Bicuspid Aortic Valve Stenosis

Abstract

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis. A series of trials in which patients were randomized to receive TAVR or surgical valve replacement have provided arguably the best data collected for this intervention. [1][2][3][4][5][6] The 2 most recent randomized clinical trials involving patients who have less than 3% risk of surgical operative mortality suggest that TAVR might be the preferred treatment strategy for this particular patient group. 5,6 The patient group tested is a critical factor for all randomized clinical trials and determines the potential for generalizability. The data from the trials involving low-risk patients are compelling and should lead to both a class I indication for TAVR in low-risk patients as well as commercial approval in the United States. When this occurs, the clinicians who provide care for patients with structural heart disease will need to grapple with patient age and whether TAVR is appropriate for patients who had been excluded from previous TAVR trials because of their bicuspid aortic valves. The mean age of the patients in the 2 randomized clinical trials involving patients at lower risk of surgical mortality 5,6 was 10 years younger than patients at higher risk of surgical mortality (73-74 years). The prevalence of bicuspid aortic valves in the patient group older than age 80 years is about 20% but is approximately 60% among younger patients aged 60 through 80 years 7 and will represent a greater percentage of the patients who are evaluated for severe aortic stenosis. Understanding the ability to treat bicuspid aortic valve in its various phenotypes with TAVR and the risks involved is a primary concern for the subspecialty area of structural heart disease.A previous study suggested that the first-generation TAVR valves had suboptimal outcomes in patients with bicuspid aortic valves but that later-generation valves might have outcomes similar to those seen in patients with trileaflet valves. 8 In the study by Makkar and colleagues 9 reported in this issue of JAMA, the authors examined outcomes for TAVR using the current-generation Sapien S3 valve from the Transcatheter Valve Therapies (TVT) Registry for patients at high-or intermediaterisk. This large study included 81 822 consecutive patients having TAVR using the current-generation valve, of which 2726 had bicuspid aortic valve TAVR and 79 096 had trileaflet TAVR. Propensity matching based on 25 covariates was used to generate 2691 similar pairs. The primary outcomes analyzed were 30-day and 1-year mortality and risk of stroke. Secondary outcomes included procedural complications, hemodynamic measures, and quality-of-life measurement.

Transcatheter Aortic Valve Implantation Current Indications and Future Directions

“…In a propensity score matched patient cohort of almost 2,700 patients with bicuspid and tricuspid aortic valves, the STS/ACC TVT Registry provided similar rates of mortality between groups at 30 days, but higher rates of stroke among patients with BAV disease. Patients with BAV were at higher risk for conversion to open heart surgery, but had similar hemodynamic outcome, paravalvular aortic regurgitation and health related quality of life after successful TAVR at 12 months, when compared with tricuspid aortic valve patients (30,31). While the results of this large patient cohort are reassuring, it remains to be elucidated, whether differences in BAV phenotype-according to raphe morphology (32) or the Sievers classification (31, 33)-may affect procedural success and clinical outcomes with TAVR.…”

Development of Innovative Biomaterials and Devices for the Treatment of Cardiovascular Diseases

“…Heart valve disease, as a common cardiovascular disease, has become one of the important reasons for the high mortality of cardiovascular disease. [78,79] What is more, due to the particular position of the heart valve, there are no effective drugs for treatment of severe heart valve disease in clinic, and the artificial heart valve replacement has been the optimal solution. [80,81] However, traditional surgical valve replacement (SVR) through thoracotomy suffers from the high risk and the long recovery time, and about one-third of patients are not suitable for SVR.…”

Bicuspid Aortic Valve—A Common Form of Structural Heart Disease

“…3 Therefore, with most of the bicuspid valves having 1 raphe, it would be expected that these valves had some degree of distortion of the orifice shape. Even among this most common anatomical type of bicuspid valve, characterized by fusion of the left and right coronary cusps, depending on the extent of cusp fusion and the length of the raphe, the orifice may be more or less asymmetrical, 6 with greater degrees of asymmetry potentially setting the stage for the development of clinical aortic stenosis over time. Among the newborns in this study with bicuspid aortic valves, it is noteworthy that only 1 had bicuspid aortic stenosis.…”