Transcatheter aortic valve implantation in bicuspid anatomy

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Abstract
Transcatheter aortic valve implantation (TAVI) is an established therapeutic option for high-risk patients with a tricuspid aortic valve, but patients with a bicuspid aortic valve (BAV) are contraindicated. In this Perspectives article, Zhao and colleagues summarize the available evidence for the use of TAVI in patients with a BAV and propose that this procedure might be appropriate in high-risk or inoperable individuals, but that more evidence is required before indications for TAVI can be extended to other patients with a BAV. Transcatheter aortic valve implantation (TAVI) is an established therapeutic option for high-risk patients with tricuspid aortic valve stenosis. Historically, the presence of a bicuspid aortic valve (BAV) has been regarded as a contraindication to TAVI, on the basis of putative concerns about the associated risks of elliptical deployment, accelerated leaflet degeneration, periprosthetic leaks, and aortic complications. Fortunately, with technological refinements and mounting experience, reasonable success has been achieved with TAVI in selected patients with a BAV. The rate of procedural success is high, and survival is similar to that in patients with a tricuspid aortic valve who undergo TAVI. Nevertheless, moderate or severe aortic regurgitation and aortic dissection seem to occur more frequently in patients with a BAV rather than a tricuspid aortic valve. Specifically-designed prospective studies should address these concerns and help to define anatomical selection criteria before TAVI can be recommended for patients with a BAV.

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