Percutaneous transcatheter heart valve implantation in a bicuspid aortic valve.
Chiam PT, Chao VT, Tan SY, Koh TH, Lee CY, See Tho VY, Chua YL.
Journal of the American College of Cardiology Interventions 2010; 3: 559-61.
A 77-year-old man presented with increasingly symptomatic severe aortic stenosis (AS). Echocardiogram showed an aortic valve area of 0.6 cm2 and a mean pressure gradient of 57 mm Hg. It could not be ascertained conclusively if the valve was tricuspid or bicuspid due to heavy calcification (Figs. 1A and 1B). Aortic annulus was 20 mm in diameter. Left ventricular ejection fraction was 40%. At cardiac catheterization, calcified leaflets were seen but it could not be determined if the valve was tricuspid on aortogram (Figs. 2A and2B). Cardiac computed tomography angiography (CTA), however, conclusively revealed a stenosed bicuspid aortic valve (Figs. 3A to 3C). Due to prohibitive perioperative risk, the patient was declined for surgery. Although bicuspid AS is a contraindication in the ongoing PARTNER (Placement of AoRTic TraNscathetER valves) trial, anecdotal experience suggests that percutaneous valve implantation is feasible (J. Webb, personal communication, February 2009). After balloon valvuloplasty, a 23-mm Sapien transcatheter heart valve (THV) (Edwards Lifesciences, Irvine, California) was successfully deployed via the transfemoral route. The patient was well at 6 months with marked improvement in functional status. Echocardiogram showed left ventricular ejection fraction of 46%, mean pressure gradient of 20 mm Hg across the aortic valve, and trivial paravalvular leak. Both the echocardiogram and cardiac CTA revealed a circular, well-expanded prosthesis (Figs. 4A and 4B).