Bicuspid Aortic Valve Stenosis Still Challenging for TAVR

Courtesy of Dr. Carlos Fava

One of the present challenges of TAVR is bicuspid aortic valve stenosis (AS), since it presents a different distribution and structure, associated to greater and more irregular calcification. There are only small series of devices and their use is still controversial.

The study analyzed 561 patients with severe bicuspid AS and 4546 patients with tricuspid AS undergoing TAVR.

Those presenting bicuspid AS were younger, and tricuspid patients had more comorbidities and higher surgical risk scores. Femoral access was similar in both groups, but bicuspid AS patients received larger diameter valves.

After propensity score matching to adjust for differences, researchers assembled 546 patients with similar characteristics.

Conversion to surgery was higher among bicuspid AS patients (2% vs. 0.2% p=0.0006) and lower device success rate (85.3% vs. 91.4% p=0.002), more need of a second valve and presence of moderate to severe paravalvular leak, with no difference in need for definite pacemaker. There were no differences in events at 30 days.

First generation valves (Sapiens XT and CoreValve) were implanted in 320 bicuspid patients and 321 tricuspid patients, and the new generation (Sapiens 3, Lotus and Evolut R) were implanted in 226 and 225 patients, respectively.

Bicuspid patients receiving first generation devices presented more aortic root injury (4.5% vs. 0% p=0.01) when receiving Sapiens XT, and more moderate to severe paravalvular leak (19.4% vs. 10.5% p=0.02) when receiving CoreValve. This did not happen with new generation devices.

At two year follow up, there were no differences in mortality between bicuspid and tricuspid patients (17.2% vs. 19.4% p=0.28)

Conclusion

Compared to tricuspid AS, TAVR in bicuspid AS was associated to similar prognosis, even though it had lower device success rate. There were procedural differences among patients treated with first generation devices, which was not observed with new generation devices.

Commentary

TAVR has been shown beneficial to high risk and inoperable patients with severe aortic valve stenosis.

This analyzis shows that the development of new valves have improved results in bicuspid AS patients. It might be necessary to develop devices for this particular scenario.

Courtesy of Dr. Carlos Fava

Original Title: Procedural and Clinical Outcomes in Transcatheter Aortic Valve Replacement for Bicuspid versus Tricuspid Aortic Valve Stenosis.

Authors: Sung-Han Yoon, et al J Am Coll Cardiol Article in Press.

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