Safety and efficacy of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in patients with bicuspid aortic stenosis: A Systematic review and meta-analysis

Abstract

Background

Bicuspid aortic valve (BAV) disease is a leading cause of aortic stenosis (AS). Surgical aortic valve replacement (SAVR) has traditionally been regarded as the best therapeutic option for bicuspid AS. However, the distinctive anatomical characteristics of BAV make the treatment with transcatheter aortic valve replacement (TAVR) challenging, so this population was often excluded from the trials. We aimed to compare TAVR and SAVR in terms of safety and efficacy in the population with bicuspid AS.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies, searched from PubMed, Cochrane, Scopus, and Web of Science (from inception until September 2025). Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes as mean differences (MDs), each with 95% confidence intervals (CIs).

Results

A total of 78,677 patients were included in one RCT, 12 retrospective cohort studies, and one prospective cohort study. TAVR, compared to SAVR, was associated with significantly higher rates of permanent pacemaker implantation (PPI) (O.R. = 2.29, 95% C.I. [1.51, 3.47], P < 0.01) and shorter length of hospital stay (M.D. = −2.24, 95% C.I. [-3.96, −0.52], P = 0.01) and lower bleeding rates (O.R. = 0.31, 95% C.I. [0.14, 0.69], P < 0.01). However, there were no significant differences in all-cause mortality (ACM) (P = 0.948), acute kidney injury (AKI) (P = 0.28), stroke incidence (P = 0.475), and vascular complications (P = 0.31). The PPI and stroke rate results were consistent during in-hospital and short-term follow-ups. However, subgroup analysis by follow-up duration revealed that long-term stroke incidence was significantly higher in the TAVI group.

Conclusion

TAVR offers benefit by minimizing significant bleeding and hospital length of stay. However, the benefits should be balanced against the considerably increased risk of PPI and PVL. Further RCTs are needed to confirm these findings.

Keywords

SAVR TAVR dyslipidemia bicuspid AS aortic stenosis meta-analysis systematic review

Introduction

Bicuspid aortic valve (BAV) disease is the most prevalent congenital heart disease and leading cause of aortic stenosis (AS) in young people. Up to 50% of people with BAV require aortic valve replacement during their lifespan.¹ The number of older patients with bicuspid AS is also rising. A BAV accelerates disease progression, raises the risk of AS, and also poses hurdles to treatments due to its distinctive anatomical characteristics, including aortopathy cusp fusion with a calcified raphe, and asymmetric leaflet calcification.^2,3

The flow hemodynamics of the aortic valve in bicuspid cases leads to premature leaflet degradation. Compared to tricuspid aortic valves, stenotic BAVs contain more calcified leaflets and raphes, as well as dilatation of the aortic annulus and root.³ The British Society of Echocardiography advocates routine echocardiograms for patients with BAV to assess valve hemodynamics, severity of stenosis, and left ventricular function.⁴

Surgical aortic valve replacement (SAVR) has traditionally been regarded as the best therapeutic option for bicuspid AS because of its younger age of presentation compared to tricuspid AS and concomitant aortopathies, which generally require aortic root repair.¹ Concomitant aortopathy necessitates aortic root repair, posing a risk of aortic dissection and presenting technical obstacles due to bicuspid anatomy.^5,6 However, the advent of transcatheter devices during the last two decades has led to debate regarding the best management strategy for patients with AS.

Early randomized controlled trials (RCTs) suggested that transcatheter aortic valve replacement (TAVR) was initially reserved for patients with significant surgical risk and contraindications to SAVR.^5,7 Subsequent trials found that TAVR was not inferior to SAVR in intermediate-risk individuals.^8,9 Recent RCTs found that tricuspid AS results were equivalent following TAVR and SAVR, especially in low-risk patients.^10,11 The PARTNER III trial found that TAVR in low-risk patients reduced the risk of death, stroke, or rehospitalization after 1 year.¹⁰ Patients with BAV were excluded from clinical studies due to technical concerns regarding their characteristics and potential for aortopathy.

With more experience with TAVR and a lower threshold for younger and lower-risk patients, there is potential in expanding the procedure to individuals with bicuspid AS. Although TAVR is commonly used in high- and extreme-risk AS patients, BAV patients with AS were omitted from pivotal trials that led to its approval in the US.^5,7,8 We aimed to compare the safety and efficacy outcomes after SAVR and TAVR in stenosis of BAV.

Methods

Protocol registration

This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020¹² (Table S1) and adhere to the Cochrane Handbook for intervention.¹³ The review protocol was registered in PROSPERO with ID: CRD420251155812 .

Data sources and search strategy

PubMed, SCOPUS, Web of Science, and Cochrane Library databases were searched from inception up to September 2025 using the search terms related to “Bicuspid Aortic Valve Disease,”, “SAVR,” and “TAVR”. The detailed search terms used for each database are written in (Table S2). Manual backward and forward citation analyses were done for all the references of the included studies.

Eligibility criteria

Eligible studies were RCTs and observational studies that had the following PICO criteria

• Population (P): Patients with bicuspid aortic valve (BAV) stenosis.

• Intervention (I): Transcatheter aortic valve replacement (TAVR).

• Comparator (C): Surgical aortic valve replacement (SAVR).

• Outcomes (O): The primary endpoints were permanent pacemaker implantation (PPI), all-cause mortality (ACM), and stroke. Secondary endpoints included length of hospital stay and need for valve reintervention. Safety outcomes were incidence of myocardial infarction (MI), acute kidney injury (AKI), bleeding events, vascular complications and paravalvular leak (PVL).

There were no restrictions based on sex, ethnicity, setting, or publication date. We excluded the previous reviews, cross-sectional studies, single-arm studies, case reports, case series, conference abstracts, preclinical studies, animal studies, editorial studies, non-English studies, pharmacokinetics, and pharmacodynamics studies, which had no clear clinical outcomes.

