Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany.
Deutsches Herzzentrum München, Klinik für Herz- und Gefäßchirurgie, Technische Universität München, Munich, Germany.
Clin Res Cardiol. 2019 Jan;108(1):6-15. doi: 10.1007/s00392-018-1295-2. Epub 2018 Jun 14.
Bicuspid aortic valve (BAV) anatomy is becoming an increasingly frequently encountered challenge in transcatheter aortic valve implantation (TAVI). Bicommissural non-raphe-type BAV (Sievers and Schmidtke Type 0) is composed morphologically of two aortic cusps with no raphe and is less common than the tricommissural or bicommissural raphe-type configurations. Precise annular sizing is a key step for successful TAVI in BAV. The challenge in bicommissural non-raphe-type BAV is that a three-dimensional structure has to be reconstructed using only two anatomical hinge points. For this reason, available software are limited when it comes to bicommissural non-raphe-type BAV. We propose that manual assessment of the aortic root in bicommissural non-raphe-type BAV using multi-planar reconstruction (MPR) software can be performed successfully by aligning the two available hinge points and measuring the smallest identifiable annular dimensions in the transverse plane (Fig. 1). We identified 12 patients with bicommissural non-raphe-type BAV undergoing TAVI between January 2013 and December 2017 in our high-volume institution. Our novel sizing strategy was employed prospectively in three patients-with good clinical outcomes-and evaluated retrospectively in the remainder (Table 1). No patient suffered a central major vascular complication or required new permanent pacemaker implantation. Device success occurred in all patients except one (post-procedural echocardiographic transvalvular gradient of 23 mmHg). In the retrospectively assessed cases, the novel annulus measure was concordant with the implanted THV size in 7 out of 9 procedures and, importantly, did not overestimate the annulus dimensions in any case. Furthermore, in two balloon-expandable THV cases the new measure may, in retrospect, have prompted consideration of a smaller implant size. To be noted, balloon sizing of the aortic annulus has additional value when selecting the valve size in BAV anatomy. Further prospective validation of this novel MDCT sizing technique is required.
二叶式主动脉瓣（BAV）解剖结构在经导管主动脉瓣植入术（TAVI）中越来越频繁地遇到挑战。双对合无连合型 BAV（Sievers 和 Schmidtke 0 型）形态上由两个无连合的主动脉瓣组成，比三叶式或双对合连合型配置少见。精确的瓣环测量是 TAVI 在 BAV 中成功的关键步骤。双对合无连合型 BAV 的挑战在于，只能使用两个解剖学铰链点来重建三维结构。出于这个原因，在双对合无连合型 BAV 中可用的软件有限。我们提出，使用多平面重建（MPR）软件对双对合无连合型 BAV 的主动脉根部进行手动评估，可以通过对齐两个可用的铰链点并在横断面上测量最小可识别的瓣环尺寸来成功完成（图 1）。我们在我们的大容量机构中识别了 12 例在 2013 年 1 月至 2017 年 12 月期间接受 TAVI 的双对合无连合型 BAV 患者。我们的新尺寸策略前瞻性地应用于 3 例患者，结果良好，其余患者进行回顾性评估（表 1）。无患者发生中央大血管并发症或需要新的永久性起搏器植入。除 1 例患者（术后超声心动图跨瓣压差 23mmHg）外，所有患者均获得器械成功。在回顾性评估的病例中，新的瓣环测量值与 9 例手术中的 7 例植入的 THV 大小一致，重要的是，在任何情况下都没有高估瓣环尺寸。此外，在 2 例球囊扩张 THV 病例中，新的测量值可能会促使考虑较小的植入物尺寸。需要注意的是，在 BAV 解剖中选择瓣膜尺寸时，主动脉瓣环的球囊测量具有额外的价值。需要进一步前瞻性验证这种新的 MDCT 尺寸技术。
