Transcatheter bicuspid versus tricuspid aortic valve replacement in patients with a small aortic annulus: an observational study.

Abstract

Objective: To compare the clinical outcomes and haemodynamic performance following transcatheter aortic valve replacement (TAVR) in patients with severe bicuspid versus tricuspid aortic stenosis (AS) and small annuli.

Design: Retrospective analysis based on a prospective observational cohort.

Setting: Single-centre registry of patients undergoing TAVR between 2016 and 2023.

Participants: A total of 427 patients (193 bicuspid (BAV) and 234 tricuspid (TAV) aortic valve) with symptomatic severe AS and small annuli (median area 381.5 mm² (IQR 348.0-406.4)), all undergoing preprocedural multidetector CT and standardised follow-up echocardiography.

Main outcomes measure: Baseline characteristics, technical success, procedural complications, haemodynamic performance and bioprosthetic-valve dysfunction (BVD) were compared between groups. The primary clinical outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause mortality, stroke and rehospitalisation for heart failure.Cox regression was used to adjust for confounders.

Results: Compared with TAV patients, BAV recipients experienced higher technical failure rates (11.4% vs 6.0%, p=0.045) but lower permanent pacemaker implantation (4.7% vs 12%, p=0.008) at discharge. The 1-year MACCE rate was similar between groups (14.5% vs 9.8%, log-rank p=0.719), and Cox regression analyses adjusting for confounders revealed no significant difference (HR 1.408 (95% CI 0.622 to 3.191), p=0.412). Both groups demonstrated significant improvements in valve haemodynamics, with comparable rates of BVD (11.4% vs 9.2%, p=0.502) and structural valve dysfunction. Multivariate analysis demonstrated equivalent long-term survivals (HR 0.950 (95% CI 0.526 to 1.714), p=0.864) between groups.

Conclusion: TAVR provides comparable clinical and haemodynamic outcomes for bicuspid and tricuspid AS with a small aortic annulus, despite greater procedural complexity in BAV cases. These findings support cautious expansion of TAVR to select BAV patients when performed with meticulous procedural planning.