Transcatheter valve replacement in the bicuspid valve is increasingly performed, but challenges remain

As experience increases, transcatheter aortic valve replacement (TAVR) has expanded to different populations and anatomies. This study sought to compare technical and clinical outcomes in patients with bicuspid versus tricuspid aortic stenosis from the Bicuspid AS TAVR Multicenter Registry.

Outcomes of 561 patients with bicuspid valves and 4546 patients with tricuspid valves were compared. Propensity score matching was used due to baseline differences, assembling 546 pairs of patients with similar baseline characteristics except for valve anatomy.

Patients who received bicuspid valves had more frequent conversion to surgery (2.0% vs. 0.2%; p = 0.006) and significantly lower device success rates (85.3% vs. 91.4%; p = 0.002).

A group of 320 patients with bicuspid aortic stenosis received first-generation valves (Sapiens XT and CoreValve) and presented recurrent aortic root injury with balloon-expandable devices (4.5% vs. 0.0%; p = 0.015) and more frequent moderate-to-severe paravalvular leak with self-expandable devices (19.4% vs. 10.5%; p = 0.02).

Among patients with second-generation devices (Sapiens 3, Evolut R, and Lotus), results with bicuspid and tricuspid valves were comparable.

The cumulative all-cause mortality rates at 2 years were comparable between bicuspid and tricuspid valves (17.2% 19.4%; p = 0.28).

Conclusion

Compared with patients who received tricuspid valves, transcatheter aortic valve replacement in patients who received bicuspid valves was associated with a similar prognosis, but lower device success rates. There were outcome differences in patients treated with first-generation balloon-expandable and self-expandable devices, whereas no differences were observed with second-generation devices.

Editorial

In this study, patients with bicuspid aortic stenosis were younger and presented less comorbidities than patients with tricuspid stenosis, and these differences required the use of propensity score matching.

Given the shift towards treating younger and lower surgical-risk patients with TAVR, the proportion of patients with bicuspid aortic stenosis assessed for valve replacement is likely to increase.

New devices have managed to limit differences between bicuspid and tricuspid stenosis, although the technical challenge will always be higher.

Original title: Outcomes in Transcatheter Aortic Valve Replacement for Bicuspid Versus Tricuspid Aortic Valve Stenosis.

Reference: Sung-Han Yoon et al. J Am Coll Cardiol 2017;69:2579-89.

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