Aortic valve anatomy and feasibility of transcatheter bioprosthetic valve implantation in isolated aortic regurgitation
M Menhem, S Smolka, M Moshage, F Ciotola, T Zuhair Kassem, S Achenbach, M MarwanAbstract
Background
The introduction of a dedicated prosthesis for transcatheter treatment of patients with severe isolated aortic valve regurgitation (JenaValve Trilogy®) offers an interventional treatment option for patients unable to undergo surgical valve replacement. It is currently not known what proportion of all-comer patients with isolated aortic regurgitation unsuitable for surgery has appropriate valve anatomy for treatment with this transcatheter heart valve. Similarly, the specific reasons that preclude placement of the valve prosthesis have not been systematically explored.
Methods
An all-comer cohort of 107 consecutive patients with symptomatic aortic valve disease under consideration for transcatheter aortic valve implantation (TAVI) using the Trilogy Valve (JenaValve®) was included in this analysis. A detailed echocardiographic and computed tomographic (CT)-based assessment of aortic root anatomy and dimensions was performed. Mechanisms of aortic regurgitation, screening failure rate, and reasons for unsuitability were identified and compared between eligible and non-eligible patients.
Results
Out of 107 consecutive patients who underwent diagnostic workup prior to TAVI using the Trilogy Valve, 57 were excluded due to previous valve replacement, mixed aortic valve pathology including stenosis, or indications for TAVI using the Trilogy Valve other than isolated aortic regurgitation. Consequently, 50 patients were included (77±9 years, 22 females (44%), left ventricular ejection fraction (LVEF) 46±11%, vena contracta 6.5±1 mm, New York Heart Association (NYHA) class III in 50% and class II in 43%). Mechanisms of aortic regurgitation were as follows: 22% prolapse of the right coronary cusp, 20% prolapse of the non-coronary cusp, 16% annular dilatation, 34% degenerative disease, 4% bicuspid degenerative disease, 1 patient with prolapse of the left coronary cusp. Anatomy was suitable for implantation of the Trilogy Valve in 27 patients (54%), and unsuitable in 23 (46%). Reasons for screening failure included: large annular dimensions (61%), unfavourable aortic anatomy (22%), severe leaflet restriction (9%), bicuspid valve morphology (4%), and small annular dimensions (4%). Unsuitable patients had larger annular dimensions than suitable patients (mean diameter 27 vs 25.4 mm; area 588 vs 509 mm²; perimeter 87 vs 81 mm; all p<0.05). Other CT parameters such as the presence and degree of aortic valve calcification, aortic root angle, eccentricity index, and aortic dimensions were not significantly different between both groups.
Conclusion
Among patients with isolated aortic valve regurgitation at high risk for conventional surgery, approximately 50% were eligible for transcatheter treatment with the currently available models of the Trilogy heart valve. The most frequent reasons for non-eligibility include large annular dimensions or unfavourable anatomy of the aortic valve cusps.