SEOUL VALVES 2026
Bicuspid TAVR: Asan Medical Center Data and a Contemporary Meta-Analysis
At SEOUL VALVES 2026, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), delivered a keynote lecture titled “Bicuspid TAVR – AMC Data and Meta-Analysis” in the session Advancing TAVR in 2026. He opened by noting that, although a pooled analysis of six low-risk randomized trials (N = 5,341) showed TAVR to be at least as safe as SAVR for death and disabling stroke, the bicuspid population remained conspicuously under-represented in that evidence: in NOTION-2, which enrolled patients ≤ 75 years of age, the bicuspid cohort showed numerically higher rates of death or disabling stroke after TAVR than after SAVR (6.1% vs. 2.0%; HR 3.1, 95% CI 0.3–30.0). This signal prompted the two analyses he presented.
The Asan TAVR Registry analysis included 1,879 patients treated with a balloon-expandable SAPIEN-series valve for native aortic stenosis, of whom 268 (14.2%) had a bicuspid aortic valve (BAV). The proportion of BAV rose steeply as age fell — from 5.6% in patients older than 85 years to 42.7% in those aged 70 years or younger (P for trend < 0.001) — a reminder that any strategy to extend TAVR into younger populations must first solve bicuspid anatomy (Figure 1).
Figure 1. Age distribution of the Asan TAVR Registry cohort. The proportion of bicuspid aortic valve rose from 5.6% in patients >85 years to 42.7% in those ≤70 years (P for trend < 0.001).
Compared with tricuspid patients, BAV patients were younger (77.0 ± 6.2 vs. 80.8 ± 5.6 years), more often male (67.9% vs. 43.4%), and at lower surgical risk (STS-PROM 2.7 vs. 3.7; all P < 0.001). Aortic stenosis was more severe (peak velocity 5.0 vs. 4.7 m/s; mean gradient 58 vs. 52 mmHg), and CT demonstrated a consistently larger and more complex aortic valve complex: annulus area 510.8 ± 96.5 vs. 434.0 ± 76.0 mm², LVOT area 506 vs. 419 mm², sinus of Valsalva area 992 vs. 812 mm², and higher coronary ostia. The most striking difference was leaflet calcification, roughly twice as heavy in BAV (median 744 [364–1176] vs. 371 [198–634] mm³) and characteristically asymmetric along the raphe (Figure 2).
Figure 2. Leaflet calcification volume in bicuspid versus tricuspid aortic stenosis (median 744 vs. 371 mm³).
These anatomical features translated directly into procedural differences. Larger prostheses were implanted more often (29 mm THV in 27.6% vs. 10.3%), device-to-annulus area oversizing was lower (104.2 ± 6.5% vs. 110.1 ± 6.0%), and balloon pre-dilation was performed far more frequently (76.5% vs. 45.3%). Notably, less oversizing was applied in BAV across every calcium volume stratum, not only in the most heavily calcified valves.
At 30 days, BAV patients experienced more paravalvular aortic regurgitation greater than mild (9.3% vs. 2.7%), more aortic annular or root injury (2.2% vs. 0.8%) and more cardiac tamponade (1.9% vs. 0.4%), yielding a higher composite procedural endpoint (11.9% vs. 4.3%; P < 0.001). Mortality at 30 days was nevertheless identical (0.7% vs. 0.8%), and new permanent pacemaker implantation (7.1% vs. 7.1%), major vascular complications (3.4% vs. 3.4%) and severe prosthesis–patient mismatch (6.4% vs. 4.1%) did not differ (Figure 3). He summarized this pattern as “more complications in bicuspid, without excess mortality.”
Figure 3. Thirty-day procedural outcomes: more complications in bicuspid anatomy, without excess mortality.
Hemodynamic performance was reassuring. Indexed effective orifice area was comparable between BAV and tricuspid patients through two years, and this held true across all calcification strata, including valves with more than 1,000 mm³ of leaflet calcium. In a propensity-matched cohort of 259 pairs, two-year death was numerically lower in BAV patients (6.9% vs. 13.4%; P = 0.42), attributed largely to their younger age, while stroke was slightly but not significantly higher (3.7% vs. 2.4%; P = 0.20) (Figure 4).
Figure 4. Two-year death and stroke in the propensity-matched cohort (259 pairs).
To place these single-center findings in a broader context, he presented a meta-analysis of 52 studies (Kumar S, Ahn JM, et al. JACC Advances, in press) addressing two questions. For TAVR in bicuspid versus tricuspid anatomy (39 studies), BAV was associated with higher early risk: moderate or greater paravalvular leak (RR 1.44), aortic root injury (RR 1.83), 30-day stroke (RR 1.27) and 30-day mortality (RR 1.25). By one year, however, mortality (RR 0.84) and stroke (RR 1.00) no longer differed, and STS score rather than valve morphology predicted one-year death. Meta-regression further showed that outcomes of bicuspid TAVR improved progressively with publication year (RR 0.93 per year; P for trend = 0.048), consistent with iterative gains in device technology and implantation technique (Figure 5).
Figure 5. Central illustration of the meta-analysis of 52 studies: TAVR in bicuspid versus tricuspid anatomy, and TAVR versus SAVR in bicuspid stenosis.
For the second question — TAVR versus SAVR in bicuspid stenosis (13 studies) — the evidence was limited and described a trade-off rather than a clear winner. TAVR carried more moderate or greater paravalvular leak (RR 7.08) and more permanent pacemaker implantation (RR 2.13), whereas major bleeding was substantially less frequent with TAVR (RR 0.27). Thirty-day stroke and mortality did not differ, and there were no data supporting a categorical preference for surgery in bicuspid anatomy.
He concluded that carefully selected patients with BAV could undergo TAVR with current-generation devices, and offered several guiding principles:
Procedural complications remained more frequent in BAV, so meticulous patient selection and pre-procedural CT planning were essential.
Sizing should incorporate calcification volume and its distribution; less oversizing combined with liberal pre-dilation was the strategy adopted at Asan Medical Center.
Post-procedural optimization mattered increasingly as the treated population became younger and lifetime management came into play.
Not all bicuspid anatomies were suitable for TAVR. Just as the echocardiographic score guides balloon valvuloplasty in rheumatic mitral stenosis, a BAV-specific scoring system should be developed to guide the choice between TAVR and SAVR.
His lecture underscored that bicuspid anatomy remained one of the most demanding frontiers in transcatheter therapy — technically manageable today, but still awaiting the dedicated selection tools and long-term durability data needed to treat the younger patients in whom bicuspid disease predominates.
Keynote Session: Advancing TAVR in 2026
Thursday, August 6, 1:00 PM ~ 2:00 PM
Main Arena, Level 2
Watch Session Video
September 3, 2026 458
