Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.).
Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- European Genomic Institute for Diabetes, F-59000 Lille, France (F.V., E.VB.).
Circulation. 2021 Mar 9;143(10):1043-1061. doi: 10.1161/CIRCULATIONAHA.120.048048. Epub 2021 Mar 8.
After 15 years of successive randomized, controlled trials, indications for transcatheter aortic valve replacement (TAVR) are rapidly expanding. In the coming years, this procedure could become the first line treatment for patients with a symptomatic severe aortic stenosis and a tricuspid aortic valve anatomy. However, randomized, controlled trials have excluded bicuspid aortic valve (BAV), which is the most frequent congenital heart disease occurring in 1% to 2% of the total population and representing at least 25% of patients 80 years of age or older referred for aortic valve replacement. The use of a less invasive transcatheter therapy in this elderly population became rapidly attractive, and approximately 10% of patients currently undergoing TAVR have a BAV. The U.S. Food and Drug Administration and the "European Conformity" have approved TAVR for low-risk patients regardless of the aortic valve anatomy whereas international guidelines recommend surgical replacement in BAV populations. Given this progressive expansion of TAVR toward younger and lower-risk patients, heart teams are encountering BAV patients more frequently, while the ability of this therapy to treat such a challenging anatomy remains uncertain. This review will address the singularity of BAV anatomy and associated technical challenges for the TAVR procedure. We will examine and summarize available clinical evidence and highlight critical knowledge gaps regarding TAVR utilization in BAV patients. We will provide a comprehensive overview of the role of computed tomography scans in the diagnosis, and classification of BAV and TAVR procedure planning. Overall, we will offer an integrated framework for understanding the current role of TAVR in the treatment of bicuspid aortic stenosis and for guiding physicians in clinical decision-making.
经过 15 年连续的随机对照试验，经导管主动脉瓣置换术（TAVR）的适应证正在迅速扩大。在未来几年，该手术可能成为有症状的严重主动脉瓣狭窄和三尖瓣主动脉瓣解剖结构的患者的一线治疗方法。然而，随机对照试验排除了二叶式主动脉瓣（BAV），BAV 是最常见的先天性心脏病，在总人口中发生率为 1%至 2%，在 80 岁或以上接受主动脉瓣置换的患者中至少占 25%。在老年人群中使用这种微创经导管治疗方法变得非常有吸引力，目前约有 10%接受 TAVR 的患者存在 BAV。美国食品和药物管理局和“欧洲合格评定”已经批准 TAVR 用于低危患者，无论主动脉瓣解剖结构如何，而国际指南建议在 BAV 人群中进行手术置换。鉴于 TAVR 向年轻和低危患者的不断扩展，心脏团队越来越多地遇到 BAV 患者，而这种治疗方法对这种具有挑战性的解剖结构的疗效仍不确定。这篇综述将讨论 BAV 解剖结构的独特性以及 TAVR 手术相关的技术挑战。我们将检查和总结现有的临床证据，并强调关于 TAVR 在 BAV 患者中应用的关键知识空白。我们将全面概述计算机断层扫描在 BAV 诊断和分类以及 TAVR 手术规划中的作用。总的来说，我们将提供一个综合框架，用于理解 TAVR 在治疗二叶式主动脉瓣狭窄中的当前作用，并指导医生进行临床决策。
