Bicuspid Aortic Valve Leaflet Modification Before Transcatheter Aortic Valve Replacement: A New Paradigm

Area of Science:

• Cardiovascular Surgery
• Biomedical Engineering
• Medical Imaging

Background:

• Bicuspid aortic valve (BAV) anatomy poses challenges for transcatheter aortic valve replacement (TAVR).
• Incomplete stent expansion and valve deformation are common complications in BAV TAVR.
• Pre-TAVR leaflet modification (LM) may mitigate these issues by reducing leaflet stress and improving THV deployment.

Purpose of the Study:

• To introduce a novel approach for pre-TAVR BAV leaflet modification.
• To demonstrate the feasibility of improving transcatheter heart valve (THV) geometry using this technique.
• To provide proof-of-concept for enhanced THV expansion in BAV.

Main Methods:

• Finite element simulations of self-expanding valve (SEV) deployment in 5 BAV anatomies with and without leaflet splitting.
• Ex vivo testing of SEV and balloon-expandable valve (BEV) deployment in 4 reconstructed BAV models.
• Analysis of THV opening area, ovality, expansion ratio, and eccentricity before and after leaflet modification and postdilatation.

Main Results:

• Pre-TAVR BAV splitting improved SEV/BEV THV expansion ratio (up to 33%) and eccentricity (up to 31%) in both simulation and ex vivo models.
• Compared to native BAVs, deployed THVs showed better geometry after LM.
• Dual pre-TAVR splitting in a BEV deployment model resulted in a >10% increase in THV area and a ~5% decrease in ovality compared to single splitting.

Conclusions:

• Pre-TAVR BAV leaflet modification is a promising adjunctive technique.
• This approach can significantly enhance THV expansion and circularity.
• LM may reduce complications associated with TAVR in BAV patients.