CT Imaging of Bicuspid Aortic Valve Disease:
Anatomic patterns favorable and unfavorable for TAVR
and factors influencing device selection
Antonios Chalapas, MD, PhD, FESC
THV & Hygeia Hospital Heart Team
Athens, Greece
Disclosures
I and the HYGEIA Hospital «Heart Team» have received research and travel grants from:
Medtronic, St Jude, Europe, ABBOTT Vascular, Europe
HYGEIA Hospital Heart Team
Cardiologists: A Chalapas, M Chrissoheris, K Papadopoulos, P Kourkoveli, K Spargias
Congenital cardiologist: A. Tzifa
CT Surgeons: N Boumboulis, S Skardoutsos, A Tsolakis, S Pattakos, G Pattakos
Anesthesiologist: I Nikolaou, C. Nastoulis
Vascular Surgeons: I Bellos, S Kaliafas
Radiologists: C Mourmouris, F Laspas
Bicuspid Aortic Valve Incidence Rate
BAV occurring in
15-20% of the TAVR population
not a very rare situation in TAVR population
TAVR in younger population
Bicuspid Aortic Valve Incidence Rate
BAV is the most common congenital valvular abnormality occurring in 1-2% of the general population
Male predominance 3:1
Approximately 10% of 1st-degree relatives have the disorder
Incidence rate is higher in younger patients
Bicuspid Aortic Valve Disease and TAVR
Types of BAV
Morphological heterogeneity
Sievers and Schmidtke Classification
depending on the # of raphes
spatial position of raphes and functional status of the valve
Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg. 2007 May;133(5):1226-33.
Circ Cardiovasc Interv. 2019;12:e007107.
Leaflets distribution in the bicuspid cohort
Sizing for TAVR in BAV remains controversial
The aim of the BAVARD (Bicuspid Aortic Valve Anatomy and Relationship With Devices) retrospective multicenter registry is to capture the sizing ratios used for TAVI in BAV and
analyze the 2nd-generation prostheses geometry pos-timplantation.
Circ Cardiovasc Interv. 2019;12:e007107.
Leaflets distribution in the bicuspid cohort
Sizing for TAVR in BAV remains controversial
The aim of the BAVARD (Bicuspid Aortic Valve Anatomy and Relationship With Devices) retrospective multicenter registry is to capture the sizing ratios used for TAVI in BAV and
analyze the 2nd-generation prostheses geometry pos-timplantation.
Representative images of BAV cases
that missed by echocardiography
25-50% of TTE have
non-diagnostic findings
for BAV morphology
due to
severe valvular calcification
type 1 L-R
type 1 L-R
Circ Cardiovasc Interv. 2013;6:284-291
Diagnostic Value of Cardiac CT in Evaluation of BAV
Key Features of BAV Stenosis Patients to be Evaluated for TAVR
ECG-gated cardiac CT
is pivotal for
the accurate morphologic
assessment of BAV stenosis
based on the large variability in BAV
configurations
Circ Cardiovasc Imaging. 2017;10:e005987
Proposed TAVR-Specific BAV Classificationheterogeneity of BAV morphological phenotypes
A. Leaflet morphology is classified on the basis of number of commissures
B. Leaflet orientation is classified on the basis of cusp fusion
A
B
J Am Coll Cardiol Img 2016;9:1145–58
Bicommissural raphe type Bicommissural non raphe typeTricommissural raphe type
Coronary cusp fusion
Coronary cusp fusion
Coronary cusp fusion
Mixed cusp fusion
Mixed cusp fusion
Mixed cusp fusion
Functional” or “acquired” BAV True BAV
23%
56%
21%
Most commonly, the R and L raphe fuse, and the NC sinus is larger than the other sinuses, providing challenges to THV sizing
The aim of the BAVARD (Bicuspid Aortic Valve Anatomy and Relationship With Devices) retrospective multicenter registry is to capture the sizing ratios used for TAVI in BAV and
analyze the 2nd-generation prostheses geometry pos-timplantation.
Circ Cardiovasc Interv. 2019;12:e007107.
TAV BAV
Baseline MDCT analysis
BAV group is characterized by:
• Larger annulus and ascending aorta
• Higher coronaries ostium
• Significantly higher calcium volume
• Ellipticity index was not significantly different
14 centers in the US, Canada, Europe, and Asia, 130 BAV-AS patients underwent TAVR.
