SEOUL VALVES 2025
Bicuspid TAVR: Technical Challenges and Asan Data Insights
At the 14th SEOUL VALVES 2025 meeting, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), delivered a comprehensive lecture titled “Bicuspid TAVR: All the Technical Issues and Data from Asan Medical Center.” His lecture summarized the unique anatomical and clinical challenges of bicuspid aortic valve (BAV) patients undergoing TAVR, findings from the Asan TAVR Registry and an ongoing meta-analytic review. Bicuspid aortic valve disease is typically found in younger, male-predominant populations with fewer comorbidities compared with tricuspid valve disease. Echocardiographic and CT findings show that BAV is associated with more severe aortic stenosis, larger and asymmetric annuli, and markedly higher calcification volumes. In the Asan registry, mean calcification volume in tricuspid valves is about 300 mm³, whereas in bicuspid valves it nearly doubles to around 600 mm³ (Figure 1). In surgical series, up to 65% of patients under 60 years presented with BAV, highlighting the need to consider long-term valve durability and lifetime management strategies in this younger population. Figure 1. The heavier and asymmetric calcification burden in BAV makes device sizing particularly challenging. In cases with severe calcification (>1000 mm³), nominal sizing or undersizing is used to avoid annular rupture. With lower calcification burden, oversizing may be applied, even in type 0 BAV anatomy (Figure 2). Figure 2. Procedurally, larger transcatheter valves and more frequent pre- and post-dilation are often required, increasing the potential for annular rupture, coronary obstruction, or conduction disturbances. Nevertheless, Asan data suggest that overall complication rates remain acceptable and are not significantly higher than in tricuspid cases (Figure 3). Figure 3 . Two-year echocardiographic follow-up in the Asan registry showed that BAV patients achieved comparable outcomes to tricuspid patients; 1) Effective orifice area remained favorable, 2) Prosthesis–patient mismatch (PPM) was lower in BAV patients, owing to larger annular size, and 3) Mortality and stroke rates were similar between the groups at two years (Figure 4 and 5). Still, he emphasized that long-term outcomes beyond five years remain uncertain. In the NOTION-2 trial, bicuspid patients younger than 75 years undergoing TAVR demonstrated numerically higher death and stroke rates, raising concern about durability and safety in this subgroup. Figure 4. Figure 5. In the meta-analytic review discussed during the lecture, which pooled results from 35 studies including over 13,000 BAV and nearly 200,000 TAV patients, BAV TAVR was associated with higher risks of adverse outcomes compared with tricuspid TAVR. Specifically, bicuspid patients experienced more frequent paravalvular leakage, aortic root injury, and higher rates of early mortality and stroke (Figure 6). By contrast, the incidence of permanent pacemaker implantation and major bleeding did not differ significantly between the two groups. Figure 6. When comparing TAVR and SAVR in BAV patients, published data suggest broadly similar short-term mortality and stroke rates. However, TAVR is associated with a greater risk of paravalvular leak, whereas SAVR carries a higher risk of bleeding complications (Figure 7). Figure 7. He concluded that TAVR is feasible and safe in carefully selected bicuspid patients with current-generation devices, but several key principles must guide practice: Meticulous patient selection and pre-procedural CT planning are essential. Sizing algorithms incorporating calcification volume help mitigate complications. Strategies to reduce pacemaker implantation are particularly important in younger patients. Not all bicuspid anatomies are suitable for TAVR—there is a clear need for a BAV-specific scoring system to guide decision-making between TAVR and SAVR. His lecture underscored that bicuspid anatomy remains one of the most challenging frontiers in TAVR. With ongoing data collection and refinement of devices and implantation techniques, patient-tailored strategies will be critical to optimizing outcomes for this complex group. Live Case & Lecture 2: Complex TAVR (Bicuspid) Thursday, August 7, 2:00 PM-3:30 PM Main Arena, B2 Watch Session Video
August 29, 2025 985
