Reddy Pavan, Rodriguez-Weisson Fernando J, Medranda Giorgio A, Merdler Ilan, Cellamare Matteo, Gordon Paul, Ehsan Afshin, Parikh Puja, Bilfinger Thomas, Buchbinder Maurice, Roberts David, Hanna Nicholas, Ben-Dor Itsik, Satler Lowell F, Garcia-Garcia Hector M, Asch Federico M, Weissman Gaby, Sadeghpour Anita, Schults Christian C, Waksman Ron, Rogers Toby
Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (P.R., I.M., I.B.-D., L.F.S., H.M.G.-G., R.W., T.R.).
MedStar Health Research Institute, Washington, DC (F.J.R.-W., M.C., F.M.A., A.S.).
Circ Cardiovasc Interv. 2025 Jun;18(6):e014802. doi: 10.1161/CIRCINTERVENTIONS.124.014802. Epub 2025 Apr 22.
Patients with bicuspid aortic stenosis who receive transcatheter aortic valve replacement (TAVR) may require subsequent valve interventions in their lifetime; however, the feasibility of redo-TAVR in this population is uncertain. We aimed to assess redo-TAVR feasibility in bicuspid patients and develop a predictive virtual valve planning algorithm.
We studied computed tomography scans of bicuspid patients who received a balloon-expandable transcatheter heart valve (THV) in the LRT trial (Low Risk TAVR). Redo-TAVR feasibility, determined by valve-to-coronary and valve-to-aorta measurements on 30-day computed tomography, was assessed according to raphe location and calcification. A virtual valve planning algorithm was developed using baseline and 30-day computed tomography scans.
Among 42 patients (left/right cusp fusion: n=34; right/noncusp fusion: n=4; 2-sinus: n=4), redo-TAVR was feasible in 64%, while 36% would likely require leaflet modification to prevent coronary obstruction. Patients with left/right fusion and calcified raphe had higher redo-TAVR feasibility (88% versus 35%, <0.001) due to favorable shifting of the THV away from the coronary ostia. A bicuspid virtual planning algorithm accounting for 83.4% THV underexpansion, resulting in an 11.9% taller frame and translation of the THV away from the calcified raphe (mean valve shift 6.6 mm) achieved 86.7% sensitivity and 88.9% specificity for predicting redo-TAVR feasibility.
Calcified raphe in left/right cusp fusion shifts the THV away from the coronary ostia, reducing coronary obstruction risk during redo-TAVR. Underexpansion causing increased THV frame height and valve shifting is common in bicuspid patients; a virtual planning algorithm accounting for these aspects can accurately assess redo-TAVR risk.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02628899.
接受经导管主动脉瓣置换术（TAVR）的二叶式主动脉瓣狭窄患者在其一生中可能需要后续的瓣膜干预；然而，该人群再次TAVR的可行性尚不确定。我们旨在评估二叶式患者再次TAVR的可行性，并开发一种预测性虚拟瓣膜规划算法。
我们研究了在LRT试验（低风险TAVR）中接受球囊扩张式经导管心脏瓣膜（THV）的二叶式患者的计算机断层扫描。根据瓣叶联合线位置和钙化情况，通过30天计算机断层扫描上的瓣膜至冠状动脉和瓣膜至主动脉测量来确定再次TAVR的可行性。使用基线和30天计算机断层扫描开发了一种虚拟瓣膜规划算法。
在42例患者中（左/右瓣叶融合：n = 34；右/无瓣叶融合：n = 4；双窦：n = 4），64%的患者再次TAVR可行，而36%的患者可能需要进行瓣叶修正以防止冠状动脉阻塞。由于THV向远离冠状动脉口的方向有利移位，左/右融合且瓣叶联合线钙化的患者再次TAVR的可行性更高（88%对35%，<0.001）。一种考虑了83.4%的THV扩张不足情况的二叶式虚拟规划算法，使框架高度增加了11.9%，并使THV从钙化的瓣叶联合线移位（平均瓣膜移位6.6 mm），对预测再次TAVR可行性的敏感性达到86.7%，特异性达到88.9%。
左/右瓣叶融合中的钙化瓣叶联合线使THV向远离冠状动脉口的方向移位，降低了再次TAVR期间冠状动脉阻塞的风险。二叶式患者中，扩张不足导致THV框架高度增加和瓣膜移位很常见；考虑这些方面的虚拟规划算法可以准确评估再次TAVR风险。
