Background

The evolution of transcatheter heart valve (THV) technology coupled with optimized pre-procedural planning has expanded the use of transcatheter aortic valve implantation (TAVI) to patients with bicuspid aortic valve (BAV) disease. However, the impact of different BAV phenotypes on outcome after TAVI remains uncertain.

Methods

Patients with BAV from a single high-volume center who underwent TAVI were retrospectively classified according to the international consensus statement on nomenclature and classification of the congenital BAV. Outcome data were analyzed according to the proposed BAV phenotypes.

Results

Between 2018 and 2020, TAVI was performed in a total of 2755 patients, of which 133 had BAV (4.8%). Fused BAV type was present in 107 patients (80.5%), while two-sinus and partial fusion types were present in 5 (3.8%) and 21 (15.8%) patients, respectively. In the fused BAV group, type L-R subphenotype was present in 83 (77.6%), R-N in 18 (16.8%) and L-N in 5 (4.7%) of included patients. Mean transvalvular pressure gradient was 44.4 ± 13.4 mmHg before TAVI and 11.7 ± 4.6 mmHg after TAVI. Balloon-expandable THVs were used in 95 (71.4%), self-expanding THVs in 26 (19.5%) and mechanically-expanding THVs in 13 (9.1%) of treated patients. The frequency of pre- and post-dilatation was not significantly different across the phenotypes/subphenotypes. There was no procedural mortality. Greater than mild paravalvular aortic regurgitation after TAVI was observed in 2.3% (L-R n=3 vs. R-N n=0 vs. L-N n=0) and implantation of a new permanent pacemaker was required in 18.8%. One-year all-cause mortality was 7.2% (fused BAV n=6 vs. two-sinus BAV n=0 vs. partial fusion BAV n=2). There were no significant differences between different phenotypes/subphenotypes for both clinical and echocardiographic outcomes.

Conclusions

This is the first attempt to stratify outcomes of TAVI in BAV according to the newly proposed BAV nomenclature. Type L-R fused BAV subphenotype was the most commonly treated, and there were no significant differences between morphological phenotypes/subphenotypes with regard to clinical and echocardiographic outcomes up to one year. TAVI in adequately selected patients with BAV appears to be a safe and effective treatment option, but larger studies are required to evaluate the impact of BAV morphology on long-term clinical outcome.