Study selection

The retrieved references were screened in two steps by four reviewers working in two independent pairs (O.H.A., A.A.A., F.A.A., F.S.A.). At both the title/abstract and full-text levels, each record was screened independently by two reviewers; disagreements were resolved by discussion within the pair or, if needed, by another reviewer (A.M.). The Rayyan website was used for the selection process.¹⁴

Data extraction

Using a standard Google spreadsheet, four authors independently (A.F.A., T.N.A., R.M.A., A.G.A.) extracted the data, and any conflicts were resolved by discussion within the pair or, if needed, by another reviewer (A.M). Extracted data were divided into three domains:

(1) Study characteristics: (study ID, study design, country, registry, trial name, time frame, total sample size, inclusion criteria, follow-up duration (months), and conclusion).

(2) Baseline characteristics: (number of participants, age, percentage of male participants, body mass index (BMI), distribution of New York Heart Association (NYHA) functional class III–IV, medical history of hypertension, smoking, dyslipidemia, heart failure, chronic kidney disease, chronic liver disease, coronary artery disease, myocardial infarction, atrial fibrillation, peripheral vascular disease, stroke, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and history of pacemaker or defibrillator implantation).

(3) Study outcomes: Included efficacy and safety outcomes as maintained before.

Quality assessment

Two reviewers independently (O.H.A., A.A.A.) assessed the risk of bias in included RCTs using the Cochrane Risk of Bias (ROB-2) assessment tool.¹⁵ This evaluation encompassed an assessment of the randomization process, concealment of the allocation sequence, deviations from the intended interventions, utilization of appropriate analysis to estimate the effect of assignment to intervention, measurement of the outcome, selection of the reported results, and overall risk of bias. Observational studies were appraised using the Newcastle–Ottawa Scale (NOS), which evaluates study quality across three categories: adequacy of the sample, comparability between intervention and control groups, and outcome assessment.¹⁶ Any discrepancies were resolved through consultation with a third investigator.

Statistical analysis

We used R version 4.3 and the meta packages for statistical analysis.¹⁷ We pooled results from the studies included in our analysis using mean differences (MDs) with 95% confidence intervals (CIs) for continuous data, and odds ratios (ORs) for dichotomous data. When the reported data were not normally distributed, we converted data presented with median and interquartile range (IQR) to mean and standard deviation (SD).¹⁸ A random-effects model using the restricted maximum likelihood (REML) estimator was applied to account for potential between-study heterogeneity. We used the chi-square test and quantified heterogeneity using the I-squared (I²) test, which quantifies the percentage of heterogeneity not attributed to chance. Heterogeneity was considered statistically significant if the chi-square test p-value was less than 0.1. Heterogeneity was interpreted according to the Cochrane Handbook, with an I² value of 0–40% indicating low heterogeneity, 30–60% indicating moderate heterogeneity, 50–90% representing substantial heterogeneity, and 75–100% signifying considerable heterogeneity. Additionally, we conducted a subgroup analysis based on the follow-up duration as follow: in-hospital follow-up, short term follow-up (post-discharge to less than 1 year), and long-term follow-up (1 year or longer). Finally, we conducted a sensitivity analysis using the leave-one-out method to test the stability of the effect size and its direction by removing one study at a time whenever possible, and utilized L’Abbé plots to show the effect of each study on the heterogeneity and the overall effect sizes.¹⁹ Publication bias couldn’t be assessed because of the limited number of included trials.²⁰

Results

Our initial search yielded 6923 potentially relevant articles, as shown in the PRISMA diagram (Figure 1). A total of 1912 duplicate studies were deleted, and 35 studies were retained for full-text evaluation. After exclusion of irrelevant studies based on our pre-determined eligibility criteria, 14 eligible articles^3–16 met all inclusion criteria.

Figure 1.

PRISMA flow chart for the systematic search and selection process.

Study characteristics

One RCT, 12 retrospective cohort, and one prospective cohort studies were published between 2019 and 2025 encompassing 78,677 BAV patients with 12,485 (15.9%) in the TAVR use arm and 66,162 (84.09%) in the SAVR, mean age 61.9 years (SD 11.5), a predominantly male representation of 51,574 male patients (65.56%), and 15,064 (19.1%) DM patients. BMI ranged from a mean of 24.1 to 28.26 kg/m2. 10 studies were from the United States; others were from Italy, Taiwan, and Finland, plus one international multicenter study (Tables 1 and 2).

Table 1.

Summary characteristics of the included trials.

