Successful deployment of a transcatheter aortic valve in bicuspid aortic stenosis: role of imaging with multislice computed tomography.

Transcatheter aortic valve replacement (TAVR) has recently emerged as a therapeutic option for patients with severe aortic stenosis who are considered inoperable.1 To avoid potential complications related to this novel procedure (such as coronary artery obstruction or perivalvular leakage), detailed information on the aortic valve anatomy is critically important.1,2 Multislice computed tomography (MSCT) enables a comprehensive 3D assessment of aortic valve anatomy and, particularly, the extent and location of valve calcifications, one of the reasons for inappropriate deployment of the valved stent together with the bicuspid anatomy.3 After TAVR, the positioning and deployment of the valve prosthesis can be evaluated by this imaging technique. This report concerns a 54-year-old woman with symptomatic bicuspid aortic valve stenosis (aortic valve area, 0.9 cm). Comorbidity included hypertension and hypercholesterolemia. Importantly, 2 years earlier, the patient experienced a cerebrovascular accident with severe consequences that determined a high risk for cardiac surgery. Consequently, the patient was referred for TAVR. The anatomy of the aortic root and, in particular, the aortic valve and the relation between the coronary artery ostia and the aortic annulus were evaluated using 64-slice MSCT, as previously described.4 A bicuspid aortic valve was observed, with asymmetrical closure of the valve and nodular calcifications along the basis and the free edge of the noncoronary cusp and at the valve commissures (Agatston calcium score, 2103) (Figure 1). The aortic annulus size was 26 mm, whereas the dimensions of the sinus and sinotubular junction were 37 and 33 mm, respectively. The distance between the aortic annulus and the ostium of the left coronary artery was larger than the length of the coronary cusp at that level (12.3 versus 10.5 mm, respectively). Coronary angiography showed normal epicardial coronary arteries, whereas the aortoiliac angiography revealed a narrow lumen of the iliac artery (diameter, 6.7 mm). Therefore, the TAVR was performed through a transapical approach with the guidance of transesophageal echocardiography. A 26-mm Edwards-Sapien valve (Edwards Lifesciences Inc) was successfully implanted. The mean transaortic pressure gradient reduced from 65 to 10 mm Hg. No complications were observed during the procedure. After 1 month, 64-slice MSCT was repeated, demonstrating an accurate positioning (Figure 2) and a circular deployment of the transcatheter aortic valved stent (Figure 3).