A Bicuspid Aortic Valve Imaging Classification for the TAVR Era

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Transcatheter aortic valve replacement (TAVR) is increasingly used for bicuspid aortic valve (BAV) aortic stenosis (AS).
• Outcomes with TAVR in BAV-AS are variable, with ongoing questions about the impact of valve morphology.
• Standardized imaging for BAV morphology is crucial for optimizing TAVR outcomes.

Purpose of the Study:

• To evaluate the efficacy and safety of TAVR in patients with bicuspid aortic valve (BAV) aortic stenosis (AS).
• To assess the impact of BAV morphological classification, identified through imaging, on TAVR outcomes.
• To compare outcomes between different TAVR device types and BAV anatomies.

Main Methods:

• A multicenter study involving 130 patients with BAV-AS undergoing TAVR across North America, Europe, and Asia.
• Baseline cardiac computed tomography (CT) imaging was analyzed by a dedicated Corelab to classify BAV morphology.
• Outcomes were assessed according to Valve Academic Research Consortium criteria, including mortality, cerebrovascular events, and paravalvular regurgitation.

Main Results:

• Favorable 30-day mortality (3.8%) and cerebrovascular event rates (3.2%) were observed across different BAV anatomical subsets.
• High rates of new permanent pacemaker insertion (26.2%) were noted, with no significant difference between balloon-expandable and self-expanding TAVR devices.
• Paravalvular aortic regurgitation (PAR) ≥ moderate occurred in 18.1% of patients, which was lower with pre-procedural CT imaging. Intercommissural distance in bicommissural BAVs and lack of baseline CT were predictors of PAR.

Conclusions:

• TAVR demonstrates favorable clinical outcomes in BAV-AS patients, particularly when utilizing pre-procedural CT imaging for morphological assessment.
• High rates of permanent pacemaker implantation persist as a significant concern, irrespective of TAVR device type or BAV morphology.
• Pre-procedural CT is vital for accurate annular measurement and may reduce the incidence of moderate or severe paravalvular aortic regurgitation.