Bicuspid aortic annuli were significantly less elliptical (EI, 1.24 6 0.1 vs. 1.29 6 0.1, P 5 0.006) and more circular (39% vs. 4%, P < 0.001) compared to the TAV annulus. There was more eccentric annular calcification in BAV vs. TAV (68% vs. 32%, P < 0.001). The mean distance from the aortic annulus to the left main coronary ostium was less than the right coronary ostium. Less than 10% of the BAV annuli would not fit a currently available valved stents. Conclusion: Bicuspid aortic valves have a larger annulus size, sinus of Valsalva and ascending aorta dimensions. In addition, the BAV aortic annuli appear circular and most will fit currently available commercial valved stents. VC 2015 Wiley Periodicals, Inc. Key words: aortic valve disease; percutaneous intervention; percutaneous valve therapy; structural heart disease intervention
INTRODUCTION
Transcatheter aortic valve replacement (TAVR) for the treatment of degenerative tricuspid aortic valve (TAV) stenosis is a good therapeutic option in patients at high surgical risk. There is a paucity of data regarding patients who have not been included in the clinical trials. Bicuspid aortic valve (BAV) has been considered an exclusion criterion in most clinical trials because of the risk of uneven expansion and subsequent malfunction of the bioprosthesis [1]. Severe aortic stenosis (AS) due to bicuspid aortic valve (BAV) represents a C 2015 Wiley Periodicals, Inc. V
Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio Conflict of interest: Nothing to report. *Correspondence to: Samir R. Kapadia, MD, FACC, FAHA, Professor of Medicine, Director, Sones Cardiac Catheterization Laboratory Cleveland Clinic Cleveland, Ohio 441195. E-mail: [email protected] Received 25 August 2014; Revision accepted 14 March 2015 DOI: 10.1002/ccd.25948 Published online 24 April 2015 in Wiley Online Library (wileyonlinelibrary.com)
Aortic Annulus in Bicuspid Aortic Valve
relatively common anomaly that occurs in 0.5–2.0% of the general population and have been noted in over 50% of aortic valves that were resected during surgical aortic valve replacement [2]. However, anatomical data about the aortic root and annulus in this population are limited. In the clinical experience outside of the randomized trials, there are several reports of TAVR implantation in patients with BAV with a low complication rate and comparable safety and efficacy outcomes [3]. The purpose of this study was to characterize the aortic root and annulus in BAV and TAV to determine the anatomic feasibility of TAVR in this population. METHODS Patient Population
Four hundred consecutive patients with symptomatic severe AS due to TAV or BAV who were referred for surgical aortic valve replacement (SAVR) or TAVR from 2010 to 2013 were included in this study. Inclusion criteria consisted of TAV or BAV without moderate or significant aortic insufficiency (AR grade
VALVULAR AND STRUCTURAL HEART DISEASES Original Studies Aortic Annulus and Root Characteristics in Severe Aortic Stenosis due to Bicuspid Aortic Valve and Tricuspid Aortic Valves: Implications for Transcatheter Aortic Valve Therapies Femi Philip, MD, Nadine Nadar Faza, MD, Paul Schoenhagen, MD, Milind Y. Desai, MD, E. Murat Tuzcu, MD, Lars G. Svensson, MD, and Samir R. Kapadia,* MD Background: Patients with severe aortic stenosis due to BAV are excluded from transcatheter aortic valve replacement (TAVR) due to concern for asymmetric expansion and valve dysfunction. We sought to characterize the aortic root and annulus in bicuspid aortic valve (BAV) and tricuspid aortic valves (TAV). Methods and Results: We identified patients with severe AS who underwent multi-detector computed tomographic (MDCT) imaging prior to surgical aortic valve replacement (SAVR, n 5 200) for BAV and TAVR (n 5 200) for TAV from 2010 to 2013. The presence of a BAV was confirmed on surgical and pathological review. Annulus measurements of the basal ring (short- and long-axis, area-derived diameter), coronary ostia height, sinus area (SA), sino-tubular junction area (STJ), calcification and eccentricity index (EI, 1-short axis/long axis) were made. Patients with TAV were older (78.8 years vs. 57.8 years, P 5 0.04) than those with BAV. The aortic annulus area (5.21 6 2.1 cm2 vs. 4.63 6 2.0 cm2, P 5 0.0001), sinus of Valsalva diameter (3.7 6 0.9 cm vs. 3.1 6 0.1 cm, P 5 0.001) and ascending aorta diameter (3.5 6 0.7 cm vs. 2.97 6 0.6 cm, P 5 0.001) were significantly larger with BAV. Bicuspid aortic annuli were significantly less elliptical (EI, 1.24 6 0.1 vs. 1.29 6 0.1, P 5 0.006) and more circular (39% vs. 4%, P < 0.001) compared to the TAV annulus. There was more eccentric annular calcification in BAV vs. TAV (68% vs. 32%, P < 0.001). The mean distance from the aortic annulus to the left main coronary ostium was less than the right coronary ostium. Less than 10% of the BAV annuli would not fit a currently available valved stents. Conclusion: Bicuspid aortic valves have a larger annulus size, sinus of Valsalva and ascending aorta dimensions. In addition, the BAV aortic annuli appear circular and most will fit currently available commercial valved stents. VC 2015 Wiley Periodicals, Inc. Key words: aortic valve disease; percutaneous intervention; percutaneous valve therapy; structural heart disease intervention
INTRODUCTION
Transcatheter aortic valve replacement (TAVR) for the treatment of degenerative tricuspid aortic valve (TAV) stenosis is a good therapeutic option in patients at high surgical risk. There is a paucity of data regarding patients who have not been included in the clinical trials. Bicuspid aortic valve (BAV) has been considered an exclusion criterion in most clinical trials because of the risk of uneven expansion and subsequent malfunction of the bioprosthesis [1]. Severe aortic stenosis (AS) due to bicuspid aortic valve (BAV) represents a C 2015 Wiley Periodicals, Inc. V
Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio Conflict of interest: Nothing to report. *Correspondence to: Samir R. Kapadia, MD, FACC, FAHA, Professor of Medicine, Director, Sones Cardiac Catheterization Laboratory Cleveland Clinic Cleveland, Ohio 441195. E-mail: [email protected] Received 25 August 2014; Revision accepted 14 March 2015 DOI: 10.1002/ccd.25948 Published online 24 April 2015 in Wiley Online Library (wileyonlinelibrary.com)
Aortic Annulus in Bicuspid Aortic Valve
relatively common anomaly that occurs in 0.5–2.0% of the general population and have been noted in over 50% of aortic valves that were resected during surgical aortic valve replacement [2]. However, anatomical data about the aortic root and annulus in this population are limited. In the clinical experience outside of the randomized trials, there are several reports of TAVR implantation in patients with BAV with a low complication rate and comparable safety and efficacy outcomes [3]. The purpose of this study was to characterize the aortic root and annulus in BAV and TAV to determine the anatomic feasibility of TAVR in this population. METHODS Patient Population
Four hundred consecutive patients with symptomatic severe AS due to TAV or BAV who were referred for surgical aortic valve replacement (SAVR) or TAVR from 2010 to 2013 were included in this study. Inclusion criteria consisted of TAV or BAV without moderate or significant aortic insufficiency (AR grade
