Surgical vs. trans-catheter aortic valve replacement in patients With bicuspid aortic valve stenosis

Aortic valve stenosis can be treated surgically or with transcatheter aortic valve implantation (TAVI). However, bicuspid aortic valve (BAV) anatomy presents unique challenges that may affect procedural outcomes. We aimed to compare outcomes between the two approaches.

a retrospective cohort of 480 patients with BAV stenosis: 75 (16%) underwent TAVI and 405 (84%) underwent SAVR. Median age was 76 (Q1-Q3: 72-82) in the TAVI group and 61 (Q1-Q3: 52-70) in the SAVR group. Patients with isolated aortic insufficiency were excluded. Primary analyses were adjusted for age, sex, and comorbidities, followed by a sensitivity analysis using 1:1 age matching. Outcomes included overall survival, stroke/TIA, pacemaker implantation, paravalvular leak, and heart failure hospitalizations.

During a mean follow-up of 9 ± 5 years, 72 patients died (28 TAVI, 44 SAVR). TAVI was associated with higher mortality (adjusted HR = 5.9, 95% CI 2.6-12.9, p < 0.001), higher rates of pacemaker implantation (19% vs. 4%; HR = 2.6, 95% CI 1.1-6.7, p < 0.001), paravalvular leak (adjusted OR = 5.8, 95% CI 2.6-12.7, p < 0.001) and heart failure hospitalizations (IRR=7.7, 95% CI 2.7-22.2, p < 0.001). Stroke rates were similar. Age-matched analyses confirmed higher mortality (adjusted HR = 3.6, 95% CI 1.5-8.6, p = 0.004), increased pacemaker implantation (adjusted HR = 3.9, 95% CI 1.04-14.5, p = 0.002), and heart failure hospitalizations (IRR=7.7, 95% CI 3.9-15.1, p < 0.001).

In BAV stenosis, SAVR was associated with better survival and fewer complications than TAVI, while stroke/TIA rates were similar. Randomized trials are needed to determine the optimal treatment approach.