Baseline cardiac CT was analyzed by a dedicated Corelab. Outcomes were assessed in line with VARC criteria.
CT Evaluation of BAV Morphology
JACC Img 2016;9:1145–58
Prognostic Implications of Raphe in BAV Anatomy
Association Between Raphe and Significant Valve Dysfunction
JAMA Cardiol. 2017;2(3):285-292
International multicenter registry of 2118 patients with BAVsBw 1991 - 2015
The frequency of significant AR was slightly higher
among pts with BAV with 2 raphes but
evenly distributed among pts with 1 raphe
Significant AS was significantly
higher among pts with BAV with 2 raphes
followed by pts with R-NC cusp fusion
JAMA Cardiol. 2017;2(3):285-292
The presence of a raphe
is associated with increased
rates of all-cause mortality
International multicenter registry of 2118 patients with BAVs
Bw 1991 - 2015
Prognostic Implications of Raphe in BAV Anatomy
Association Between Raphe
and Aortic Dilation and Dissection
JAMA Cardiol. 2017;2(3):285-292
The presence of a raphe
was NOT associated
with the pattern of AORTIC DILATATION
International multicenter registry of 2118 patients with BAVsBw 1991 - 2015
BAV associated Aortopathy
phenotypes
Normal aorta Dilated aortic root Dilated the entire
ascending aorta
and the transverse
aortic arch
Dilated the tubular portion
of the ascending aorta
JAMA Cardiol. 2017;2(3):285-292
38.9%
35-40%
32.4%
28.7%
Difference bw TAV and BAV
Review of 17 studies (series and case report)
Nature Reviews-Cardiology. 2014
BAV and Horizontal aorta
Horizontal aorta is defined as an angle of <30° between the plane perpendicular to the aortic annulus plane and a horizontal reference line
May complicate with
an accurate positioning
of the prosthesis during TAVR,
particularly when using
a self-expanding valve
Porcelain aorta is
more frequent in horizontal aortas
The presence of significant calcifications of the
ascending aorta limits the capability to control
the tension on the delivery catheter during the
device release and may lead to implantation
failure
Aortic Angulation
Attenuates Procedural Success
following Self-Expandable But Not Balloon-Expandable TAVR
J Am Coll Cardiol Img 2016;9:964–72
Angle >70 is an exclusion criteria for clinical trials with SE valves
Type 1 BAV with L-R fusion and calcified fusion
Dilated horizontal aorta
77yo male, NYHA III-IV, LVEF 40%, CABG x3, STS 4.6%, Euroscore I 30%
Horizontal aorta Type 1 BAV
33x28mm
Balloon Valvuloplasty
Nucleus 22x40mm (nominal) x1
VT successfully treated with CV (200J)
Deployment of a Core Valve 31mm
Aortography post CV 31mm Deployment
Moderate to severe PVL
Low implantation
Severe AI due to TVL and PVL
Post dilation
Nucleus 28x40mm (x1)
Final Aortography post Balloon Valvuloplasty
ViV with Core Valve 31mm
Next day
Final Aortography
Mild PVL
CT Post-TAVR in BAV
prosthesis inflow levelmid sinus of Valsalva level
Axial CT scan
Extreme eccentricity of stent frame expansion
Severe PVL
Bicommissural
raphe type
calcified raphe
Bicommissural
raphe type
Non-calcified raphe
Bicommissural
Non-raphe type
Circular expansion
Mild PAR
Mild degree of eccentric
Moderate PAR
Circ Cardiovasc Interv. 2019;12:e007107.
Outcomes in Recent Studies of TAVR in
BAV and TAV Aortic Stenosis
JACC Img 2016;9:1145–58
Circ Cardiovasc Interv. 2019;12:e007107.
Sizing for TAVR in BAV remains controversial
Balloon pre-dilatation was more frequently
carried out in TAV patients (51 vs 28%, P<0.01),
with similar rates of post-dilatation in both
groups (18 vs 20%, P=0.77).
TAVI was a more complex procedure in BAV pts
as expressed by a higher need for a 2nd valve.
No coronary obstruction was observed in TAV or
BAV patients.
