Transcatheter and surgical aortic valve replacement in patients with bicuspid aortic valve

Annastiina Husso,Peter Raivio,Markku Eskola,Tatu Juvonen,Sebastian Dahlbacka,Juhani Airaksinen,Fausto Biancari,Marko Virtanen,Mika Laine,Timo Mäkikallio,Matti Niemelä,Antti Valtola,Mikko Savontaus

doi:10.1007/s00392-020-01761-3

Abstract

ObjectivesTo compare the outcomes after surgical (SAVR) and transcatheter aortic valve replacement (TAVR) for severe stenosis of bicuspid aortic valve (BAV).MethodsWe evaluated the early and mid-term outcome of patients with stenotic BAV who underwent SAVR or TAVR for aortic stenosis from the nationwide FinnValve registry.ResultsThe FinnValve registry included 6463 AS patients and 1023 (15.8%) of them had BAV. SAVR was performed in 920 patients and TAVR in 103 patients with BAV. In the overall series, device success after TAVR was comparable to SAVR (94.2% vs. 97.1%, p = 0.115). TAVR was associated with increased rate of mild-to-severe paravalvular regurgitation (PVR) (19.4% vs. 7.9%, p < 0.0001) and of moderate-to-severe PVR (2.9% vs. 0.7%, p = 0.053). When newer-generation TAVR devices were evaluated, mild-to-severe PVR (11.9% vs. 7.9%, p = 0.223) and moderate-to-severe PVR (0% vs. 0.7%, p = 1.000) were comparable to SAVR. Type 1 N-L and type 2 L-R/R-N were the BAV morphologies with higher incidence of mild-to-severe PVR (37.5% and 100%, adjusted for new-generation prostheses p = 0.025) compared to other types of BAVs. Among 75 propensity score-matched cohorts, 30-day mortality was 1.3% after TAVR and 5.3% after SAVR (p = 0.375), and 2-year mortality was 9.7% after TAVR and 18.7% after SAVR (p = 0.268)ConclusionsIn patients with stenotic BAV, TAVR seems to achieve early and mid-term results comparable to SAVR. Type 1 N-L and type 2 L-R/R-N BAV morphologies had higher incidence of PVR. Larger studies evaluating different phenotypes of BAV are needed to confirm these findings.Clinical trial registrationClinicalTrials.gov Identifier: NCT03385915.Graphic abstract

Highlights

Bicuspid aortic valve (BAV) is the most common congenital cardiac defect with a prevalence of 0.65% in the most recent autopsy series [1]
The proportion of transcatheter aortic valve replacement (TAVR) for stenotic BAV in each center ranged from 2.0% to 8.2%, and 80.6% of TAVR procedures for stenotic BAV were performed after 2014
In patients with stenotic BAV, 30-day and 2-year mortality as well as device success and paravalvular regurgitation (PVR) were comparable after TAVR and SAVR

Summary

Introduction

Bicuspid aortic valve (BAV) is the most common congenital cardiac defect with a prevalence of 0.65% in the most recent autopsy series [1]. Recent randomized studies showed comparable outcomes in tricuspid AS after TAVR and SAVR even in low-risk patients [5, 6]. The increased risk of vascular complications, permanent pacemaker implantation and paravalvular regurgitation (PVR) after TAVR in BAV is a matter of concern [7, 8]. The risk of such complications seems to be reduced with the use of newer-generation TAVR devices [7, 9, 10], but current guidelines do not provide any advice regarding the routine use of TAVR in BAV patients [11, 12]. We sought to analyze the early and mid-term outcomes of these treatment methods in patients with BAV from a nationwide registry

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