Impact of Transcatheter Aortic Valve Replacement in Cases with Bicuspid Aortic Valve Stenosis Compared with Tricuspid Aortic Valve Stenosis

Q: What are the key findings of this study?

In patients undergoing transcatheter aortic valve implantation, early in-hospital adverse events, including the need for permanent pacemaker implantation and paravalvular leak, did not differ significantly between bicuspid and tricuspid aortic valve anatomies.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe symptomatic aortic stenosis (n=60). Intervention: Bicuspid aortic valve morphology vs. Tricuspid aortic valve morphology. Primary outcome: Early in-hospital permanent pacemaker implantation (p=0.619).

Q: What does this research mean for the field?

Transcatheter aortic valve implantation with contemporary self-expanding valves yields early in-hospital clinical outcomes and complication rates in bicuspid aortic valve stenosis comparable to those in tricuspid aortic valve stenosis. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Hager Ibrahim Allam; Osama Sanad Arafa; Mahmoud Shawky Abd Elmoneum; Hatem Ibrahim Helal; Muhammad Aidy Hassan

doi:10.4274/ijca.2026.26918

September 29, 2026International Journal of the Cardiovascular AcademyOpen Access

Impact of Transcatheter Aortic Valve Replacement in Cases with Bicuspid Aortic Valve Stenosis Compared with Tricuspid Aortic Valve Stenosis

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Key result

Bicuspid anatomy yields similar early in-hospital adverse events to tricuspid anatomy after TAVI.

P=0.619
n=60

Why the study?

The bicuspid aortic valve poses technical challenges for TAVI due to altered valve geometry, asymmetric calcification, and larger annular dimensions, and early in-hospital outcomes compared to tricuspid valves are unclear.

Does transcatheter aortic valve implantation using contemporary self-expanding valves yield comparable early in-hospital adverse events in patients with bicuspid versus tricuspid aortic valve stenosis?

Key Points

To compare early in-hospital clinical and procedural outcomes of transcatheter aortic valve implantation (TAVI) in patients with bicuspid versus tricuspid aortic valve stenosis using contemporary self-expanding valves.
Prospective observational two-center cohort study enrolling 60 patients with significant symptomatic aortic stenosis who underwent TAVI.
Participants were categorized by aortic valve anatomy into a bicuspid aortic valve group (n=15) and a tricuspid aortic valve group (n=45) receiving Evolut R or Evolut PRO prostheses.
Annular dimensions on computed tomography were significantly larger in the bicuspid group, including mean annular area (533.07±35.31 vs. 473.79±54.31 mm2, P < 0.001; mean difference 59.3 mm2, 95% CI 29.2-89.4).
Early post-procedural complication rates did not differ significantly between bicuspid and tricuspid groups for complete heart block (13.3% vs. 6.7%), permanent pacemaker implantation (13.3% vs. 8.9%, P = 0.619), or paravalvular leak (13.3% vs. 6.7%, P = 0.423).
Vascular complications and stroke occurred in 3.3% (0% vs. 4.4%, P = 0.406) and 1.7% (0% vs. 2.2%, P = 0.560) of the overall cohort, respectively, with 0% in-hospital mortality across both groups.

Study Design

Type

Cohort (n=60)

Multicenter

Yes

Structured PICO

Does transcatheter aortic valve implantation using contemporary self-expanding valves yield comparable early in-hospital adverse events in patients with bicuspid versus tricuspid aortic valve stenosis?

P

Population

60 older adults with symptomatic severe aortic stenosis, including 15 with bicuspid and 45 with tricuspid valve morphology, who underwent transcatheter aortic valve implantation and were monitored for early in-hospital outcomes.

E

Exposure

Transcatheter aortic valve implantation (TAVI) using new-generation self-expanding Evolut R and Evolut PRO valves in patients with bicuspid aortic valve (BAV) stenosis.

C

Comparator

Transcatheter aortic valve implantation (TAVI) using new-generation self-expanding Evolut R and Evolut PRO valves in patients with tricuspid aortic valve (TAV) stenosis.

