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June 11, 2019

Bicuspid Aortic Valve Stenosis: Is There a Role for TAVR?

Author Affiliations
  • 1Department of Medicine, Vanderbilt University, Nashville, Tennessee
  • 2Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Texas
JAMA. 2019;321(22):2170-2171. doi:10.1001/jama.2019.7078

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.1-6 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 mortality5,6 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 years7 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.