Original title: Comparison of Results of Transcatheter Aortic Valve Implantation in Patients with Severely Stenotic Bicuspid versus Tricuspid or Non-Bicuspid Valves. Reference: Charis Costopoulos et al. Am J Cardiol. 2014 Jan 31. pii: S0002-9149(14)00554-2.

The bicuspid aortic valve (BAV) is the most common congenital cardiac malformation. It occurs in approximately 1% of the general population and often manifests with stenosis or insufficiency. 

Information on transcatheter aortic valve implantation (TAVR) for severe bicuspid aortic valve (BAV) stenosis is limited, and even more limited is how this compares to that for tricuspid aortic valve (TAV) stenosis, given that bicuspid valves are part of the exclusion criteria in practically all TAVR trials.

21 consecutive patients with severe stenosis developed from a bicuspid valve were treated with the Edwards or the CoreValve prosthesis between 2007 and 2012 in a center. Results were compared with a cohort of patients receiving TAVR (n = 447) with the same prostheses over the same period of time. Patients with bicuspid valves were younger and with a larger annulus than the tricuspid valve cohort. Devices were successfully implanted in 85.7% of patients with BAV, vs. 94.4% (p = 0.10) in patients with TAV. 

Valves were successfully implanted in 85.7% of BAV patients vs 94.4% (p=0.10) of TAV patients, mainly due to second valve placement, more frequent in the first group. In addition, the need of post dilation was more frequent in the bicuspid cohort (52.4% vs. 23.5%; p<0.01).

Global mortality rate (14.2% vs 3.6%, p = 0.02) and cardiovascular mortality (9.5% vs. 2.7%, p=0.07) at 30 days were more frequent in the BAV group, and the same was observed at one year follow up (global mortality rate 31.7% vs. 13.7%; p=0.03 and cardiovascular mortality 10.5% vs. 7.4%; p=0.62 respectively). 

Conclusion

Transcatheter aortic valve replacement in high risk surgical patients with severe BAV stenosis is feasible, though it has lower success rates compared to TAV patients, which shows that more studies are required to identify the subgroup of patients that will best adapt to transcatheter valve replacement.

Comment

The greater need of post dilation could result from the asymmetrical calcification (typical of BAV) preventing a complete expansion and, consequently, increasing aortic regurgitation. Post dilation could be useful though, especially in these patients, the risk of annulus rupture is higher. Probably the self-expandable CoreValve will adapt better to the elliptical annulus of these patients.

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