Study ID	Study design	Country	Registry/Trial name	Time frame	Total sample size	Inclusion criteria	Follow-up, months	Conclusion
Kassab 2025	Retrospective cohort study, PSM.	The USA	TriNetX database	January 2012 and January 2022	1326	Patients aged ≥18 years old with confirmed BAV stenosis who underwent AVR between January 2012 and January 2022 were identified.	24	TAVR and SAVR demonstrated comparable 2-years mortality, stroke, and re-intervention rates.
Mehaffey 2025	Retrospective cohort study.	The USA	The United States centers for medicare and medicaid services (CMS) inpatient claims database.	January 2018 to December 2022.	11289	Patients aged 65 to 85 years with documented BAV undergoing isolated SAVR or TAVR.	31.2 for SAVR. 28.8 for TAVR.	Among medicare beneficiaries with BAV, TAVR was associated with a reduced index of in-hospital mortality; however, it was also linked to a lower risk-adjusted 5-years freedom from longitudinal stroke when compared to SAVR, even among the youngest patients categorized as low-risk.
Chiariello 2024	Prospective cohort study.	Italy	-	January 2015 to December 2021.	189	Patients with congenital BAV underwent isolated AVR, either with SAVR or with TAVI.	55.2	AV patients who underwent SAVR exhibited significantly slower long-term progression of AA diameter compared to those treated with a transcatheter procedure.
Chen 2024	Retrospective cohort study, PSM.	The USA	The centers for medicaid and medicare services administrative data.	2012 to 2019.	1594	Patients undergoing isolated surgical aortic valve replacement or transcatheter aortic valve replacement for bicuspid aortic stenosis.	28.8	Among matched medicare beneficiaries undergoing TAVR or SAVR for BAV stenosis, 3-years mortality was higher following TAVR. Nevertheless, TAVR was associated with a comparable early mortality risk and a reduced rate of heart failure readmissions within the first 6 months post-procedure. Randomized comparative trials are warranted to guide optimal treatment selection.
Connolly 2024	Retrospective cohort study.	The USA	The STS-ACC-TVT (society of thoracic surgeons-american college of cardiology-transcatheter valve therapy) registry and the STS adult cardiac surgery database.	January 2016 to December 2021.	152	Patients with bicuspid AS undergoing TAVR or SAVR.	1	In patients with bicuspid AS undergoing aortic valve replacement, TAVR provides a predicted EOA comparable to that achieved with SAVR. These findings support the selective use of TAVR in this population and may aid in heart team decision-making.
Ogami 2024	Retrospective cohort study, PSM.	The USA	The nationwide readmissions database (NRD).	2012 to 2018.	1146	Patients aged 65 or older who underwent TAVR and SAVR with bioprosthetic valves.	3	Ninety-day readmissions were frequent in both groups. Although readmission-related mortality was comparable between TAVR and SAVR patients, the associated hospital costs were significantly higher in the TAVR group
Jørgensen 2024	RCT	Denmark, Norway, Sweden, Finland, and Iceland.	The NOTION-2 trial	June 2016 to February 2023.	100	Patients were ≤75 years of age with a severe bicuspid AS (aortic valve area <1.0 cm2 or <0.6 cm2/m2 and mean transvalvular gradient >40 mmHg or peak jet velocity >4.0 m/s), with an estimated low 30-days mortality risk after surgery (STS score <4%) and suitable to undergo either transfemoral TAVI or SAVR.	12	In low-risk patients aged ≤75 years with severe symptomatic AS, the 1-year incidence of the composite endpoint—death, stroke, or rehospitalization—was comparable between TAVI and surgical intervention. However, outcomes following TAVI in younger patients with bicuspid AS remain uncertain and warrant further investigation.
Sanaiha 2023	Retrospective cohort study.	The USA	The nationwide readmissions database (NRD).	2012 to 2019.	56331	Adults with BAV stenosis receiving SAVR or TAVR procedures.	3	This analysis shows that in-hospital mortality and morbidity were similar between TAVR and SAVR patients during the moderate-risk era. As TAVR use expands in BAV cases, careful refinement of patient selection criteria is essential, particularly with respect to associated aortopathy and the potential need for future reintervention.
Majmundar 2022	Retrospective cohort study, PSM.	The USA	The nationwide readmission database (NRD).	2016 to 2018.	2786	Adults who underwent TAVI or SAVR for BAV stenosis.	6	In the propensity score-matched cohort, TAVI was linked to lower odds of in-hospital mortality and demonstrated comparable risks of 30-days and 6-months MACE, supporting its feasibility in BAV patients who do not require concomitant aortic root repair.
Tsai 2021	Retrospective cohort study.	Taiwan	The cheng hsin general hospital.	July 2013 to August 2018.	130	Patients with a BcAV who underwent SAVR or TAVR.	34.32	The analysis identified SAVR as a significant predictor of superior functional recovery, whereas TAVR was associated with reduced functional capacity. In conclusion, TAVR remains a viable option for AS patients with BcAV; however, early intervention targeting the enhancement of functional capacity is strongly recommended to improve prognosis in this population.
Husso 2021	Retrospective cohort study, PSM.	Finland	The nationwide FinnValve registry.	January 2008 to November 2017.	150	Patients who underwent TAVR or SAVR with a bioprosthesis for AS with or without coronary artery revascularization.	36	In patients with stenotic BAV, TAVR appears to yield early and mid-term outcomes comparable to those of SAVR. However, higher rates of PVR were observed in type 1 N-L and type 2 L-R/r-N BAV morphologies. Further large-scale studies evaluating various BAV phenotypes are required to validate these observations.
Soud 2020	Retrospective cohort study, PSM.	The USA	The national inpatient sample (NIS) database.	January 2011 to December 2014.	136	Patients with BAV who underwent TAVR and SAVR.	In-hospital	A consistent rise in TAVR utilization for patients with BAV stenosis has been observed, accompanied by a significant reduction in hospital length of stay.
Mentias 2020	Retrospective cohort study, PSM.	The USA	Medicare data.	2015 to 2017.	1398	Patients with BAV who underwent TAVR and SAVR.	20.7	TAVR is more commonly performed in higher-risk patients with BAS compared to SAVR. Despite a greater incidence of periprocedural complications in the SAVR group, midterm follow-up showed no significant differences in the risks of mortality, stroke, or HF between the two approaches.
Elbadawi 2019	Retrospective cohort study, PSM.	The USA	The national inpatient sample (NIS) database.	2012 to 2016	1950	Patients ≥18 years of age with bicuspid AS who underwent isolated SAVR or TAVR.	In-hospital	In-hospital mortality rates were comparable between TAVR and SAVR among patients with bicuspid AS. Similarly, TAVR performed for bicuspid AS demonstrated in-hospital mortality equivalent to that seen in tricuspid AS. Additional studies are necessary to clarify the long-term efficacy and safety of TAVR in the bicuspid AS population.

Abbreviations: Bicuspid Aortic Valve (BAV), Surgical Aortic Valve Replacement (SAVR), Transcatheter Aortic Valve Implantation (TAVI), Transcatheter Aortic Valve Replacement (TAVR), Randomized Controlled Trial (RCT), Major Adverse Cardiac Events (MACE), Aortic Stenosis (AS), Effective Orifice Area (EOA), Heart Failure (HF).

Table 2.

Baseline characteristics of the included patients.

