Aims: Supra-annular sizing in transcatheter aortic valve replacement (TAVR) of bicuspid aortic valve (BAV) disease is a concept not reproducibly demonstrated and specific measurements to assess a supra-annular plane are not standardized among operators. The main objective of our study was to evaluate a novel supra-annular plane analytical algorithm to optimize prosthesis sizing in raphe-type BAV. Methods and Results: All patients with available cardiac computed tomography (CT) scans before and after TAVR performed in three high-volume centers between January 2007 and March 2018 were screened. Patients with BAV type 1 and 2 were included in the final analysis. On the pre-TAVR CT scans, we identified the plane with the most rigid anatomical structures (calcific/fibrotic raphes) in the aortic root that might facilitate valve anchoring during deployment, defined as LIRA (Level of Implantation at the RAphe) plane (Figure 1). The distance of the LIRA plane from the virtual basal ring (VBR) in pre-TAVR CT scans was compared with the distance of the prosthesis waist from the VBR in post-TAVR CT scans. 65 patients with BAV where included in the final analysis. The distance of the LIRA plane from the VBR in pre-TAVR CT scans was similar to the distance of the prosthesis waist from the VBR in post-TAVR CT scans (respectively 8.4±1.7 and 7.9±1.7; p=0.10). Conclusions: The LIRA plane is a new method to localize the level where TAVR prosthesis anchoring is expected to occur in raphe-type BAV disease. Figure 1: A) (1-6): BAV type 1 with a fibrotic raphe where a LotusTM valve (Boston Scientific, MA, USA) was implanted. B) (1-6): BAV type 1 with a calcific raphe where a SAPIEN 3 valve (Edwards Lifesciences, CA, USA) was implanted. C) (1-6): BAV type 1 with a calcific raphe where a CoreValveVR (Medtronic, Minneapolis, MN, USA) was implanted. D) (1-6): BAV type 2 where a CoreValve was implanted. 1. LIRA plane with a fibrotic/calcific raphe on the short axis. 2. LIRA plane on the long axis corresponding to the cut at the raphe maximum protrusion level (dotted yellow line). 3. The raphe maximum protrusion point and the LIRA plane (dotted yellow line). 4. Prosthesis waist on the short axis. 5. Prosthesis waist on the long axis corresponding to the level where the valvular frame becomes less expanded in the transverse direction along the aortic root due to the compression by the surrounding anatomy (fibrotic/calcific raphe). 6. 3D image that indicates the prosthesis waist.
