Author + information
- Received October 2, 2009
- Accepted November 13, 2009
- Published online May 1, 2010.
- Paul T.L. Chiam, MBBS⁎,⁎ (, )
- Victor T.T. Chao, MBBS†,
- Swee-Yaw Tan, MBBS⁎,
- Tian-Hai Koh, MBBS, MMed⁎,
- Chung-Yin Lee, MBBS, MMed⁎,
- Ving-Yuen See Tho, MBBS, MMed‡,
- Yoong-Kong Sin, MBBS† and
- Yeow-Leng Chua, MBBS†
- ↵⁎Reprint requests and correspondence:
Dr. Paul T. L. Chiam, 17 Third Hospital Avenue, Mistri Wing 168752, Singapore
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 and 2B). 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). This case illustrates the utility of cardiac CTA in determining the bicuspid nature of the aortic valve when both echocardiography and aortography were inconclusive. It also demonstrates that the THV can achieve full and circular expansion in a bicuspid aortic valve. However, as a previous study documented frequent incomplete and asymmetric THV expansion in bicuspid valves (1), more data are required to guide clinical practice. Whether a self-expandable stent design (which may continue to gradually expand against the annulus) or balloon-expandable stent design (with its very high initial radial force) would achieve better expansion in such cases remains to be determined. Thus at present, THV implantation in bicuspid AS should be considered only in very select patients, particularly those with contraindications to surgery.
The authors would like to thank John Webb, MD, for his technical assistance during the procedure.
- Received October 2, 2009.
- Accepted November 13, 2009.
- American College of Cardiology Foundation