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Bicuspid aortic valve (BAV) remains challenging in transcatheter aortic valve replacement (TAVR) because of unfavorable anatomy. New-generation balloon-expandable valve (BEV) appears to be a valid alternative to surgery, especially in some Asian countries with a higher prevalence of BAV. This tutorial review summarizes current thinking about how to plan and implant BEV in BAVs using versatile techniques. First, the authors depict the main morphological characteristics of BAVs and their effects on the TAVR procedure. Next, the authors provide preprocedural analysis on sizing, obtaining the optimal deployment projection, and how to simplify valve-crossing. Finally, the authors provide step-by-step guidance on how to deploy the BEVs with evolved iterations in terms of specific anatomies, calcified annulus, and giant annulus.

Background This study sought to investigate the role of postprocedural troponin elevations in mortality prediction after transcatheter aortic valve implantation and to define the threshold at which clinically relevant postprocedure myocardial injury determines mortality. Methods and Results A total of 1333 consecutive patients with transcatheter aortic valve implantation with available postprocedural high‐sensitivity cardiac troponin T measurements were included in the analysis. The threshold at which postprocedure myocardial injury determines long‐term mortality was identified using restricted cubic spline analysis. A >18.3‐fold increase of troponin above the upper reference limit was identified as threshold for relevant postprocedure myocardial injury. Associations remained significant in a landmark analysis between 30 days and 2 years (hazard ratio [HR], 1.61, [95% CI, 1.13–2.28]; P =0.01), after adjusting for known confounders (adjusted HR, 1.90 [95% CI, 1.40–2.57]; P P P P =0.003). Conclusions This study determined a troponin threshold for the identification of patients at increased mortality risk after transcatheter aortic valve implantation. The proposed definition of postprocedure myocardial injury advances risk stratification in patients with transcatheter aortic valve implantation and may assist in postprocedural patient management.

Introduction and hypothesis Transcatheter aortic valve implantation (TAVI) has become the standard treatment in intermediate and high-risk patients with high degree aortic stenosis (AS).(1–2) These has been also extended to low-risk and younger patients.(3–5) Besides the use of computed-tomography (CT) as diagnostic method to measure the aortic anatomy for transcatheter heart valve (THV) size decision and the radiation exposure (RE) during TAVI, younger patients are more exposed to radiation and contrast media (CM) complications due to a potentially second procedure.(6) Reducing RE and CM using only angiography aortic measurement could reduce the risk of RE and CM related complications without compromising the efficacy of the THV. We hypothesize that angiographic aortic root (AR) measure has good correlation with CT measure without compromising safety and efficacy of the THV. Methods Observational analysis: 1250 transfemoral TAVI patients with balloon or self-expandable valves were included. Aortic root CT measurement was done in all patients. AR measurement using Follow the right cup rule (7) was additionally done in 505 patients. Correlation between CT only (Group I n=745) versus CT and AR measurement (Group II n=505) was done. An inter and intraobserver validation analysis was done. Primary endpoint was VARC-2 device success. Secondary safety endpoints were composite of in-hospital and 30-days complications. Results Really good intra (0.86, p Conclusions Compared to CT, AR measurement is a good option selecting THV size. No differences regarding device success and in-hospital and 30 days follow-up complications were observed. AR measurement could replace CT in specific cases. Funding Acknowledgement Type of funding sources: None. Angiographic and CT measurementsEndpoints

TAVI - New Frontiers

Introduction Restenosis after percutaneous coronary intervention (PCI) with stent implantation in patients with prior CABG is poorly studied. The aim of this study was to investigate the incidence and predictors of angiographic restenosis after PCI in patients with and without prior CABG. Methods Patients undergoing successful PCI of 1 or more de novo lesions with available surveillance angiography at 6–8 months after intervention were eligible for inclusion. Exclusion criteria were cardiogenic shock, renal replacement therapy and prior cardiac transplantation. Patients with prior CABG were further classified into patients who underwent bypass graft PCI versus native vessel PCI. The primary endpoint was in-segment binary restenosis at 6–8 months angiographic follow-up. Multivariate analyses were performed to adjust for differences in baseline characteristics between groups and to determine predictors of binary restenosis. Results 10,004 patients with 14,999 lesions were included, 8,803 patients (88%) without prior CABG and 1,201 (12.0%) with prior CABG. Of patients with prior CABG, 379 (31.6%) patients had PCI to a bypass graft and 822 (68.4%) to a native vessel. A study flow diagram is shown in figure 1. Compared with patients without prior CABG, patients with prior CABG were older, had higher rates of diabetes and prior myocardial infarction, lower left ventricular ejection fraction and larger reference vessel diameter (2.95 vs. 2.85 mm, p Conclusions Compared with patients without prior CABG, patients with prior CABG had overall higher rates of restenosis. In patients with prior CABG, restenosis rates were similar in patients undergoing bypass graft PCI and native vessel PCI and native vessel PCI was independently associated with binary restenosis at 6–8 months.