Andrzej Ochala, MD Medical University of Silesia, Katowice, Poland

Transcription

1 Andrzej Ochala, MD Medical University of Silesia, Katowice, Poland

2 Bicuspid aortic valve o Most common congenital heart disease in adults (1% - 2%) o AS is the most common complication of BAV o Patophysiology o accelerated leaflet degeneration o calcification o endothelial dysfunction o abnormal valve hemodynamics o abnormal flow in aortic root o AVR necessary in 20% - 50% patients with BAV o BAV in ca. 50% of patients undergoing isolated SAVR for AS Circulation. 2005;111: Circulation 2002;106: J Am Coll Cardiol 2010;55:

3 Bicuspid aortic valve o Most common congenital heart disease in adults (1% - 2%) o AS is the most common complication of BAV o Patophysiology o accelerated leaflet degeneration o calcification 30-45% of TAVI candidates o endothelial dysfunction o abnormal valve hemodynamics o Abnormal flow in aortic root o AVR necessary in 20% - 50% patients with BAV o BAV in ca. 50% of patients undergoing isolated SAVR for AS Circulation. 2005;111: Circulation 2002;106: J Am Coll Cardiol 2010;55:

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5 Classification - based on number of raphes Type 0 No raphe Type 1 One raphe Type 2 Two raphes Pure BAV Sievers & Schmidtke. J Thorac Cardiovasc Surg 2007; 133:

6 - based on spatial position of raphe Sievers & Schmidtke. J Thorac Cardiovasc Surg 2007; 133:

7 Hasan Jilaihawi et al, In press, JACC Imaging 7

8 62,3% Patients aged years undergoing AVR Patients aged years undergoing AVR % of patients with a BAV might have been precluded from undergoing TAVI Reported experiences derive from a very selected subset of patients. KTW (N=244) Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007;133: Roberts WC, Ko JM. Frequency of unicuspid, bicuspid and tricuspid aortic valves by decade in adults having aortic valve replacement for isolated aortic stenosis. Circulation 2005;111: Zhao, Z.G., et al., Transcatheter aortic valve implantation in bicuspid anatomy. Nat Rev Cardiol, (2): p

9 Patients with BAV have >100% larger volume of calcifications >10% annulus perimeter a higher risk of valve underexpansion a higher post procedural aortic gradient a trend toward a higher risk of PVL. compared to TAV patients. Watanabe, Y., et al., Comparison of multislice computed tomography findings between bicuspid and tricuspid aortic valves before and after transcatheter aortic valve implantation. Catheter Cardiovasc Interv, (2): p

10 1. Large annulus 2. Horizontal, dilated aorta 3. Elliptic orifice 4. High calcium burden A. Valve sizing B. Valve positioning C. Aortic dissection, progression of ascending aorta dilatation D. Paravalvular leaks E. Conduction disturbance Hope MD et al. Bicuspid aortic valve: four-dimensional MR evaluation of ascending aortic systolic flow patterns. Radiology 2010;255:

11 25 mm balloon sizing Annulus 27 x 35 mm (perimeter 96 mm) Sinus of Valsalva 44 x 51 mm ST-J 44 x 44 mm Ascending aorta 45,1 mm LVOT 24 x 34 mm LM 15,1 mm RCA 19,8 mm Medtronic CoreValve 31 11

12 Girdauskas E, Rouman M, Disha K, et al. Functional aortic root parameters and expression of aortopathy in bicuspid versus tricuspid aortic valve stenosis. J Am Coll Cardiol 2016;67:

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15 TTE: S: v max 2,5 m/s, P max 25 mmhg, P mean 12 mmhg 15

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17 TTE: S: v max 2,0 m/s, P max 15 mmhg, P mean 8 mmhg 17

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21 TTE: Pmax 38 mmhg, P mean 22 mmhg 21

22 VALVE SIZE IN A BICUSPID VALVES Avoid oversizing - risk of rapture - large self-expanding valves may have less radial force Usually it is safe to undersize Very large annuli may still be suitable for TAVI due to higher degree of calcification

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25 Significant Transaortic Gradient After Direct FlowAortic Valve Implantation. Rosa-Ana HernandezAntolin et al. CCI 86: (2015) First Explantation of Direct Flow Medical Transcatheter Valve. Scholtz et al. J Heart Valve Dis May;24(3):342-4.

26 Perlman GY, Blanke P, Dvir D, et al. Bicuspid aortic valve stenosis: favorable early outcomes with a nextgeneration transcatheter heart valve in a multicenter study. J Am Coll Cardiol Intv 2016;9:

27 Procedural Complications Complications Rate Valve embolization 0% Second valve 0% Annular rupture 0% Coronary occlusion 0% Conversion to surgery 0% Post implant gradient >20mmHg 1.9% G Perlman, Vancouver, TCT 2015

28 Factors that contribute to suboptimal TAVR outcomes inpatients with BAV are: Fused raphe with variable degrees of calcification Asymmetry of aortic valve cusps Annular eccentricity Calcification of the left ventricular outflow tract, Aortopathy and aortic root dilation that may render anchoring the THV problematic

29 Polish experience with TAVI in BAV 42 patients with bicuspid aortic valve (confirmed with MSCT) High risk: LOG ES 19,7 Prostheses: CoreValve 10 Evolut R 6 Sapien XT 6 Sapien 3 11 Lotus 9 Device success 93% Mean pressure gradient 15.6 mmhg 30d mortality: 7% 30d stroke: 5% 29

30 TAVI in BAV we should remember: o Supra-annular measurements and high implantation o Oversizing of the valve should be avoided o Rupture of the ascending aorta in patients with ascending aneurysm may occur o Balloon sizing may be better than sizing based on CT only o Patients with large annulus may still be suitable for TAVI if the valve is bicuspid o MSCT-guided assessment is a key part of procedural planning especially in intermediate and lower surgical risk groups who are younger and in whom BAV is more common

31 The Bicuspid Aoritc Valve and TAVI - Conclusions Not an exclusion for TAVI Associated aoric root dilation may argue for surgery Larger annuli may require larger THVs Finding a coplanar view and positioning may be difficult Pacemaker rates may be increased PVL rates may be increased Postprocedural gradient may be increased Second generation TAVI systems may allow for Better sealing of asymmetrical AV cusp orifice Self-adapting Sealing dress Respositioning Need for stronger clinical evidence (research cooperation) TAVI system developments to address BAV anatomy 31