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The Surgical Experience of Transcatheter Aortic Valve Replacement for Bicuspid Aortic Valve
Kizuku Yamashita, Yusuke Shimahara, Tomoyuki Fujita, Hiroki Hata, Yuta Kume, Yorihiko Matsumoto, Junjiro Kobayashi.
National Cerebral and Cardiovascular Center, Suita city, Japan.

OBJECTIVE: Bicuspid aortic valve (BAV) remains challenging structural valve disease of transcatheter aortic valve replacement (TAVR). The aims of this study were the efficacy and safety of TAVR in patients with severe aortic stenosis described as BAV.
METHODS: Between October 2013 and December 2015, consecutive 104 patients underwent TAVR for severe aortic stenosis (AS) in our institute. Of those, BAV was diagnosed based on transesophageal echocardiography (TEE) and multidetector computed tomography (MDCT) in 4 patients (3.9%, median 85.4 years-old (range; 69.0-88.5), 3 females). TAVR with balloon-expandable prosthetic valve was performed in each patient. Society of Thoracic Surgeons Predicted Risk of Mortality (STS) were median 5.5 % (range; 2.7-5.9). We examined clinical outcomes and intra- and postoperative complications.
RESULTS: The median aortic annulus diameter was 25.8 (range; 23.1-28.1) x 20.1 (range; 16.2-21.5) mm and median aortic valve area was 448 (range; 404-465) mm2 detected by preoperative MDCT during end-systolic phase. Each BAV had a raphe between right and left coronary cusp in 3 patients and non- and left coronary cusp in one patient. Transaortic approach and transfemoral approach were performed in one patient and 3 patients, respectively. Annulus rupture occurred in one patient who had a bulcky calcification of the raphe and cured by immediate subxiphoid pericardial drainage. The patient required permanent pacemaker implantation after TAVR. Stroke of the cerebellum occurred in another patient. Although the postoperative rehabilitation was required, neurologic symptoms were improved. There were no other major complications and conversions to surgical aortic valve replacement. TAVR except annulus rupture case accomplished without blood transfusion. The median operation time were 2.4 hours (range; 1.8-2.7), intensive care unit stay were median 2.5 days (range; 1-6). Postoperative paravalvular leak were less than mild in all patients and severe aortic stenosis disappeared by transthoracic echocardiography follow-up. There were no rehospitalizations due to cardiac events including heart failure and no early or late mortality.
CONCLUSIONS: TAVR for BAV is feasible in selected patients with low to intermediate STS score. Understanding of the aortic valve anatomy and preparation for major adverse complications such as annulus rupture or valve malposition are crucial to achieve successful outcomes.

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