Study ID	Groups	N	Age (y), mean (SD)	Sex (male), N (%)	BMI (kg/m²), mean (SD)	Past medical history, N (%)
Study ID	Groups	N	Age (y), mean (SD)	Sex (male), N (%)	BMI (kg/m²), mean (SD)	DM	HTN	Dyslipidemia	HF	CKD	Chronic liver disease	Chronic pulmonary disease	CAD	MI	AF	PVD	Stroke	PCI	CABG	Pacemaker/defibrillator implantation
Kassab 2025	SAVR	663	64.5(9.9)	463 (69.7)	-	239 (36.1)	524 (79.1)	462 (69.8)	383 (57.8)	155 (23.5)	-	141 (21.4)	383 (57.9)	-	137 (20.7)	53 (8.0)	-	-	-	-
Kassab 2025	TAVR	663	64.8 (11.6)	445 (67.1)	-	240 (36.3)	543 (82.0)	456 (68.8)	387 (58.5)	137 (20.7)	-	127 (19.3)	379 (57.2)	-	135 (20.5)	48 (7.3)	-	-	-	-
Mehaffey 2025	SAVR	8123	69 (4.45)	5455 (67.2)	-	1606 (19.8)	-	-	2255 (27.8)	1176 (14.5)	279 (3.43)	1441 (17.7)	3104 (38.2)	-	1746 (21.5)	605 (7.45)	171 (2.1)	-	0 (0)	487 (6)
Mehaffey 2025	TAVR	3166	71 (5.93)	1829 (57.8)	-	851 (26.9)	-	-	1960 (61.9)	683 (21.6)	173 (5.46)	750 (23.7)	1646 (52)	-	712 (22.5)	402 (12.7)	63 (2)	-	0 (0)	237 (7.5)
Chiariello 2024	SAVR	143	65.67 (9.47)	97 (68)	26.17 (3.22)	23 (16)	107 (75)	69 (48)	-	-	-	16 (11)	25 (17)	-	-	3 (2)	-	-	-	-
Chiariello 2024	TAVR	46	78 (7.65)	28 (61)	26.8 (5.28)	8 (17)	40 (87)	25 (54)	-	-	-	8 (17)	13 (28)	-	-	10 (22)	-	-	-	-
Chen 2024	SAVR	797	73 (5.94)	464 (58.2)	-	295 (37.1)	730 (91.6)	673 (84.4)	589 (73.9)	263 (33)	176 (22.1)	280 (35.1)	635 (80)	175 (21.9)	259 (32.5)	324 (40.7)	58 (7.3)	166 (20.8)	67 (8.4)	-
Chen 2024	TAVR	797	73.67 (8.91)	457 (57.3)	-	326 (40.9)	730 (91.6)	668 (83.8)	579 (72.7)	258 (32.4)	172 (21.6)	265 (33.3)	637 (79.9)	164 (20.6)	265 (33.3)	325 (40.8)	61 (7.7)	166 (20.8)	74 (9.3)	-
Connolly 2024	SAVR	74	66.04 (8.29)	47 (64)	28.26 (4.77)	15 (20)	51 (69)	-	52 (70)	9 (12)	1 (1)	12 (16)	32 (43)	-	16 (22)	-	-	9 (12)	-	2 (3)
Connolly 2024	TAVR	78	74.14 (8.93)	42 (54)	27.93 (5.81)	21 (27)	63 (81)	-	77 (99)	13 (17)	3 (4)	33 (42)	39 (50)	-	25 (32)	-	-	14 (18)	-	6 (8)
Ogami 2024	SAVR	573	74 (7.43)	161 (62.6)	-	367 (33.3)	896 (81.3)	716 (65)	843 (76.5)	285 (25.8)	-	279 (25.3)	674 (61.1)	-	-	163 (14.8)	-	-	-	-
Ogami 2024	TAVR	573	74.67 (8.92)	165 (61)	-	373 (35.7)	859 (82.3)	679 (65)	745 (71.3)	307 (29.4)	-	281 (26.9)	700 (67)	-	-	173 (16.6)	-	-	-	-
Jørgensen 2024	SAVR	51	70 (3.4)	29 (56.9)	25.9 (3.3)	5 (9.8)	31 (60.8)	-	-	-	-	7 (13.7)	1 (2)	1 (2)	5 (9.8)	2 (3.9)	3 (5.9)	1 (2)	-	4 (7.8)
Jørgensen 2024	TAVR	49	69.7 (3.6)	27 (55.1)	26.8 (4.6)	4 (8.2)	27 (55.1)	-	-	-	-	6 (12.2)	6 (6.1)	1 (2)	11 (22.5)	1 (2)	2 (4.1)	2 (4.1)	-	1 (2)
Sanaiha 2023	SAVR	52476	58.67 (11.12)	36313 (69.2)	-	8186 (15.6)	-	-	14011 (26.7)	-	1312 (2.5)	9078 (17.3)	11912 (22.7)	-	-	17212 (32.8)	-	-	210 (0.4)	-
Sanaiha 2023	TAVR	3855	69 (10.38)	2359 (61.2)	-	1029 (26.7)	-	-	2587 (67.1)	-	301 (7.8)	1122 (29.1)	1769 (45.9)	-	-	775 (20.1)	-	-	185 (4.8)	-
Majmundar 2022	SAVR	1393	68.1 (8.6)	858 (61.6)	-	410 (29.4)	1053 (75.6)	885 (63.5)	920 (66)	332 (23.8)	116 (8.3)	400 (28.7)	-	-	309 (22.2)	355 (25.5)	95 (6.8)	135 (9.7)	94 (6.7)	79 (5.7)
Majmundar 2022	TAVR	1393	68.3 (10.1)	867 (62.2)	-	391 (28)	1098 (78.8)	870 (62.5)	935 (67.1)	1332 (23.8)	116 (8.3)	436 (31.3)	-	-	305 (21.9)	368 (26.4)	94 (6.8)	142 (10.2)	81 (5.8)	84 (6)
Tsai 2021	SAVR	82	51.5 (32.3)	57 (69.5)	25.4 (4.4)	10 (12.2)	40 (48.8)	-	18 (22)	-	-	-	-	2 (2.4)	7 (8.5)	-	1 (1.2)	3 (3.7)	0 (0)	-
Tsai 2021	TAVR	48	65.7 (7.8)	28 (58.3)	24.1 (3.7)	16 (33.3)	29 (60.4)	-	15 (31.3)	-	-	-	-	2 (4.2)	8 (16.7)	-	7 (14.6)	14 (29.2)	1 (2.1)	-
Husso 2021	SAVR	75	75.7 (6.3)	41 (54.7)	27.3 (4.9)	11 (14.7)	-	-	-	-	-	19 (25.3)	21 (28)	-	38 (50.7)	-	7 (9.3)	6 (8)	-	2 (2.7)
Husso 2021	TAVR	75	75.8 (8.4)	42 (56)	27.2 (4.6)	16 (21.3)	-	-	-	-	-	16 (21.3)	21 (28)	-	29 (38.7)	-	6 (8)	12 (16)	-	5 (6.7)
Soud 2020	SAVR	68	64.6 (12.4)	49 (72.1)	-	16 (23.5)	25 (36.8)	29 (42.6)	3 (4.4)	14 (20.6)	4 (5.9)	16 (23.5)	3 (4.4)	-	23 (33.8)	13 (19.1)	7 (10.3)	-	-	-
Soud 2020	TAVR	68	65 (14.8)	46 (67.6)	-	16 (23.5)	49 (72.1)	39 (57.4)	0 (0)	13 (19.1)	2 (68)	17 (25)	3 (4.4)	-	25 (36.8)	16 (23.5)	7 (10.3)	-	-	-
Mentias 2020	SAVR	699	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Mentias 2020	TAVR	699	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
Elbadawi 2019	SAVR	975	65.20 (11.52)	620 (63.6)	-	300 (30.8)	630 (64.6)	-	60 (6.2)	235 (24.1)	75 (7.7)	250 (25.6)	-	-	-	295 (30.3)	110 (11.3)	70 (7.2)	85 (8.7)	35 (3.6)
Elbadawi 2019	TAVR	975	65.70 (16.53)	585 (60)	-	290 (29.7)	630 (64.6)	-	45 (4.6)	190 (19.5)	55 (5.6)	315 (32.3)	-	-	-	270 (27.7)	90 (9.2)	85 (8.7)	100 (10.3)	40 (4.1)

