Author + information
- Abdul Hakeem, MD∗ ( and )
- Mehmet Cilingiroglu, MD
- ↵∗Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Central Arkansas VA Health System, 4301 West Markham Street, UAMS, Little Rock, Arkansas 72205
The study by Yoon et al. (1) provides the largest series to date evaluating the role of transcatheter aortic valve replacement (TAVR) in bicuspid valve morphology. The authors concluded that although there was no difference in all-cause mortality at 2 years in patients undergoing TAVR for bicuspid valve aortic stenosis compared with tricuspid valve stenosis, the incidence of periprocedural complications was significantly higher with TAVR for bicuspid morphology. This effect was no longer evident with the use of newer generation valves. Compared with tricuspid valves, stenotic bicuspid patients receiving the Sapien XT (Edwards Lifesciences, Irvine, California) had significantly higher aortic root injury, whereas patients receiving Core Valve (Medtronic, Minneapolis, Minnesota) had higher rates of procedural failure, moderate-to-severe aortic regurgitation, and the need for a second valve.
Although appropriate sizing takes on added significance with bicuspid valve on account of multiple anatomic factors including the elliptical shape of the annulus, aortopathy, and eccentricity of calcium distribution (2), the use of valvuloplasty before TAVR appears to be an important variable that seems unaccounted for in the current report. As pointed out by the editorialist, valvuloplasty before TAVR may help in accurate sizing of the valve, particularly so in bicuspid morphology; still others have raised concern about the potential hazards of pre-TAVR valvuloplasty in bicuspid morphology. Similarly, the size of the ascending aorta and baseline aortic regurgitation seem to be likely determinants of TAVR outcomes. In this context, it would be important to study the interaction between use of valvuloplasty and procedural success and outcomes between: 1) TAVR in general and valve morphology (bicuspid vs. tricuspid valve); 2) older versus newer generation valves; and 3) balloon expandable versus self-expanding valves.
Yoon et al. (1) are to be congratulated for comprehensively evaluating this important aspect of what is still considered an off-label use for TAVR.
Please note: Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation