Comparative outcomes of transcatheter aortic valve replacement in bicuspid vs. tricuspid aortic valve stenosis patients: insights from the SWEDEHEART registry.

BACKGROUND

Limited data exist on transcatheter aortic valve replacement (TAVR) outcomes in patients with bicuspid aortic valve (BAV) stenosis. This study compared TAVR outcomes in BAV versus tricuspid aortic stenosis.

METHODS

This observational study included all patients who underwent TAVR in Sweden from 2016 to 2022, excluding those with pure aortic insufficiency and valve-in-valve procedures. Only Evolut-, SAPIEN-, ACURATE-, and Portico/Navitor-family devices were included. A doubly robust method was used, combining propensity score estimation and multivariable regression.

RESULTS

Among 7,095 patients, 577 (8.1 %) had BAV stenosis. The mean EUROSCORE II-predicted mortality risk was 3.8 % for BAV and 4.5 % for TAV. BAV patients were younger, predominantly male, and had fewer comorbidities but higher baseline aortic valve gradients, larger annulus diameters, and more reduced ejection fraction.After matching, 30-day mortality and all-cause mortality (median follow-up: 690 days) were similar between BAV and TAV patients (p = 0.8 for both). While BAVs had numerically lower technical success per VARC-3 criteria, this was not statistically significant (p = 0.08). However, BAV patients had lower device success (aOR = 0.8, p = 0.04) and a higher incidence of post-TAVR pacemaker implantation (aOR = 1.76, 95 % CI: 1.14-2.58, p = 0.007). No significant differences were observed in prosthesis-patient mismatch (p = 0.3), paravalvular leakage (p = 0.6), stroke (p = 0.3), or post-TAVR gradients (p > 0.9).

CONCLUSION

TAVR in BAV patients yields similar mortality and hemodynamic outcomes as in TAV patients. However, BAVs are associated with lower device success and higher pacemaker rates. While TAVR is a viable alternative to SAVR, treatment should be individualized, especially in younger BAV patients, considering lifetime management and coronary access.