Outcomes of Transcatheter Aortic Valve Replacement in Mixed Aortic Valve Disease: A Comparison Between Bicuspid and Tricuspid Valves

Background The impact of aortic valve morphology on outcomes after transcatheter aortic valve replacement in patients with mixed aortic valve disease, characterized by the coexistence of aortic stenosis and regurgitation, remains poorly defined. This study aimed to compare outcomes of transcatheter aortic valve replacement between bicuspid and tricuspid aortic valve morphologies in patients with mixed aortic valve disease. Methods We retrospectively analyzed 282 patients with mixed aortic valve disease who underwent transcatheter aortic valve replacement between January 2019 and June 2024, including 82 with bicuspid aortic valve and 200 with tricuspid aortic valve. Propensity score matching at a 1:1 ratio yielded 82 well‐balanced pairs. The primary end point was all‐cause death, and secondary end points included technical success, paravalvular leak, clinical adverse events, hemodynamic performance, and left ventricular reverse remodeling. Results Both groups achieved high technical success rates (97.6% versus 93.9%; P =0.443) with comparable procedural outcomes. Although mild or greater paravalvular leak occurred more frequently in the bicuspid aortic valve group, this difference did not translate into higher 1‐year all‐cause death (3.7% versus 3.7%; P >0.999) or adverse events. Hemodynamic performance and left ventricular remodeling improved significantly in both groups; however, patients with bicuspid aortic valve showed more pronounced increase in left ventricular ejection fraction (median, 6.5% interquartile range, −2.0% to 15.5% versus 0.5% interquartile range, −5.0% to 12.0%; P =0.023), whereas the degree of reverse remodeling was less evident (median, −7.0 interquartile range, −17.0 to −3.0 versus −11.0 interquartile range, −20.0 to −6.0 mm; P =0.045). Conclusions In patients with mixed aortic valve disease undergoing transcatheter aortic valve replacement, bicuspid aortic valve morphology was associated with more mild or greater paravalvular leak but similar procedural safety, hemodynamic outcomes, and clinical prognosis compared with tricuspid aortic valve, with distinct left ventricular recovery patterns.