Abbreviations: BMI (Body Mass Index), SD (Standard Deviation), DM (Diabetes Mellitus), HTN (Hypertension), HF (Heart Failure), CKD (Chronic Kidney Disease), CAD (Coronary Artery Disease), MI (Myocardial Infarction), AF (Atrial Fibrillation), PVD (Peripheral Vascular Disease), PCI (Percutaneous Coronary Intervention), CABG (Coronary Artery Bypass Grafting), SAVR (Surgical Aortic Valve Replacement), TAVR (Transcatheter Aortic Valve Replacement).

Risk of bias assessment

According to the NOS tool, 12 included studies were considered to have good quality,^{3,4,6–8,10–16} while one study (Sanaiha 2023) was rated as fair quality due to limited comparability between groups, as potential confounders were not adequately controlled⁹ (Table S3). Additionally, when the Rob2 tool was used to assess the risk of bias, Jørgensen et al. showed that it has a low risk of bias⁵ (Figure S1).

Primary outcomes

PPI

The pooled analysis of 8,247 patients demonstrated a significantly higher rate of PPI in the TAVR group compared to the SAVR group (O.R. = 2.29, 95% C.I. [1.51, 3.47], P < 0.01), with the pooled studies showing substantial heterogeneity (I² = 68.6%) (Figure 2). Nevertheless, the results remained consistent across sensitivity analyses using the leave-one-out method, as the exclusion of individual studies did not alter the direction, significance, magnitude of effect, or width of the CIs (Figure S2).

Figure 2.

Forest Plot of the PPI rates. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement, PPI permeant pacemaker implantation.

In the L'Abbé plot, the studies displayed consistent positioning above the line of no effect, with all studies contained within the 95% prediction interval (PI) and 95% CI, suggesting acceptable concordance among studies despite the heterogeneity except for Majmundar et al.¹⁰ (Figure S3).

Upon stratification by follow-up timeframe, PPI was significantly higher with TAVR in hospital (OR 2.91, 95% CI [1.72, 4.92], p < 0.001) and at short term (OR 1.76, 95% CI [1.20, 2.58], p = 0.004). However, long-term follow-up showed similar PPI rate between the two groups (O.R. = 6.75, 95% C.I. [0.28, 155.47], P < 0.24) (Figure 3).

Figure 3.

Forest Plot of PPI rates subgroup analysis based on follow up duration. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement, PPI permeant pacemaker implantation.

ACM

The pooled analysis of 17,920 patients showed no significant difference in ACM rates between the TAVR and SAVR groups (O.R. = 1.23, 95% C.I. [0.84, 1.80], P = 0.29). The pooled studies demonstrated substantial heterogeneity (I² = 58.4%) (Figure 4). However, the results remained consistent across sensitivity analyses using the leave-one-out method (Figure S4). Moreover, in the L'Abbé plot, the studies showed variable distribution around the line of no effect, with most studies falling within the 95% PI and 95% CI, except for four studies^7,10–12 (Figure S5).

Figure 4.

Forest Plot of the ACM. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement, ACM All Cause-Mortality.

When stratifying studies by follow-up duration, there was no significant difference in all-cause death across all subgroups, in-hospital (O.R. = 0.97, 95% C.I. [0.42, 2.23], P = 0.948), long-term (O.R. = 1.38, 95% C.I. [0.69, 2.79], P = 0.364), and short-term follow-up (O.R. = 1.35, 95% C.I. [0.95, 1.93], P = 0.097) (Figure 5).

Figure 5.

Forest Plot of ACM subgroup analysis based on follow up duration. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement, ACM All-Cause Mortality.

Stroke

The pooled analysis of 8,036 patients revealed no statistically significant difference in stroke rates between the TAVR group versus the SAVR group (O.R. = 1.32, 95% C.I. [0.81, 2.13], P = 0.475), with moderate heterogeneity (I² = 47.9%) (Figure 6). Nevertheless, the findings demonstrated robustness when subjected to sensitivity analyses employing the leave-one-out approach (Figure S6). In the L'Abbé plot, the studies displayed heterogeneous positioning relative to the line of no effect, with most studies contained within the 95% PI and 95% CI, except for four studies^5,10–12 (Figure S7).

