Preoperative symptoms and survival after SAVR in bicuspid and tricuspid aortic stenosis

Background This study evaluated the prognostic impact of preoperative symptom severity in patients with bicuspid (BAV) and tricuspid (TAV) valve morphology undergoing surgical aortic valve replacement (SAVR) for severe aortic stenosis. Methods In this single-centre observational study, 1054 patients with preserved left ventricular ejection fraction undergoing isolated SAVR (± concomitant aortic surgery) between 2005 and 2021 were included. Patients were stratified by valve morphology (516 BAV; 538 TAV) and symptom burden using the New York Heart Association (NYHA) classification. NYHA I–II defined mildly symptomatic and NYHA III–IV highly symptomatic patients. The primary endpoint was all-cause mortality. Survival was assessed using Kaplan–Meier analysis and multivariable Cox regression including the interaction between valve morphology and symptom severity. Relative survival was calculated using age-, sex-, and calendar year–matched life tables. Results BAV patients were younger with fewer comorbidities than TAV patients. Over a median follow-up of 8.6 years, 15-year survival among mildly vs highly symptomatic patients was 78% vs 54% in BAV (P < .001) and 41% vs 26% in TAV (P = .005). A significant interaction between valve morphology and symptom severity (P = .029) demonstrated a disproportionately worse prognosis in highly symptomatic BAV patients. At 15 years, relative survival was 82% (95% CI 69-97%) in highly symptomatic BAV patients vs 105% (95% CI 93%–119%) in mildly symptomatic BAV patients, whereas TAV patients showed reduced relative survival regardless of symptom severity. Conclusions Preoperative symptom severity significantly influenced long-term outcomes in BAV but not TAV patients, suggesting earlier surgery may be particularly beneficial in BAV patients.