11. AngioClub: TAVR in the Bicuspid Aortic Valve with Dr. Niko Spilias and Dr. Grant Reed

!https://cathmasters.com/wp-content/uploads/2026/08/11.-AngioClub-TAVR-in-the-Bicuspid-Aortic-Valve.webp In this AngioClub-style episode from the CardioNerds CathMasters, Drs. **Amit Goyal**, **Nazli Okumus**, **Niko Spilias**, and **Grant Reed** discuss transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) stenosis. Through a case of a 71-year-old man with severe aortic stenosis (AS), reduced left ventricular ejection fraction (LVEF), a recent heart failure hospitalization, and a heavily calcified Sievers type 1 BAV, the panel works through TAVR versus surgical aortic valve replacement (SAVR) selection, lifetime management, anatomic and procedural risk (paravalvular leak \[PVL], permanent pacemaker \[PPM], stroke, annular rupture), balloon/valve sizing, cerebral embolic protection (CEP), and expected LVEF recovery. The episode highlights that BAV is not itself a contraindication to TAVR but demands meticulous CT-based planning and phenotype-specific risk stratification.  CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay # Pearls 1. **BAV was excluded from the pivotal TAVR randomized trials** — every comparison of TAVR vs SAVR in bicuspid anatomy comes from registries and observational cohorts, so shared decision-making and Heart Team review are essential. 2. **“The more tricuspid-like the bicuspid valve behaves, the more predictable the TAVR.”** Symmetric calcification and absence of a heavily calcified raphe/LVOT favor good outcomes. 3. **The highest-risk BAV phenotype is a calcified raphe plus excess leaflet calcification** — this combination tracks with roughly 3-fold higher 2-year mortality (~25.7%) and more aortic root injury and PVL; in general, avoid TAVR in these patients unless surgical risk is prohibitive. 4. **“Perfection is the enemy of the good.”** Accept mild PVL rather than aggressively post-dilating against a rock-hard calcified annulus, where chasing perfection risks annular rupture. 5. **A high mean gradient despite a low LVEF signals afterload-mediated dysfunction with reserve** — these ventricles often recover after TAVR; about one-third of low-EF patients show early LVEF improvement, and very-low-EF/low-flow cohorts recover even more. # Notes 1. **When is TAVR reasonable instead of SAVR in a bicuspid valve?** <!--THE END--> - SAVR remains first-line for truly young, low-risk BAV patients, particularly those <70–75 years, with aortopathy requiring repair, or with hostile annular/LVOT calcification. - BAV patients are increasingly encountered as TAVR expands to younger, lower-risk populations because bicuspid AS presents earlier — BAV represents ~50% of AS in younger patients and ~25% in those >80. - Registry and meta-analytic data show comparable short-term mortality but signals for higher stroke, PPM, PVL, and inferior long-term survival with TAVR vs SAVR in BAV; NOTION-2 showed a non-significant higher event rate with TAVR in the bicuspid subgroup (20.4% vs 7.8%). - The case patient’s low STS score (1.6%) underestimates true risk given severe mobility limitation, non-ischemic-appearing LV dysfunction, and a recent decompensated heart failure admission — factors not captured by STS-PROM that justified favoring TAVR after Heart Team discussion. <!--THE END--> 2. **How does lifetime management inform the index procedure?** <!--THE END--> - Lifetime management aims to minimize the number of sternotomies and to sequence interventions (redo-TAVR, valve-in-valve, TAVR explant/SAVR) optimally over a patient’s remaining lifespan. - Guidelines favor SAVR in patients <70 years with low surgical risk and TAVR as primary therapy in patients ≥70 years with tricuspid anatomy suitable for transfemoral access; all other candidates warrant individualized Heart Team decisions. - Key lifetime-management inputs include age/life expectancy, aortopathy, coronary access for future procedures, annular dimensions/patient–prosthesis mismatch, likelihood of PPM, and feasibility of future valve-in-valve. <!--THE END--> 3. **What are the anatomic and procedural risks specific to bicuspid TAVR?** <!--THE END--> - Principal risks: paravalvular leak (elliptical annulus, asymmetric sinuses, eccentric calcium), permanent pacemaker (especially right–left fusion pushing the frame toward the conduction system and with self-expanding valves), annular/root rupture, and stroke. - With new-generation devices, the historical gap in device success and PVL between BAV and tricuspid anatomy has narrowed substantially. - The highest-risk CT phenotype — calcified raphe plus excess leaflet calcification — is associated with higher aortic root injury (up to 4.5%), moderate/severe PVL (up to 6.5%), and ~25.7% 2-year mortality; this patient had excess leaflet calcification but a non-bulky raphe. - A prolonged baseline QRS (128 ms) plus right–left cusp fusion raises PPM concern; a high valve calcium score (>10,000 AU) plus internal carotid stenosis raises embolic concern. <!--THE END--> 4. **How should the balloon and valve be sized in bicuspid anatomy?** <!