Transcatheter vs. surgical aortic valve replacement in bicuspid aortic valve stenosis

Patients with bicuspid aortic valve (BAV) stenosis were excluded from major TAVR trials, and data comparing TAVR and SAVR in this population remain limited. To compare real-world, risk-adjusted outcomes of TAVR vs. SAVR in patients with BAV stenosis. We conducted a retrospective cohort analysis using the TriNetX research network database. Adults (≥18 years) with echocardiographically confirmed BAV stenosis undergoing isolated TAVR or SAVR from 2012 to 2022 were included. Patients with prior cardiac procedures or concomitant cardiac interventions were excluded. Propensity score matching (PSM) (1:1) was used to balance covariates. Primary outcomes were 2-year all-cause mortality, stroke, and valve re-intervention. Secondary outcomes included new pacemaker implantation (PPM), 30-day AKI, and bleeding. 5547 patients (TAVR: 1444; SAVR: 4103) were included. In unadjusted analysis, TAVR patients were sicker and older at baseline and had a higher risk of death and/or stroke compared with those who underwent SAVR (10.9% vs. 5.37%, P < 0.0001). Following PSM, 663 matched pairs were analyzed with all covariates balanced. At 2 years, all-cause mortality (TAVR: 4.8% vs. SAVR: 5.3%; OR: 0.91, P = 0.71) and stroke (TAVR: 7.3% vs. SAVR: 4.5%; OR: 1.67, P = 0.058) were similar between the two groups. Re-intervention rates were low and comparable. TAVR was associated with higher PPM rates but lower AKI and bleeding rates. In propensity-matched BAV patients, TAVR and SAVR demonstrated comparable 2-year mortality, stroke, and re-intervention rates. These findings support TAVR as a viable option in appropriately selected BAV patients, warranting further prospective validation.