Figure 6.

Forest Plot of Stroke. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement.

Upon stratification of studies by follow-up timeframe, no significant differences in stroke occurrence were observed across in-hospital (O.R. = 0.99, 95% C.I. [0.79, 1.24], P = 0.931), and short-term follow-up (O.R. = 1.79, 95% C.I. [0.46, 6.99], P = 0.403). However, subgroup analysis by follow-up duration revealed that long-term stroke incidence was significantly higher in the TAVI group (O.R. = 1.43, 95% C.I. [1.04, 1.97], P = 0.029) (Figure 7).

Figure 7.

Forest Plot of Stroke rates subgroup analysis based on follow up duration. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement.

Secondary outcomes

PVL were significantly higher in the TAVR group compared to the SAVR group (O.R. = 4.60, 95% C.I. [1.43, 14.78], P = 0.01) (Figure 8). Hospital length of stay was significantly shorter in the TAVR group compared to the SAVR group (M.D. = −2.24, 95% C.I. [-3.96, −0.52], P = 0.01) (Figure S8). MI rates were comparable between the TAVR and SAVR groups (O.R. = 0.85, 95% C.I. [0.45, 1.60], P = 0.62) (Figure S9). Similarly, AKI rates showed no significant difference between the two groups (O.R. = 0.66, 95% C.I. [0.31, 1.39], P = 0.28) (Figure S10). However, bleeding rates were significantly lower in the TAVR group compared to the SAVR group (O.R. = 0.31, 95% C.I. [0.14, 0.69], P < 0.01) (Figure S11). Conversely, the two groups had similar vascular complications (O.R. = 1.77, 95% C.I. [0.59, 5.30], P = 0.31) (Figures S12). Nevertheless, valve reintervention rates showed no significant difference between the two groups (O.R. = 2.59, 95% C.I. [0.63, 10.65], P = 0.19) (Figure S13).

Figure 8.

Forest Plot of PVL. O.R. Odds ratio, CI Confidence Interval, TAVR Transcatheter Aortic Valve Replacement, SAVR Surgical Aortic Valve Replacement.

Discussion

Summary of findings

In this meta-analysis, we included 14 studies with 78,677 patients having bicuspid aortic valves and aimed to compare the safety and efficacy outcomes of TAVR and SAVR in this group. We found that TAVR was associated with a significantly higher risk of PPI compared to SAVR and this result was consistent during in-hospital and short-term follow-ups. However, there were no significant differences in all-cause mortality and stroke at follow-up. However, on subgrouping stroke outcome by follow-up duration, long-term stroke incidence was higher in the TAVR group. TAVR was superior to SAVR in reducing the risk of major bleeding and the length of hospital stay, however, it was associated with a significantly higher risk of PVL. We found no significant differences in the rates of MI, AKI, vascular complications, and the need for valve reintervention.

Interpretation of findings

There are still concerns regarding the use of TAVR in BAV patients for some technical and anatomical issues. The lifelong care of patients with AS is affected by the fact that BAV patients usually develop AS at a younger age, and are at reduced surgical risk than those with senile calcific tricuspid AS.²¹ Also, it should be taken into account that there is still a lack of long-term data on TAVR. Further, the entire valve expansion in TAVR that could be potentially prevented by the non-circular orifice of BAV combined with more calcified and asymmetrical leaflets, may limit appropriate and circular expansion.²¹ For younger, operable patients with severe BAV stenosis, SAVR is currently the gold standard. TAVR has, however, lately been suggested for BAV patients, and encouraging outcomes have been documented.^22–24 The use of TAVR in BAV patients is not explicitly recommended by current guidelines, which typically advise surgery for younger patients with severe and symptomatic AS.²⁵

The NOTION-2 trial was the first to compare TAVR and SAVR in patients ≤75 years of age without excluding BAV.²⁶ BAV stenosis is more typically found in young individuals, hence, it is critical to include it in a trial comparing both treatment modalities in a young population.²⁷ In the surgical group, individuals with BAV had a lower primary event rate (3.9%) compared to those with tricuspid valves (8.3%).²⁶ BAV stenosis patients may have a lower cardiovascular risk because of their younger age.²⁷ However, given the small size of the bicuspid AS cohort in the NOTION-2 trial,²⁶ it may be possible that the observed results are affected to some degree by coincidence. TAVR was associated with lower rates of new-onset atrial fibrillation and significant bleeding compared to SAVR, as observed in earlier trials. Other reported unfavorable outcomes by previously published studies such as PPI and PVL supported surgery.^9,28–30

Recent data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies (STS/ACC TVT) registry compared 2,691 matched BAV patients with an equal number of patients who had a tricuspid valve and were deemed intermediate or high risk for open-heart surgery and underwent TAVR.³¹ All-cause death rates were comparable after 30 days (2.6% vs 2.4%) and 1 year (10.8% vs 12.1%) after the intervention.³¹ Individuals with a BAV had a 50% increased incidence of stroke after 30 days as of 2.4% compared to 1.6% for tricuspid cases.³¹

Kaang et al. reported similar rates of in-hospital mortality and stroke. Similar to our findings, they reported that patients who underwent TAVR had higher rates of PPI and PVL.³² On the other hand, patients who underwent TAVR displayed lower rates of AKI, major bleeding, and pulmonary complications.³² A more recent meta-analysis found that TAVR was associated with a much lower risk of major bleeding but a higher risk of PPI, which supports our findings. The authors found no significant differences in 30-days or mid-term mortality, stroke, major vascular complications, AKI, PVL, or conduction abnormalities.

