Late outcome of patients with a bicuspid aortic valve undergoing surgical aortic valve replacement in the transcatheter era

Objectives This study aimed to evaluate short- and long- term clinical outcomes of bicuspid aortic valve (BAV) patients who underwent surgical aortic valve replacement (SAVR) at a single high-volume center before and after the introduction of transcatheter aortic valve implantation (TAVI). Methods We retrospectively analyzed the data of 2378 BAV patients who underwent primary SAVR at the Quebec Heart & Lung Institute-Laval University between 2000 and 2024. The primary study endpoint was all-cause mortality, and the secondary endpoint was a composite endpoint of cardiac reintervention and all-cause mortality. Follow-up was censored at 5 years, with a sensitivity analysis at 10 years. Results The mean age of the overall cohort was 64±9 years, and the mean EuroSCORE II was 3.05±3.45. Among the cohort, 1,999 (84%) underwent a biological SAVR and 379 (16%) a mechanical SAVR. After 2010, mechanical valve use decreased significantly (31% vs 10%, p<0.001) while concomitant procedures increased (50% vs 60%, p<0.001). In hospital mortality was significantly higher in the pre-TAVI vs. TAVI era (2% vs. 0.5%; p=0.01) but the mid-term survival and even-free survival were not statistically different between the two time periods. Time period (pre-TAVI vs. TAVI era) was not associated with increased risk of clinical events. In multivariable analysis, age (HR=1.06 per each year increase; 95% CI, 1.04-1.09) and COPD (HR=3.17; 95% CI, 2.11-4.78) were independently associated with increased all-cause mortality at 5 years. Concomitant procedures, including CABG, ascending aortic replacement and annular enlargement, were not associated with all-cause mortality or the composite endpoint (all log-rank p>0.08). Results were consistent in the 10-year sensitivity analysis. Conclusion SAVR in BAV patients is associated with excellent long-term outcomes. Concomitant procedures do not appear to adversely impact long-term outcomes. These findings may help inform lifetime management strategies, particularly in the context of the evolving role of TAVI in this population.