1036

MAENO Y et al.

ORIGINAL ARTICLE

Circ J 2017; 81: 1036 – 1042
doi: 10.1253/circj.CJ-16-1240

Valvular Heart Disease

Transcatheter Aortic Valve Replacement With Different
Valve Types in Elliptic Aortic Annuli
Yoshio Maeno, MD, PhD; Yigal Abramowitz, MD; Sung-Han Yoon, MD;
Hasan Jilaihawi, MD; Sharma Raul, MD; Sharjeel Israr, MD; Masaki Miyasaka, MD;
Hiroyuki Kawamori, MD, PhD; Yoshio Kazuno, MD; Tanya Rami; Nobuyuki Takahashi, MD;
Geeteshwar Mangat, MD; Mohammad Kashif, MD; Tarun Chakravarty, MD;
Mamoo Nakamura, MD; Wen Cheng, MD; Raj R. Makkar, MD
Background: The aim of this study was to determine the influence of an elliptic annulus on acute device success rates following
self-expanding (SE) transcatheter aortic valve replacement (TAVR) vs. balloon-expandable (BE) TAVR.
Methods and Results: Outcomes were assessed using Valve Academic Research Consortium-2 definitions. Aortic annulus ratio(AAR) was measured as short axis diameter/long axis diameter. Mean AAR was 0.81±0.06. Patients were therefore divided into 2groups: AAR <0.82 and AAR ≥0.82. For circular annuli (AAR ≥0.82; 363 patients), high device success rates were achieved in bothvalve groups (SE valve, 90.5% vs. BE valve, 95.0%, P=0.14). Conversely, for AAR <0.82 (374 patients), SE valves had lower device
success rates than BE valves (82.5% vs. 95.3%, P=0.002). For elliptic annuli, SE-TAVR was an independent predictor of unsuccessful device implantation (OR, 6.34, P<0.001). Nonetheless, increased oversizing of SE valves for elliptic annuli was associated withan exponential rise in device success (threshold ≥17.5%; area under the curve, 0.83) but not for BE-TAVR. Furthermore, optimallyoversized SE valves and BE valves had a similarly high device success for elliptic annuli (SE valve, 96.2% vs. BE valve, 95.3%).
Conclusions: For circular annuli, similarly high device success was achieved for the 2 valve types. Conversely, for elliptic annuli,
SE valves had a lower device success than BE valves. Device success following optimal oversizing of SE valves, however, wassimilar to that for BE valves.
Key Words: Device success; Elliptic annulus; Transcatheter aortic valve implantation; Transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is awell-established alternative to surgical aortic valve
replacement for high-risk patients with aortic valve
stenosis.1–3 Historically, the transcatheter heart valve has
been developed with balloon-expandable (BE) or selfexpanding (SE) systems. The CHOICE study demonstrated
that the use of BE valve resulted in a greater rate of device
success than the use of SE valves.4 Except for differences invalve design, device success depends on the anatomy of theaortic root (i.e., calcification of aortic-valvular complex,angulation of the aorta) or procedural technique (i.e.,degree of oversizing, implantation depth).5–8 Aortic annulus
dimension measurements using 3-D cross-sectional imaging
modalities reduces procedural complications.9 Although
the transcatheter heart valves are designed to expand circularly, the native aortic annulus is often oval in shape.9
These different shapes give rise to gaps between the aortic
annulus wall and the prosthesis frame. Device success is awell-defined outcome as a composite primary endpoint.
Nevertheless, only a few studies have reported the frequencyof device success for both prostheses using the Valve
Academic Research Consortium (VARC)-2 definitions.4,10
Therefore, the interaction between the degree of non-circular annuli and device success is not well understood. The
aim of this study was to determine the influence of elliptic
annulus on acute device success rates following SE valve
vs. BE valve implantation, and to evaluate pre-proceduralpredictors of acute device success for an elliptic annulus.

Methods
Subjects and Procedure
Between January 2013 and January 2016, a total of 796
consecutive patients with symptomatic severe aortic stenosis (aortic valve area <1.0 cm2) were treated with SE or BE
valve at the present institution. These patients were prospectively included in the TAVR database. After excluding
patients with previous bioprosthesis, aortic annulus measurements using diastolic phase, and patients with poor
computed tomography (CT) quality, a total of 737 patients

Received December 6, 2016; revised manuscript received January 31, 2017; accepted February 13, 2017; released online March 23,2017   Time for primary review: 40 days
Cedars-Sinai Medical Center, Heart Institute, Los Angeles, CA, USA
Mailing address: Raj R. Makkar, MD, Cedars-Sinai Medical Center, Heart Institute, 127 South San Vicente Boulevard, Suite
A3421, Los Angeles, CA 90048, USA.   E-mail: Raj.Makkar@cshs.org
ISSN-1346-9843   All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp
Circulation Journal Vol.81, July 2017