Transcatheter Aortic Valve Replacement for Bicuspid Versus Tricuspid Aortic Stenosis: A Systematic Review and Meta-Analysis

Background:Although the bicuspid aortic valve (BAV) is a major cause of aortic stenosis (AS), limited evidence exists regarding the safety and efficacy of transcatheter aortic valve replacement (TAVR) in BAV patients. This study aimed to compare TAVR outcomes between BAV and tricuspid aortic valve (TAV) cohorts.Methods:We conducted a systematic search of PubMed, Web of Science, Embase, and the Cochrane Library to identify studies reporting 1-year follow-up outcomes. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were derived from a random-effects model.Results:The analysis included 31 studies involving 192,691 patients. Patients with BAV were younger than those with TAV (71.2 vs. 73.2 years, p < 0.01) and exhibited lower society of thoracic surgeons (STS) scores (3.5% vs. 4.3%, p < 0.05). Compared with TAV, BAV was associated with a lower likelihood of device success (OR = 0.80; 95% CI 0.65–0.98; p = 0.03) and an increased risk of moderate/severe paravalvular leak (PVL) (OR = 1.39; 95% CI 1.22–1.58; p < 0.01). No significant differences were observed in in-hospital mortality (OR = 1.10, 95% CI 0.86–1.42; p = 0.44), or major peri-procedural complications between the two cohorts. At 30 days, all-cause mortality (OR = 1.19, 95% CI 0.96–1.47, p = 0.11) and cardiovascular mortality (OR = 1.59, 95% CI 0.87–2.90; p = 0.13) were similar between BAV and TAV groups. While 1-year cardiovascular mortality showed no significant difference (OR = 0.70, 95% CI 0.42–1.16; p = 0.17), BAV patients exhibited a significant reduction in 1-year all-cause mortality (OR = 0.84, 95% CI 0.73–0.97; p = 0.01). This survival benefit was consistent in propensity-score matched cohorts (OR = 0.78, 95% CI 0.64–0.95; p = 0.01). Subgroup analysis further identified distinct survival advantages for BAV patients who were younger (OR = 0.82, 95% CI 0.71–0.95, p = 0.01), had lower STS scores (OR = 0.68, 95% CI 0.50–0.92, p = 0.01), or received balloon-expandable valves (OR = 0.76, 95% CI 0.61–0.94, p = 0.01). Notably, 1-year all-cause mortality rates were similar when stratified by aortic diameter or paravalvular leak (PVL) incidence.Conclusion:This meta-analysis demonstrated that TAVR had similar safety and efficacy profiles for BAV and TAV patients. Additionally, BAV patients undergoing TAVR exhibited a reduced 1-year all-cause mortality compared to TAV patients.The PROSPERO Registration:CRD42025618185, https://www.crd.york.ac.uk/PROSPERO/view/CRD42025618185.