Bicuspid aortic valve (BAV) represents an anatomical challenge for transcatheter aortic valve replacement (TAVR) due to the frequent presence of elliptical annuli, fibroc calcific raphe, and extensive calcification of the valvular apparatus and the left ventricular outflow tract, which may complicate sizing, deployment, and prosthetic sealing. Since these patients were excluded from most randomized trials, evidence regarding outcomes is still evolving.
In this context, the authors retrospectively analyzed a contemporary cohort, placing special emphasis on two anatomical characteristics considered high risk and central to the study: the presence of calcified raphe and excessive valvular calcium, both assessed by computed tomography.
The study included 110 patients with severe aortic stenosis and bicuspid valve confirmed by computed tomography who underwent TAVR between 2012 and 2023. Mean age was 75.3 ± 8.4 years and the mean STS score was 2.7 ± 2.4% (predominantly intermediate-low risk population). Sievers type 1 morphology was the most frequent, present in 100 patients (90.9%). Sixty-six percent had calcified raphe and 50% had excess valvular calcification. In the subgroup analysis, 20 patients (20%) had none of these high-risk anatomical features, 44 (44%) had one, and 36 (36%) had both. The mean annular ellipticity index was 0.81 ± 0.08. Supra-annular self-expanding valves were used in 73 patients (66.4%) and balloon-expandable valves in 37 (33.6%).
TAVI in Bicuspid Aortic Valve: Impact of Calcified Raphe and Calcium Burden on Clinical Outcomes
Regarding procedural outcomes, mild paravalvular leak occurred in 30% of patients without high-risk features, 26.7% in those with one feature, and 29.4% in those with both; mild-to-moderate leak occurred in one patient per group.
No cases of moderate or severe leak, annular rupture, aortic dissection, or conversion to surgery were reported. The study does not provide data on permanent pacemaker implantation rates or conduction disturbances as reported variables.
During follow-up, no significant differences were observed in 4-year overall mortality among groups according to morphology or calcium burden, and the presence of calcified raphe and/or excess valvular calcium was not independently associated with higher mortality in adjusted analysis.
A non-significant trend toward higher survival was observed in patients with both factors (88.3%) compared with those with one (80.2%) or none (81.6%), a finding the authors attribute to possible selection bias, more meticulous planning, and differences in valve type used.
Conclusion: Safety and Mid-Term Mortality of TAVR in High-Risk Bicuspid Anatomy
In conclusion, in this contemporary cohort, careful patient selection and computed tomography-based planning allowed TAVR to be performed safely and effectively in patients with bicuspid aortic valve, with favorable mid-term clinical outcomes even in the presence of anatomical features considered high risk, without a significant increase in mortality or major complications.
Título Original: Can TAVR Be Safely Performed in Patients With Bicuspid Aortic Valve Morphology?
Referencia: Chloe Kharsa, MD, MSc, Min-Fang Chao, MD, Gal Sella, MD, Mangesh Kritya, MD, Sahar Samimi, MD, Su Min Chang, MD, Michael J. Reardon, MD, Joe Aoun, MD, Neal S. Kleiman, MD, and Sachin S. Goel, MD.
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