Department of Cardiology - University Campus BioMedico of Rome, Italy.
Department of Cardiac Surgery - University Campus BioMedico of Rome, Italy.
Surg Technol Int. 2021 Nov 8;39:303-307. doi: 10.52198/21.STI.39.CV1468.
Bicuspid aortic valve (BAV) disease is the most common congenital abnormality and is characterized by a risk of premature aortic valve disease, predominantly aortic stenosis. Surgery remains the treatment of choice for patients with symptomatic BAV disease, but, in patients who are unsuitable for surgical aortic valve replacement, transcatheter aortic valve replacement (TAVR) is currently used as an alternative to surgery, although there is no official recommendation for their management, since BAV patients with severe aortic stenosis have been excluded from the major TAVR randomized clinical trials. Patients with BAV stenosis present anatomic challenges for treatment with TAVR. The BAV annulus often has an elliptical shape and is larger than the tricuspid valve, and is more likely to exhibit severe eccentric calcification. In addition, BAV is often associated with a dilated, horizontal ascending aorta, and effaced sinuses. The calcified raphe may also place differential stress on the expansion of the transcatheter valve, increasing the risk of suboptimal positioning and consequently the risk of paravalvular leakage, new pacemaker implantation, new-onset left bundle branch block, and annular rupture. Moreover, coronary obstruction may occur when leaflet fusion results in a longer leaflet. Although some of these challenges have been successfully overcome using new-generation devices, the complication rate is still relatively high and requires a deeper understanding of the patient's specific complex and variable anatomy. Selection of the type and size of the transcatheter valve according to the patient's individual anatomy is critical to achieving successful results. Therefore, given the increasing frequency of BAV stenosis in younger patients, and the worldwide expansion in the application of TAVR in younger and lower surgical-risk patients, preprocedural multimodality imaging involving CT scan and three-dimensional echocardiography is mandatory to understand the complex and variable anatomy of BAV disease and improve both procedural results and short- and long-term outcomes in these patients.
二叶式主动脉瓣（BAV）疾病是最常见的先天性异常，其特征是主动脉瓣疾病（主要是主动脉瓣狭窄）的发病风险增加。对于有症状的 BAV 疾病患者，手术仍然是治疗的首选，但对于不适合手术主动脉瓣置换的患者，经导管主动脉瓣置换（TAVR）目前被用作手术的替代方法，尽管对于其管理尚无官方建议，因为重度主动脉瓣狭窄的 BAV 患者已被排除在主要的 TAVR 随机临床试验之外。BAV 狭窄患者的 TAVR 治疗存在解剖学挑战。BAV 瓣环通常呈椭圆形，且大于三尖瓣，并且更可能出现严重偏心钙化。此外，BAV 常伴有扩张的水平升主动脉和窦腔变平。钙化嵴也可能对经导管瓣膜的扩张产生不同的压力，增加定位不佳的风险，从而增加瓣周漏、新起搏器植入、新发左束支传导阻滞和瓣环破裂的风险。此外，当瓣叶融合导致瓣叶变长时，可能会发生冠状动脉阻塞。虽然使用新一代器械成功克服了其中的一些挑战，但并发症发生率仍然相对较高，需要更深入地了解患者特定的复杂和多变的解剖结构。根据患者的个体解剖结构选择合适的经导管瓣膜类型和尺寸对于获得成功的结果至关重要。因此，鉴于年轻患者中 BAV 狭窄的频率增加，以及全球范围内在年轻和低手术风险患者中应用 TAVR 的扩展，术前多模态成像（包括 CT 扫描和三维超声心动图）是必要的，以了解 BAV 疾病的复杂和多变的解剖结构，并改善这些患者的手术结果和短期及长期预后。
