Mind the gap: avoiding paravalvular leak using computer simulation in bicuspid transcatheter aortic valve replacement, a case report

Abstract Background Transcatheter aortic valve replacement (TAVR) is becoming increasingly prevalent worldwide and is now more common than surgical aortic valve replacement (SAVR). It is expanding into all patient subsets including younger and lower risk patients. Bicuspid aortic valve (BAV) accounts for a significant proportion of TAVR but due to heterogenous anatomy, are of increased complexity. One of the greatest challenges in BAV is the selection of the correct TAVR size. TAVR sizing is based upon computed tomography derived annular measurements. There are a number of sizing algorithms for BAV based upon anatomical characteristics, often yielding different results. This is noted especially when a patient falls near the borderline between two valve sizes, an anatomical grey-zone. Complimentary to the algorithm approach is the use of pre-procedural patient specific computer simulation using finite element modelling. Case Summary An 86 year old female was treated for heart failure secondary to severe and calcific BAV aortic stenosis with TAVR. Due to anatomical difficulty and grey-zone valve sizing, we demonstrate the use of pre-procedural patient specific computer simulation with the novel Medtronic Evolut PRO+ platform to achieve a good result. Conclusion Using patient specific computer simulation we were able to safely select the valve, the deployment height and then accurately predict the result in a difficult, severely calcified BAV. In addition to improving outcome, this allows for patient-specific, tailored discussion to occur at Heart Team meetings.