O

Outcome

Composite incidence of early (in-hospital) VARC-2-defined procedure-related adverse events, comprising permanent pacemaker implantation (PPI) for high-grade conduction disturbance, moderate-or-greater paravalvular leak (PVL), major vascular complication, stroke, and death.composite

Main Result

Absolute Event Rate: 13.3% vs 8.9%

p-value: p=0.619

TAVI using contemporary self-expanding valves yielded statistically comparable early in-hospital safety outcomes in patients with bicuspid versus tricuspid aortic valve stenosis.

Limitations

Small sample size in the bicuspid group (n=15) significantly limiting statistical power.
Single-center (two affiliated hospitals) non-randomized observational design with potential selection bias.
Lack of multivariable adjustment for baseline differences such as diabetes mellitus and annular dimensions.
Short follow-up period limited strictly to the index hospital stay.
Operator-dependent decisions without standardized sizing or detailed anatomical assessments like Sievers classification.
Small sample size, especially for the BAV group (n=15), leading to low power and increased risk of Type II error
Short follow-up limited to the in-hospital period
Lack of multivariable adjustment to account for potential confounders
Absence of systematic recording for specific BAV anatomies like Sievers classification, raphe status, calcium asymmetry, and eccentricity index
Prevalence-driven cohort rather than power-driven for specific clinical outcomes

Implication

Supports TAVI feasibility with contemporary valves in bicuspid anatomy; extends observational data but leaves open need for randomized confirmation.

Abstract

Background and Aim: Transcatheter aortic valve implantation (TAVI) is a well-established intervention for severe aortic stenosis (AS).The bicuspid aortic valve (BAV) continues to pose a technical challenge because of altered valve geometry, asymmetric calcification, and larger annular dimensions.Objectives to compare the early in-hospital clinical and procedural outcomes of TAVI in patients with bicuspid versus tricuspid aortic valve (TAV) stenosis using new-generation self-expanding Evolut R and Evolut PRO valves.We hypothesized that early in-hospital outcomes would be broadly comparable between the two groups despite the more complex bicuspid anatomy. Materials and Methods:This prospective observational cohort study enrolled 60 patients with significant symptomatic AS who underwent TAVI and were categorized by valve morphology into a BAV group (n=15) and a TAV group (n=45).Results: Diabetes mellitus was more prevalent in the TAV group than the BAV group (64.4% vs. 33.3%,P = 0.035; odds ratio 0.28, 95% confidence interval 0.08-0.95,favoring a lower prevalence in the BAV group).Annular dimensions, including the minimum, maximum, and mean annular diameters, the derived perimeter, and the annular area, were significantly larger in the BAV group (all P < 0.05).Post-procedural conduction abnormalities, complete heart block, atrial fibrillation, aortic regurgitation, and paravalvular leak did not differ significantly between groups.Mean and maximal pressure gradients after TAVI were significantly higher in the BAV group.Early adverse events were infrequent overall, with vascular complications and stroke occurring in 3.3% and 1.7% of the whole cohort, respectively, and did not differ significantly between groups.Conclusion: TAVI using contemporary self-expanding valves produced early in-hospital outcomes in BAV patients that were statistically comparable to those in TAV patients, despite significantly greater anatomical complexity, thereby supporting the feasibility of TAVI in carefully selected bicuspid patients.These early, hypothesis-generating findings from a two-center cohort warrant confirmation in larger, adequately powered, multicenter studies with longer follow-up.

Discussion

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Cite This Study

Allam et al. (2026) conducted a cohort in Severe symptomatic aortic stenosis (n=60). Bicuspid aortic valve morphology vs. Tricuspid aortic valve morphology was evaluated on Early in-hospital permanent pacemaker implantation (p=0.619). In patients undergoing transcatheter aortic valve implantation, early in-hospital adverse events, including the need for permanent pacemaker implantation and paravalvular leak, did not differ significantly between bicuspid and tricuspid aortic valve anatomies.

synapsesocial.com/papers/6ace6db8b52af824ab02bb01 https://doi.org/10.4274/ijca.2026.26918

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Impact of Transcatheter Aortic Valve Replacement in Cases with Bicuspid Aortic Valve Stenosis Compared with Tricuspid Aortic Valve Stenosis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Impact of Transcatheter Aortic Valve Replacement in Cases with Bicuspid Aortic Valve Stenosis Compared with Tricuspid Aortic Valve Stenosis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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