Background: Bicuspid aortic valve (BAV) stenosis presents specific challenges for transcatheter aortic valve implantation (TAVI). Several transcatheter heart valve (THV) sizing strategies have been proposed. The CASPER algorithm indicates whether and how much to downsize the THV based on anatomical characteristics. The aim of this study is to prospectively assess the CASPER algorithm in a multicenter cohort of BAV patients treated with a self-expandable THV. Methods: Consecutive BAV patients undergoing TAVI were prospectively enrolled across six centers from 2022 to 2024. Pre-procedural computed tomography (MSCT) was used for THV sizing according to CASPER. Procedural features and clinical outcomes at 30 days and 1 year were recorded. Patients were compared based on whether CASPER recommended downsizing. Results: A total of 101 patients were included, and THV downsizing was advised in 39 cases (34.6%). The mean post-TAVI transvalvular gradient was 8.3±4.3mmHg, and moderate paravalvular leak occurred in six patients (6%). No deaths or major structural complications were reported, while the 30-day permanent pacemaker implantation rate was 25%. No significant differences between downsizing and non-downsizing groups were observed regarding procedural characteristics, hemodynamic performance, or clinical outcomes. Post-procedural MSCT (available in 84/101 patients, 83%) showed comparable THV eccentricity in both groups. Conclusions: The CASPER algorithm offers a practical and reproducible sizing strategy for use in BAV anatomy and appears to support appropriate THV expansion while identifying cases requiring downsizing. However, in the absence of a comparator group, these findings should be considered hypothesis-generating and require validation in prospective comparative or randomized studies. Nct registration number: NCT04817735.
Angelillis, M., Costa, G., Primerano, C., Giannini, C., Pesarini, G., Toušek, P., Malkin, C., Aurigemma, C., Fiorina, C., Galli, V., Ribichini, F., Sulženko, J., Kočka, V., Cunnington, M., Blackman, D., Trani, C., Pancaldi, E., De Carlo, M., Petronio, A. S., Computed Tomography Sizing Algorithm for Transcatheter Aortic Valve Implantation in Bicuspid valve: Results from the CASPER Registry, <<CANADIAN JOURNAL OF CARDIOLOGY>>, 2026; (May 29): N/A-N/A. [doi:10.1016/j.cjca.2026.05.016] [https://hdl.handle.net/10807/340220]
Computed Tomography Sizing Algorithm for Transcatheter Aortic Valve Implantation in Bicuspid valve: Results from the CASPER Registry
Aurigemma, Cristina;Trani, Carlo;
2026
Abstract
Background: Bicuspid aortic valve (BAV) stenosis presents specific challenges for transcatheter aortic valve implantation (TAVI). Several transcatheter heart valve (THV) sizing strategies have been proposed. The CASPER algorithm indicates whether and how much to downsize the THV based on anatomical characteristics. The aim of this study is to prospectively assess the CASPER algorithm in a multicenter cohort of BAV patients treated with a self-expandable THV. Methods: Consecutive BAV patients undergoing TAVI were prospectively enrolled across six centers from 2022 to 2024. Pre-procedural computed tomography (MSCT) was used for THV sizing according to CASPER. Procedural features and clinical outcomes at 30 days and 1 year were recorded. Patients were compared based on whether CASPER recommended downsizing. Results: A total of 101 patients were included, and THV downsizing was advised in 39 cases (34.6%). The mean post-TAVI transvalvular gradient was 8.3±4.3mmHg, and moderate paravalvular leak occurred in six patients (6%). No deaths or major structural complications were reported, while the 30-day permanent pacemaker implantation rate was 25%. No significant differences between downsizing and non-downsizing groups were observed regarding procedural characteristics, hemodynamic performance, or clinical outcomes. Post-procedural MSCT (available in 84/101 patients, 83%) showed comparable THV eccentricity in both groups. Conclusions: The CASPER algorithm offers a practical and reproducible sizing strategy for use in BAV anatomy and appears to support appropriate THV expansion while identifying cases requiring downsizing. However, in the absence of a comparator group, these findings should be considered hypothesis-generating and require validation in prospective comparative or randomized studies. Nct registration number: NCT04817735.
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