Bicuspid aortic valve sizing for transcatheter aortic valve implantation: Development and validation of an algorithm based on multi-slice computed tomography

Anna S Petronio, Marco Angelillis, Ole De Backer, Cristina Giannini, Giulia Costa, Claudia Fiorina, Fausto Castriota, Francesco Bedogni, Jean C Laborde, Lars Søndergaard


BACKGROUND: No indication are available for transcatheter aortic valve implantation (TAVI) sizing in bicuspid aortic valve (BAV). Aim of the study is to develop and validate a Multi-Slice Computed Tomography (MSCT)-based algorithm for transcatheter heart valve (THV) sizing in patients with stenotic BAV under evaluation for TAVI.

METHODS: A two steps method was applied: 1)evaluation of a cohort of 19 consecutive patients with type I BAV stenosis undergoing TAVI through pre and post-procedural MSCT, and development of an algorithm for THV sizing; 2)validation of the algorithm on a new cohort of 21 patients.

RESULTS: In the first cohort, a high correlation was found between the raphe-level area measured at pre-procedural MSCT and the smallest THV area measured at post-procedural MSCT (p < 0.001). Moreover, reduced THV expansion was observed among patients with higher calcium burden (p = 0.048). Then, a new algorithm for TAVI sizing in BAV was develop (CASPER: Calcium Algorithm Sizing for bicusPid Evaluation with Raphe). This algorithm is based on the reassessment of the perimeter/area derived annulus diameter, according to three main anatomical features: 1) the ratio between raphe length and annulus diameter; 2)calcium burden; 3)calcium distribution in relation to the raphe. The algorithm was then validated in a new cohort of 21 patients, achieving 100% of procedural success and excellent TAVI performance.

CONCLUSION: MSCT assessment of raphe length, calcium burden and its distribution is of crucial relevance in the pre-procedural evaluation of patients with BAV. These anatomical features can be combined in a new and simple algorithm for TAVI sizing.

Original languageEnglish
JournalJournal of Cardiovascular Computed Tomography
Issue number5
Pages (from-to)452-461
Number of pages10
Publication statusPublished - 1 Feb 2020


  • Aged
  • Aged, 80 and over
  • Algorithms
  • Aortic Valve/abnormalities
  • Aortic Valve Stenosis/diagnostic imaging
  • Bicuspid Aortic Valve Disease
  • Diagnosis, Computer-Assisted
  • Female
  • Heart Valve Diseases/diagnostic imaging
  • Heart Valve Prosthesis
  • Humans
  • Male
  • Multidetector Computed Tomography
  • Predictive Value of Tests
  • Prospective Studies
  • Prosthesis Design
  • Radiographic Image Interpretation, Computer-Assisted
  • Reproducibility of Results
  • Transcatheter Aortic Valve Replacement/instrumentation
  • Treatment Outcome


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