Long-term durability of self-expandable transcatheter heart valves in bicuspid versus tricuspid aortic valve stenosis: a matched-cohort analysis

BACKGROUND: A bicuspid aortic valve (BAV) presents unique challenges for transcatheter aortic valve implantation (TAVI), and evidence on long-term bioprosthetic durability in an BAV compared to a tricuspid aortic valve (TAV) remains limited. We aimed to compare the 5-year durability and hemodynamic performance of self-expandable TAVI in patients with BAV versus TAV stenosis, using propensity score-matched data from a large, real-world, multicentre registry. METHODS: This retrospective, multicentre analysis included patients treated with self-expandable TAVI (2009-2020) from the Medtronic One Hospital ClinicalService registry. Patients with at least one echocardiographic follow-up were matched 1 : 1 (n = 106 BAV; n = 106 TAV) based on key clinical and procedural characteristics. Primary endpoints were structural valve deterioration (SVD) and bioprosthetic valve failure (BVF), defined by VARC-3 criteria, analysed as cumulative incidence functions accounting for competing risk of death. All-cause mortality was analysed using Kaplan-Meier estimates. RESULTS: At 5 years, the cumulative incidence of SVD was 1.07% [95% confidence interval (CI): 0.09-5.26] in BAV and 1.79% (95% CI: 0.14-8.50) in TAV (P = 0.829). BVF occurred in 2.38% (95% CI: 0.44-7.62) of BAV and 2.8% (95% CI: 0.47-9.19) of TAV patients (P = 0.782). Hemodynamic performance remained stable over time, with no statistically significant differences between the mean gradients at 5 years (7.8 ± 2.8 mmHg BAV versus 9.5 ± 11.7 mmHg TAV, P = 0.304). All-cause mortality at 5 years was 41.7% (BAV) versus 51.5% (TAV, P = 0.09). CONCLUSION: In this propensity-matched, real-world multicentre cohort, BAV and TAV patients treated with self-expandable TAVI showed no statistically significant differences in 5-year durability and hemodynamic performance. These findings are hypothesis-generating and suggest TAVI may be a reasonable option for selected BAV patients, pending further validation from randomized controlled trials.