--THE END--> - Predilation goals are crossability and, more importantly, circular, well-expanded valve deployment within the limits of the calcium; adequate expansion of a properly sized valve is increasingly linked to reduced HALT, lower gradients, and durability. - For heavily calcified BAV, size the balloon conservatively — often to the minimum annular diameter and adjusted down further for focal annular calcium — with a low threshold to post-dilate for expansion (not to chase trivial PVL). - Balloon-expandable valves apply more radial force and expand calcified annuli more reliably; self-expanding platforms rely more on adequate predilation and are now sized/predilated to the average diameter per contemporary guidance. - Beyond the virtual basal ring, assess for root tapering and intercommissural distance a few millimeters above the annulus; downsize if the supra-annular root is restrictive to avoid root injury. <!--THE END--> 5. **When should cerebral embolic protection be used?** <!--THE END--> - The randomized PROTECTED TAVR trial found no statistically significant reduction in periprocedural stroke with CEP (2.3% vs 2.9%), though the confidence interval did not exclude benefit and disabling stroke was numerically lower (0.5% vs 1.3%). - Meta-analyses conflict: pooled randomized data (including PROTECTED TAVR and BHF PROTECT-TAVI) suggest no significant stroke reduction, whereas some analyses incorporating observational data report lower stroke. - Given the absence of a clear randomized benefit, use is individualized; a heavily calcified BAV with a very high calcium score, carotid disease, and planned predilation is a reasonable selective indication, though data does not strongly support this practice. <!--THE END--> 6. **What LVEF recovery can be expected after TAVR in low-EF AS?** <!--THE END--> - A high mean gradient (42 mm Hg here) despite LVEF 30–35% indicates predominantly afterload-mediated dysfunction with likely contractile reserve and favorable recovery potential. - Roughly one-third of high-/intermediate-risk patients with baseline LVEF <50% have early (≥10-point) LVEF improvement; low-flow/low-gradient patients with LVEF <30% show even larger absolute gains and outcomes independent of dobutamine contractile reserve. - Prior myocardial infarction, diabetes, coronary artery disease, and PPM are associated with reduced likelihood of LVEF recovery. - Case outcome mirrors this: LVEF rose to 40–45% by the next day and 55–60% at one month, with a mean gradient of 12 mm Hg, DVI 0.42, and only trace PVL. ### **References** 01. **Makkar RR, Yoon SH, Chakravarty T, et al. Association between transcatheter aortic valve replacement for bicuspid vs tricuspid aortic stenosis and mortality or stroke among patients at low surgical risk.** ***JAMA*. 2021;326(11):1034-1044.** PubMed 02. **Yoon SH, Kim WK, Dhoble A, et al. Bicuspid aortic valve morphology and outcomes after transcatheter aortic valve replacement.** ***J Am Coll Cardiol*. 2020;76(9):1018-1030.** PubMed 03. **Kapadia SR, Makkar R, Leon M, et al. Cerebral embolic protection during transcatheter aortic-valve replacement (PROTECTED TAVR).** ***N Engl J Med*. 2022;387(14):1253-1263.** PubMed 04. **Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS guidelines for the management of valvular heart disease.** ***Eur Heart J*. 2025.** PubMed 05. **Jørgensen TH, Savontaus M, Willemen Y, et al. Three-year follow-up of the NOTION-2 trial: TAVR versus SAVR to treat younger low-risk patients with tricuspid or bicuspid aortic stenosis.** ***Circulation*. 2025.** PubMed 06. Nagasaka T, Patel V, Shechter A, et al. Impact of balloon-expandable TAVR valve deformation and calcium distribution on outcomes in bicuspid aortic valve. *JACC Cardiovasc Interv*. 2024;17(17):2026-2038. PubMed 07. Baman JR, Medhekar AN, Malaisrie SC, et al. Management challenges in patients younger than 65 years with severe aortic valve disease: a review. *JAMA Cardiol*. 2023;8(3):281-289. PubMed 08. Liu J, Wei D, Wu Q, et al. Comparison of short- and long-term outcomes between transcatheter and surgical aortic valve replacement for bicuspid aortic valve stenosis: a systematic review and meta-analysis. *Int J Surg*. 2025. PubMed 09. Mehaffey JH, Jagadeesan V, Kawsara M, et al. Transcatheter vs surgical aortic valve replacement in bicuspid aortic valves. *Ann Thorac Surg*. 2025. PubMed 10. Beerkens FJ, Tang GHL, Kini AS, et al. Transcatheter aortic valve replacement beyond severe aortic stenosis: JACC state-of-the-art review. *J Am Coll Cardiol*. 2025;85(9):944-964. PubMed 11. Gupta T, Malaisrie SC, Batchelor W, et al. Decision-making approach to the treatment of young and low-risk patients with aortic stenosis. *JACC Cardiovasc Interv*. 2024;17(21):2455-2471. PubMed 12. Praz F, Beyersdorf F, Haugaa K, Prendergast B. Valvular heart disease: from mechanisms to management. *Lancet*. 2024;403(10436):1576-1589. PubMed 13. Kolte D, Bhardwaj B, Lu M, et al. Association between early left ventricular ejection fraction improvement after transcatheter aortic valve replacement and 5-year clinical outcomes. *JAMA Cardiol*. 2022;7(9):934-944. PubMed 14. Maes F, Lerakis S, Barbosa Ribeiro H, et al. Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction less than 30%: a substudy from the TOPAS-TAVI registry. *JAMA Cardiol*. 2019;4(1):64-70. PubMed 15. Otto CM, Newby DE, Hillis GS. Calcific aortic stenosis: a review. *JAMA*. 2024;332(23):2014-2026. PubMed