Repositionable and retrievable Lotus Valve System for the treatment of bicuspid aortic stenosis: is it time to treat all valves?

INTRODUCTION: For a long time, a bicuspid valve has been considered a contraindication to transcatheter aortic valve implantation (TAVI) due to worse procedural results. Currently available technologies are changing the scenario, with initial experiences reporting much better results with second-generation devices. Areas covered: This review will analyze the risk and potential pitfalls of TAVI on bicuspid valves and will try ascertain how the use of a new-generation fully repositionable device, the Lotus Valve System (LVS), could improve procedural and clinical results in bicuspid anatomies. Expert commentary: The LVS offers relevant potential advantages that could be helpful in bicuspid anatomies: its mechanical controlled expansion can reduce the risk of elliptical deployment; its adaptive seal may reduce final paravalvular leak and give the possibility of checking the final result before final deployment, with the opportunity of fully resheating or repositioning, which is crucial to minimize malpositioning and abolish final residual gradients. Although limited in population, preliminary data show good outcomes with LVS on bicuspid anatomies. Future studies are to be encouraged to confirm whether this device could be considered the first choice in this challenging anatomy and whether clinical outcomes, in presence of an excellent procedural result, could be ever compared to those obtained with surgery.