Valve–anatomy match, not anatomy alone, determines 2-year survival after TAVR in BAV-1 patients

Unadjusted survival after TAVR is better for Sievers type 1 bicuspid aortic valve (BAV-1) than for tricuspid aortic valve (TAV), but this is largely explained by baseline risk differences rather than anatomy itself. Whether a survival advantage for BAV-1 can emerge with optimal valve-anatomy match remains unknown. In this single‑center retrospective study, 583 patients undergoing transfemoral TAVR (236 BAV‑1, 347 TAV) were included. The primary analysis compared BAV‑1 and TAV stratified by valve type (balloon‑expandable vs. self‑expanding). The primary endpoint was 2‑year all‑cause mortality, assessed by Cox regression with an interaction term (native valve anatomy × valve type). The primary hypothesis tested was whether the association between native valve anatomy and survival is modified by valve type. Two-year survival was significantly higher in BAV-1 vs. TAV (88.6% vs. 80.7%; adjusted HR 0.62, 95% CI 0.42–0.91, P = 0.015). A significant interaction was observed between anatomy and valve type ( P for interaction = 0.038). The BAV-1 survival advantage was robust among SEV recipients (90.4% vs. 79.5%; HR 0.46, 95% CI 0.28–0.77, P = 0.003) but attenuated in the BEV group (86.1% vs. 82.0%; HR 0.85, 95% CI 0.49–1.48, P = 0.572). In BAV-1, BEV was associated with lower PPI (6.5% vs. 17.9%, P = 0.008) and less PVR (1.6% vs. 8.0%, P = 0.025), while SEV had less severe PPM (1.8% vs. 6.5%, P = 0.091). In this observational cohort, the 2-year survival advantage of BAV-1 over TAV appeared to be modified by valve type, but this interaction should be considered hypothesis-generating. BEV and SEV each have distinct advantage profiles in BAV-1, and valve selection should be individualized based on patient-specific anatomy. Confirmation in prospective, anatomically detailed studies is required.