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TAVI in Bicuspid Aortic Valve — EECC MCQ

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ModerateValvular Heart DiseaseTAVI in Bicuspid Aortic ValveEECC

A 70-year-old man with severe symptomatic AS is assessed for TAVI. CT shows a heavily calcified bicuspid aortic valve with asymmetric calcification. He is 72 years old. Can TAVI be performed on a bicuspid valve?

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Correct answer: D — TAVI in BAV is increasingly performed but carries specific challenges: asymmetric calcification can cause elliptical deployment, paravalvular leak, and suboptimal expansion; BAV-specific sizing protocols and newer-generation devices have improved outcomes, though surgical AVR remains preferred in younger patients

TAVI in BAV has evolved: (1) early experience showed higher rates of paravalvular leak, elliptical deployment, and need for post-dilation due to asymmetric anatomy/calcification; (2) newer-generation devices (with improved sealing skirts and repositionability) have significantly improved BAV TAVI outcomes; (3) registries (STS/ACC TVT, BAVARD) show comparable 1-year outcomes between BAV and tricuspid TAVI with newer devices; (4) BAV-specific considerations: CT-based sizing uses a different algorithm (area-derived diameter using the supra-annular landing zone), calcification distribution analysis, and assessment of raphe calcification height; (5) the 2025 ESC VHD Guidelines include TAVI as an option for BAV in patients ≥70 years with suitable anatomy at experienced centres. Below 70, SAVR remains preferred (concomitant aortopathy may need addressing, longer-term durability data needed). Self-expanding valves may adapt better to the elliptical BAV anatomy than balloon-expandable in some cases.

Reference: ESC/EACTS (2025): VHD Guidelines