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Objectives  To explore assessment of supra‐annular structure for self‐expanding transcatheter heart valve (THV) size selection in patients with bicuspid aortic stenosis (AS).    Background  Annulus‐based device selection from CT measurement is the standard sizing strategy for tricuspid aortic valve before transcatheter aortic valve replacement (TAVR). Because of supra‐annular deformity, device selection for bicuspid AS has not been systemically studied.    Methods  Twelve patients with bicuspid AS who underwent TAVR with self‐expanding THVs were included in this study. To assess supra‐annular structure, sequential balloon aortic valvuloplasty was performed in every 2 mm increments until waist sign occurred with less than mild regurgitation. Procedural results and 30 day follow‐up outcomes were analyzed.    Results  Seven patients (58.3%) with 18 mm; three patients (25%) with sequential 18 mm, 20 mm; and only two patients (16.7%) with sequential 18 mm, 20 mm, and 22 mm balloon sizing were performed, respectively. According to the results of supra‐annular assessment, a smaller device size (91.7%) was selected in all but one patient compared with annulus based sizing strategy, and the outcomes were satisfactory with 100% procedural success. No mortality and 1 minor stroke were observed at 30 d follow‐up. The percentage of NYHA III/IV decreased from 83.3% (9/12) to 16.7% (2/12). No new permanent pacemaker implantation and no moderate or severe paravalvular leakage were found.    Conclusions  A supra‐annular structure based sizing strategy is feasible for TAVR in patients with bicuspid AS.

Supra‐annular structure assessment for self‐expanding transcatheter heart valve size selection in patients with bicuspid aortic valve