Chao, Victor T.T.

Chiam, Paul T.L.

Chua, Yeow-Leng

Koh, Tian-Hai

Lee, Chung-Yin

Sin, Yoong-Kong

Tan, Swee-Yaw

Tho, Ving-Yuen See

Elsevier - Publisher Connector 

Percutaneous Transcatheter Heart Valve Implantation in a Bicuspid Aortic Valve 

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mplantation in a Bicuspid Aortic Valve
aul T. L. Chiam, MBBS,* Victor T. T. Chao, MBBS,† Swee-Yaw Tan, MBBS,*
ian-Hai Koh, MBBS, MMEd,* Chung-Yin Lee, MBBS, MMEd,*
ing-Yuen See Tho, MBBS, MMEd,‡ Yoong-Kong Sin, MBBS,† Yeow-Leng Chua, MBBS†
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ardio77-year-old man presented with increasingly
ymptomatic severe aortic stenosis (AS). Echocardio-
ram showed an aortic valve area of 0.6 cm2 and a
ean pressure gradient of 57 mm Hg. It could not be
scertained conclusively if the valve was tricuspid or
icuspid due to heavy calcification (Figs. 1A and 1B).
ortic annulus was 20 mm in diameter. Left ventric-
lar ejection fraction was 40%. At cardiac catheter-
zation, calcified leaflets were seen but it could not be
etermined if the valve was tricuspid on aortogram
Figs. 2A and 2B). Cardiac computed tomography
ngiography (CTA), however, conclusively revealed a
tenosed bicuspid aortic valve (Figs. 3A to 3C). Due
o prohibitive perioperative risk, the patient was
eclined for surgery. Although bicuspid AS is a
ontraindication in the ongoing PARTNER (Place-
ent of AoRTic TraNscathetER valves) trial, anec-
otal experience suggests that percutaneous valve
rom the Departments of *Cardiology, †Cardiothoracic Surgery, and ‡C
Figure 1. Parasternal Short-Axis Views of the Aortic Valve
(A) Parasternal short-axis view showing the valve in diastole (arrow
aortic valve in systole (arrows indicate the leaﬂets). Due to the he
valve or if 1 of the commissures was heavily fused.anuscript received October 2, 2009, accepted November 13, 2009.mplantation is feasible (J. Webb, personal commu-
ication, February 2009). After balloon valvuloplasty,
23-mm Sapien transcatheter heart valve (THV)
Edwards Lifesciences, Irvine, California) was suc-
essfully deployed via the transfemoral route. The
atient was well at 6 months with marked improve-
ent in functional status. Echocardiogram showed
eft ventricular ejection fraction of 46%, mean pres-
ure gradient of 20 mm Hg across the aortic valve,
nd trivial paravalvular leak. Both the echocardio-
ram and cardiac CTA revealed a circular, well-
xpanded prosthesis (Figs. 4A and 4B). This case
llustrates the utility of cardiac CTA in determining
he bicuspid nature of the aortic valve when both
chocardiography and aortography were inconclusive.
t also demonstrates that the THV can achieve full
nd circular expansion in a bicuspid aortic valve.
owever, as a previous study documented frequent
thoracic Anesthesiology, National Heart Center, Singapore.
icate the leaﬂets). (B) Parasternal short-axis view showing the
lciﬁcation, it could not be determined if this was a bicuspids ind
avy ca
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J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 3 , N O . 5 , 2 0 1 0
M A Y 2 0 1 0 : 5 5 9 – 6 1
Chiam et al.
Percutaneous Aortic Valve Implantation
560ncomplete and asymmetric THV expansion in bicuspid
alves (1), more data are required to guide clinical practice.
hether a self-expandable stent design (which may con-
inue to gradually expand against the annulus) or balloon-
xpandable stent design (with its very high initial radial
orce) would achieve better expansion in such cases remains
o be determined. Thus at present, THV implantation in
Figure 2. Aortogram Images of the Valve
(A) Aortogram showing the valve (arrows) in diastole. (B) Aortogram showing
was a third leaﬂet.
Figure 3. Cardiac CTA of Aortic Valve and Origin of Coronary Ostia
(A) Cardiac computed tomography angiography (CTA) showing the aortic valv
valve in systole. (C) Cardiac CTA showing the origin of the coronary ostia. The
onary artery (arrowhead) originates more posteriorly from the left coronary cu
only a right and a left, and no noncoronary cusp.icuspid AS should be considered only in very select
atients, particularly those with contraindications to
urgery.
cknowledgment
he authors would like to thank John Webb, MD, for his
echnical assistance during the procedure.
alve (arrows) in systole. Two leaﬂets are seen, and it was uncertain if there
iastole. The 2 leaﬂets (arrows) are clearly seen. (B) Cardiac CTA showing the
coronary artery arises from the right coronary cusp (arrow) and the left cor-
is is normally the region of the noncoronary cusp, conﬁrming that there isthe ve in d
right
sp. Th
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J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 3 , N O . 5 , 2 0 1 0 Chiam et al.
MA Y 2 0 1 0 : 5 5 9 – 6 1 Percutaneous Aortic Valve Implantation
561eprint requests and correspondence: Dr. Paul T. L. Chiam, 17
hird Hospital Avenue, Mistri Wing 168752, Singapore. E-mail:
Figure 4. Parasternal Short-Axis View and CTA Image of THV Post-Implanta
(A) Parasternal short-axis view showing near circular expansion of the transcat
computed tomography angiography (CTA) showing symmetric and circular expaul.chiam.t.l@nhc.com.sg.EFERENCE
. Zegdi R, Ciobotaru V, Noghin M, et al. Is it reasonable to treat all
calcified stenotic aortic valves with a valved stent? Results from a human
heart valve (THV). The prosthetic leaﬂets were not well visualized. (B) Cardiac
n of the THV. The trileaﬂet nature of the prosthesis is clearly demonstrated.tion
heteranatomic study in adults. J Am Coll Cardiol 2008;51:579–84.


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Percutaneous Transcatheter Heart Valve Implantation in a Bicuspid Aortic Valve

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