Coarctation of aorta may coexist with BAV
• Incidence 35%
• May indispensably eliminate
patient from TAVI and impose
surgical intervention.
• Type 1 L-R may be connected to
aortic coarctation, which is usually
diagnosed in younger age
Current Problems in Cardiology 30 (2005) 470–522.
Type 0 BAV and Coarctation of Aorta
73 year-old female, LVEF 50%, CABG
LE 23.7%, STS mortality 3.2%
Type 0 BAV
Type 0 BAV and Coarctation of Aorta
73 year-old female, LVEF 50%, CABG
LE 23.7%, STS mortality 3.2%
Min. Ø 23.2 mmMax. Ø 30.0 mmAvg. Ø 26.6 mm
Area derived Ø 26.5 mmPerimeter derived Ø 26.9 mm
Area 552.1 mm²Perimeter 84.5 mm
< 48 oAortographyType 0 BAV
Balloon Valvuloplasty
Edwards 23x40mm (x2)
Complete sealing with the 23 Balloon
The diameter of Balloon corresponds to the
small aortic annulus dimension
No AI
Undersize - Sapien 3 26mm
Although in Type 0 BAV the data suggest
the annulus based sizing
from BAV we decided to proceed with undersizing 26
TTE post TAVR
parasternal long axis
Sizing strategies
Annulus-based sizing Sizing based on ICD
Balloon based sizing
Annulus-based sizing
Circ Cardiovasc Interv. 2019;12:e007107.
Device – annulus ratiodegree of oversizing
Sapien 3
Evolut R
Oversizing was applied in both groups,
but lesser in BAV patients
Type 1 BAV with L-R fusion and raphe calcification
Type 0 Aorta
76 year-old male, NYHA III, LVEF 55%, sternotomy due to oesophagous-ectomy
LE 7%, STS mortality 0.9%
Balloon sizing
Min. Ø 20.5 mm
Max. Ø 28.0 mm
Avg. Ø 24.4 mm
Area derived Ø 24.2 mm
Perimeter derived Ø 24.9 mm
Area 461 mm²
Perimeter 78.3 mm
Electrocardiography (ECG)-gated MDCT
Balloon Valvuloplasty
Edwards 20x40mm (nominal)
EV Initially S3
Due to BAV instability (x3)
Evolut R 29mm
1y FU
Valve Sizing for BAV
Balloon sizing
Circ Cardiovasc Interv. 2019;12:e007107.
52%52.5% 14%34%
Sizing based on ICD
Various MSCT measurements at the level of the aortic root
Device – ICD ratio
Sizing ratios utilized for different TAVI devices
in bicuspid cohort
Circ Cardiovasc Interv. 2019;12:e007107.
Sapien 3
Evolut R
No Oversizing
Valve sizing for BAV
Circ Cardiovasc Interv. 2019;12:e007107.
Geometry of THV as Assessed in Post-TAVR MDCT
In BAV pts
Prostheses were
11% smaller than
the mean annulus
diameter at baseline
Circ Cardiovasc Interv. 2019;12:e007107.
Sizing for TAVR in BAV remains controversial
The aim of the BAVARD (Bicuspid Aortic Valve Anatomy and Relationship With Devices) retrospective multicenter registry is to capture the sizing ratios used for TAVI in BAV and
analyze the 2nd-generation prostheses geometry pos-timplantation.
Circ Cardiovasc Interv. 2019;12:e007107.
Prostheses retained
the cylindrical configuration
in BAV and TAV patients
with stable diameters
from their distal edge
to 12 mm above
Post-TAVI MDCT Data
Yoon, SH. et al. J ACC. 2017;69(21):2579–89.
Outcomes of 561 pts with BAV AS and 4,546 pts with TAV AS
compared after PSM, assembling 546 pairs of pts with similar
baseline characteristics.
Procedural and clinical outcomes were recorded
according to VARC-2 criteria.
Conclusion
• BAV is characterized by anatomical heterogeneity
• MSCT sizing - Various MSCT measurements at the level of the aortic root
• Pre-dilatation is mandatory and balloon sizing often is helpful
• BAV with horizontal aorta → Balloon expandable valves
• BAV and Dilated aorta very fragile → Increased risk of Dissection
• Aim at high implantation for leaflet sealing