Surgical versus Transcatheter Aortic Valve Replacement for Treatment of Bicuspid Aortic Valve Stenosis

Objectives: Even though a bicuspid aortic valve (BAV) was excluded in landmark clinical trials of transcatheter aortic valve replacement (TAVI), several reports suggest that TAVI is also feasible for treatment of BAV patients with aortic stenosis. The aim of this study was to compare clinical outcomes of surgical aortic valve replacement (SAVR) and TAVI for treatment of BAV stenosis.

Methods: Patients who underwent isolated SAVR or TAVI for treatment of BAV stenosis at a single center between 2015 and 2018 were identified. Baseline characteristics, BAV morphology, and in-hospital outcomes were compared between the two treatment groups.

Results: In the investigated time period, n = 109 patients with BAV were treated with SAVR and n = 21 with TAVI. Sievers’ type-I LR was the predominant BAV morphology comprising 64.5% in the SAVR and 81% in the TAVI group. SAVR patients were significantly younger (63 ± 11 vs. 79 ± 11 years, p = 0.04) and had lower STS PROM scores (1.1 vs. 2.3%, p = 0.3). In the SAVR group, 70.6% were treated with a biological valve. In-hospital mortality was 1.9% after SAVR and 0% after TAVI. A new permanent pacemaker was implanted in 3.8% after SAVR and 19.1% after TAVI (p = 0.01). In discharge echocardiography, the mean transvalvular gradient was 12 (9–16) mm Hg after SAVR and 10 (8–10) mm Hg after TAVI. Residual aortic regurgitation ≥ 2 degrees was not observed in neither treatment group.

Conclusion: In this analysis, SAVR and TAVI yielded satisfactory clinical in-hospital outcomes for patients with bicuspid aortic valve stenosis. While in-hospital mortality and hemodynamic function were comparable between both groups the rate of new pacemaker implantation was markedly elevated in the TAVI group. These results suggest that both treatment modalities are safe and effective for treatment of bicuspid aortic stenosis but treatment selection should be made on an individual patient base.