In line with our results, other research has shown a comparable 30-days mortality and stroke rate following risk adjustment, indicating that TAVR is safe for certain bicuspid AS in current practice.^33–36 But compared to SAVR, TAVR was consistently linked to a noticeably greater rate of new PPI. According to Chen et al., the incidence of PPI was 9.2% in TAVR and 6.3% in SAVR.³⁵ This risk should be taken into account when comparing young patients with bicuspid anatomy, who have a low surgical risk for TAVR against SAVR.

Similar to other authors, Chiariello et al.³⁷ discovered that the TAVR group had a greater incidence of PPI and PVL as presented in our study.^38,39 However, the selection criteria, which included older age and worse baseline clinical conditions of patients in the TAVR group, should be regarded as a limitation in the comparison of the two groups. Chiariello et al. also reported that SAVR had greater long-term survival and improvement of clinical status.³⁷ Higher PVL in TAVR may explain our observation of an increased stroke rate at long-term follow-up. A prior study demonstrated that platelets had the ability to enter PVL channels several times across subsequent cardiac cycles, increasing the thrombogenic risk of modest PVL flows.⁴⁰ The authors found that this thrombogenic potential is determined by patient-specific PVL channel characteristics and morphologies, rather than the clinical classification of PVL.⁴⁰ According to a previous study,³⁶ PPI was more common in TAVR patients than in SAVR patients, but lower than in a major systematic study of non-BAV TAVR patients, which found a prevalence of 17%.^41,42 Preprocedural atrioventricular conduction block and intraprocedural block are known indicators of a higher chance of PPI. Along with a higher risk of annular disruption, TAVR can adversely cause higher rates of post-procedural PVL and PPI.^23,33,34 These structural issues led to the original exclusion of BAV patients from TAVR trials.^23,36,43,44 However, recent prospective and retrospective investigations have shown that TAVR has the potential to help certain BAV patients, and medium-term studies have shown comparable or superior durability.⁴⁵

Sanaiha et al. reported that although BAV patients were admitted for shorter periods of time, TAVR led to a substantial increase in expenses.³⁶ The intrinsic cost discrepancies between prosthesis utilized in open and transcatheter cases, as well as variations in preprocedural diagnostic and catheterization laboratory fees, are probably the cause of this cost disparity.⁴⁶ Other studies comparing the costs of SAVR and TAVR that have indicated a persistent discrepancy in hospitalization expenses because of TAVR device-related expenditures are considered a limitation that can present in our findings supporting TAVR.⁴⁷

Strengths, limitations, and recommendations

To our knowledge, this is the most comprehensive and updated meta-analysis comparing SAVR and TAVR in patients with BAV stenosis with the largest sample size. The majority of included studies had an observational study design, which might be a limitation of our study. Also, the lack of long-term follow-up limits the conclusion of our study. Future large-scale RCTs are needed to support these findings with long-term follow-up.

Clinical implications and future directions

While SAVR remains the recommended treatment for lower-risk individuals with BAV stenosis, our findings suggest that TAVR is a feasible and safe option for certain patients, particularly those who are older or have a higher surgical risk, with advantages like less bleeding and shorter hospital stays. The 2025 ESC/EACTS guideline recommends TAVR for older patients (≥75), those at high risk (STS-PROM/EuroScore II >8%), and those unsuitable for surgery.⁴⁸ For BAV, SAVR is recommended for patients with AS affecting the BAV and associated disease.⁴⁸

Regarding the increased risks of PPI and PVL with TAVR, heart teams must carefully weigh these issues, particularly for younger patients who bear a lifetime of life-long risk from these complications.

Conclusion

Our data indicate that in patients with BAV stenosis, TAVR is a less invasive option than SAVR, with comparable short-term mortality and stroke rates. TAVR also offers benefit by minimizing significant bleeding and hospital length of stay. However, the benefits should be balanced against the considerably increased risk of PPI and PVL. However, these findings are limited by the observational nature of the available data and the absence of long-term findings. A multidisciplinary heart team must decide between TAVR and SAVR based on particular patient factors.

Supplemental material

Supplemental material - Safety and efficacy of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in patients with bicuspid aortic stenosis: A Systematic review and meta-analysis

Supplemental material for Safety and efficacy of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in patients with bicuspid aortic stenosis: A Systematic review and meta-analysis by Ahmed Farid Gadelmawla, Ahmed Mansour, Ahmed Elbataa, Osama Hamdi Asiri, Amnah Ali Alharbi, Fatimah Ashraf Alqurais5, Fatem Saleh Al-Ibrahim, Abdulaziz Fahad AlHasani, Turki Nashi Alharbi, Ruba Mohammed AL Murayyi, Abdulelah Ghazi Alotaibi, Hamza A. Abdul-Hafez and Ihab Suliman in Perfusion

Footnotes

ORCID iD

Hamza A. Abdul-Hafez

Author contributions

A.F.G.: Conceptualization, data curation, writing review/editing; A.M.: methodology, validation; A.E.: formal analysis, software; O.H.A.: methodology, writing original draft; A.A.A.: methodology, writing original draft; F.A.A.: methodology; F.S.A.: methodology; A.F.A.: methodology; T.N.A.: methodology; R.M.A.: methodology; A.G.A.: methodology; H.A.H.: writing original draft; I.S.: project administration, supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All required data are included in the manuscript or the supplementary material. Any additional data can be obtained from the corresponding author upon a reasonable request.*

Supplemental material

Supplemental material for this article is available online.

