ORIGINAL RESEARCH article
Front. Cardiovasc. Med.
Sec. Cardiovascular Imaging
Methods for improved bileaflet aortic valve detection prior to transcatheter aortic valve replacement
Justin T. Tretter 1
Mackram Eleid 2
Francesco Bedogni 3
Josep Rodes-Cabau 4
Ander Regueiro 5
Luca Testa 3
Shmuel Chen 6
Attilio Galhardo 4
Kenneth Ellenbogen 7
Martin Leon 8
Shlomo Ben-Haim 9
1. Cleveland Clinic, Cleveland, United States
2. Mayo Clinic Minnesota, Rochester, United States
3. IRCCS Policlinico San Donato, San Donato Milanese, Italy
4. Institut Universitaire de Cardiologie et de Pneumologie de Quebec - Universite Laval, Québec City, Canada
5. Hospital Clinic de Barcelona, Barcelona, Spain
6. Weill Cornell Medicine, New York, United States
7. Virginia Commonwealth University, Richmond, United States
8. Columbia University, New York, United States
9. Hobart Healthcare Research Institute, London, United Kingdom
Select one of your emails
You have multiple emails registered with Frontiers:
Notify me on publication
Please enter your email address:
If you already have an account, please login
You don't have a Frontiers account ? You can register here
Abstract
Background: Bileaflet aortic valve prevalence in transcatheter aortic valve replacement (TAVR) patients is poorly defined. We evaluated a TAVR cohort to determine the bileaflet aortic valve prevalence and understand features which may improve detection. In addition, we related valvar morphology to the occurrence of permanent pacemaker implantation (PPI) following TAVR. Methods: Aortic valvar morphology diagnosis was recorded from the pre-procedural cardiac CTA reports prior to TAVR. Commissural angles, comparison of commissural heights, and dynamic visual inspection of the aortic valve were subsequently evaluated on pre-procedural cardiac CTA by an expert cardiac anatomist and imager, methods previously validated in a surgical cohort, to determine aortic valvar morphology and compared to the historical diagnosis. Relationships between valvar morphological characteristics with the need for PPM within 30-days post-TAVR were determined. Results: Four-hundred and thirty-three (mean age 81.3±6.6 years, 53.8% female) underwent TAVR (corrected diagnosis: 393(90.8%) trileaflet vs. 40(9.2%) bileaflet valves). Bileaflet valves were historically misdiagnosed in 80% of pre-procedural cardiac CTA reports. Thirty-four (85.0%) had intercoronary leaflet fusion (mean commissural angle=148.1 (18.3) degrees). A commissural angle threshold of 141.1 degrees had a sensitivity of 0.73 and specificity of 0.86 for identifying a bileaflet valve. PPI post-TAVR occurred in 38% bileaflet vs. 19% trileaflet patients (p=0.0114) (unadjusted OR for bileaflet valve requiring PPI=2.54, 95% CI[1.25-5.01]). Conclusions: Bileaflet aortic valves are commonly misdiagnosed. Assessment of the commissural angle and comparison of commissural heights may improve CTA-based diagnostic 3 accuracy prior to TAVR. Improved detection may guide improved outcomes in this higher risk population.
Summary
Keywords
bicuspid aortic valve, Calcific aortic valve disease, Complete heart block, computed tomography, Permanent pacemaker implantation, Transcatheter aortic valve replacement
Received
27 November 2025
Accepted
05 February 2026
Copyright
© 2026 Tretter, Eleid, Bedogni, Rodes-Cabau, Regueiro, Testa, Chen, Galhardo, Ellenbogen, Leon and Ben-Haim. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Justin T. Tretter
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.