Impact of Left Ventricular Outflow Tract Calcification on Early Outcome in Patient With Bicuspid Aortic Valve Undergoing Transcatheter Aortic Valve Implantation With Self-Expandable and Balloon-Expandable Valve

Abstract

The aim of this study was to assess the impact of left ventricular outflow (LVOT) calcification on early device outcomes in a contemporary patient cohort with bicuspid aortic valve undergoing transcatheter aortic valve implantation (TAVI), and to compare outcomes between balloon-expandable (BE) and self-expandable (SE) prostheses in this population. LVOT calcification is known to be associated with adverse outcomes after TAVI in patient with tricuspid anatomy. However, its impact on patients with bicuspid anatomy remains less explored. Additionally, the differential effect of LVOT calcification on outcomes with BE versus SE prostheses remains unclear. Pre-TAVI multislice computed tomography (MSCT) scans from 198 BAV patients were analyzed to assess the presence and quantification of LVOT calcification. The cohort was divided into LVOT+ (calcium volume >10 mm³) and LVOT- groups (calcium volume <10 mm³). The amount of LVOT calcification was measured quantitatively from contrast-enhanced CT, using 3mensio Structural Heart software (Pie Medical Imaging). Outcomes were further stratified by valve type (SE vs BE). The impact of LVOT calcification on 30-day VARC-3 device success, mean trans-prosthetic gradient, and peri‑valvular regurgitation (PVR) was assessed using univariate and multivariate regression analysis. LVOT calcification was present in 48.2% of patients. Device success at 30 days was significantly lower in the LVOT+ group (75.8% vs 90.1%; p = 0.007). In subgroup analysis, BE valves showed higher mean trans-prosthetic gradients in LVOT+ patients (12.1 ± 6.3 mmHg) compared to SE valves (10.2 ± 5.8 mmHg, p = 0.04). Moderate or greater PVR was more common in SE valves (17.5% vs 10.2%; p = 0.03), especially in LVOT+ patients. On multivariate analysis, LVOT calcification remained an independent predictor of reduced device success (OR 0.237; p = 0.005). In conclusion LVOT calcification is highly prevalent in BAV patients undergoing TAVI and it is associated with reduced device success at 30 days. The impact of LVOT calcification differs between valve types, with BE valves exhibiting higher gradients and SE valves showing higher rates of PVR. These findings suggest that LVOT calcium burden should be carefully considered when selecting the type of transcatheter valve.

Keywords: aortic stenosis; bicuspid aortic valve; transcatheter aortic valve implantation.