Appendix

References

Michelena

Prakash

Della Corte

, et al. Bicuspid aortic valve: identifying knowledge gaps and rising to the challenge from the international bicuspid aortic valve consortium (BAVCon). Circulation 2014; 129(25): 2691–2704. https://doi.org/10.1161/circulationaha.113.007851

Philip

Faza

Schoenhagen

, et al. Aortic annulus and root characteristics in severe aortic stenosis due to bicuspid aortic valve and tricuspid aortic valves: implications for transcatheter aortic valve therapies. Cathet Cardiovasc Interv 2015; 86(2): E88–E98. https://doi.org/10.1002/ccd.25948

Siu

Silversides

. Bicuspid aortic valve disease. J Am Coll Cardiol 2010; 55(25): 2789–2800. https://doi.org/10.1016/j.jacc.2009.12.068

Ring

Shah

Bhattacharyya

, et al. Echocardiographic assessment of aortic stenosis: a practical guideline from the British society of echocardiography. Echo Res Pract 2021; 8(1): G19–G59. https://doi.org/10.1530/ERP-20-0035

Leon

Smith

Mack

, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363(17): 1597–1607. https://doi.org/10.1056/NEJMoa1008232

Adams

Popma

Reardon

, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 2014; 370(19): 1790–1798. https://doi.org/10.1056/nejmoa1400590

Smith

Leon

Mack

, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364(23): 2187–2198. https://doi.org/10.1056/nejmoa1103510

Reardon

Van Mieghem

Popma

, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med 2017; 376(14): 1321–1331. https://doi.org/10.1056/nejmoa1700456

Leon

Smith

Mack

, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016; 374(17): 1609–1620. https://doi.org/10.1056/nejmoa1514616

10.

Mack

Leon Martin

Thourani Vinod

, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019; 380(18): 1695–1705. https://doi.org/10.1056/nejmoa1814052

11.

Popma

Deeb

Yakubov

, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med 2019; 380(18): 1706–1715. https://doi.org/10.1056/nejmoa1816885

12.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J 2021; 372: n71. https://doi.org/10.1136/bmj.n71

13.

Cochrane handbook for systematic reviews of interventions (current version) . Cochrane [Internet]. [cited 2025 Jul 5]. Available from: https://www.cochrane.org/authors/handbooks-and-manuals/handbook/current

14.

Ouzzani

Hammady

Fedorowicz

, et al. Rayyan—A web and Mobile app for systematic reviews. Syst Rev 2016; 5(1): 210. https://doi.org/10.1186/s13643-016-0384-4

15.

Sterne

JAC

Savović

Page

, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Br Med J 2019; 366: l4898. https://doi.org/10.1136/bmj.l4898

16.

Stang

. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25(9): 603–605. https://doi.org/10.1007/s10654-010-9491-z

17.

Balduzzi

Rücker

Schwarzer

. How to perform a meta-analysis with R: a practical tutorial. Evid Base Ment Health 2019; 22(4): 153–160. https://doi.org/10.1136/ebmental-2019-300117

18.

Abbas

Hefnawy

Negida

. Meta-analysis accelerator: a comprehensive tool for statistical data conversion in systematic reviews with meta-analysis. BMC Med Res Methodol 2024; 24(1): 243. https://doi.org/10.1186/s12874-024-02356-6

19.

L’Abbe

Detsky

O'Rourke

. Meta-analysis in clinical research. Ann Intern Med 1987; 107(2): 224–233. https://doi.org/10.7326/0003-4819-107-2-224

20.

Lin

Chu

. Quantifying publication bias in meta-analysis. Biometrics 2017; 74(3): 785–794. https://doi.org/10.1111/biom.12817

21.

Gherasie

Udroiu

. Bicuspid aortic valves and transcatheter valve replacement: feasibility and safety. Maedica 2023; 18(1): 117–120. https://doi.org/10.26574/maedica.2023.18.1.117

22.

xin

feng

, et al. Ascending aortic dilatation rate after transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis: a multidetector computed tomography follow-up study. World J Emerg Med 2019; 10(4): 197.

23.

Forrest

Kaple

Ramlawi

, et al. Transcatheter aortic valve replacement in bicuspid versus tricuspid aortic valves from the STS/ACC TVT registry. Cardiovascular Interventions 2020; 13(15): 1749–1759. https://doi.org/10.1016/j.jcin.2020.03.022

24.

Yoon

Bleiziffer

De Backer

, et al. Outcomes in transcatheter aortic valve replacement for bicuspid versus tricuspid aortic valve stenosis. J Am Coll Cardiol 2017; 69(21): 2579–2589. https://doi.org/10.1016/j.jacc.2017.03.017

25.

Otto

Nishimura

Bonow

, et al. ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines. J Am Coll Cardiol 2021; 77(4): 450–500. https://doi.org/10.1016/j.jacc.2020.11.035

26.

Jørgensen

Thyregod

HGH

Savontaus

, et al. Transcatheter aortic valve implantation in low-risk tricuspid or bicuspid aortic stenosis: the NOTION-2 trial. Eur Heart J 2024; 45(37): 3804–3814. https://doi.org/10.1093/eurheartj/ehae331

27.

Roberts

. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation 2005; 111(7): 920–925. https://doi.org/10.1161/01.CIR.0000155623.48408.C5

28.

Blankenberg

Seiffert

Vonthein

, et al. Transcatheter or surgical treatment of aortic-valve stenosis. N Engl J Med 2024; 390(17): 1572–1583. https://doi.org/10.1056/nejmoa2400685

29.

Mack

Leon

Thourani

, et al. Transcatheter aortic-valve replacement in low-risk patients at five years. N Engl J Med 2023; 389(21): 1949–1960. https://doi.org/10.1056/NEJMoa2307447

30.

Fairbairn

Kemp

Young

, et al. Effect of transcatheter aortic valve implantation vs surgical aortic valve replacement on all-cause mortality in patients with aortic stenosis: a randomized clinical trial. JAMA 2022; 327(19): 1875–1887. https://doi.org/10.1001/jama.2022.5776

31.

Makkar

Yoon

Leon

, et al. Association between transcatheter aortic valve replacement for bicuspid vs tricuspid aortic stenosis and mortality or stroke. JAMA 2019; 321(22): 2193–2202. https://doi.org/10.1001/jama.2019.7108

32.

Kang

Fialka

Ryaan

, et al. Surgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: a systematic review and meta-analysis. Trends Cardiovasc Med 2024; 34(5): 304–313. https://doi.org/10.1016/j.tcm.2023.04.004

33.

Elbadawi

Saad

Elgendy

, et al. Temporal trends and outcomes of transcatheter versus surgical aortic valve replacement for bicuspid aortic valve stenosis. JACC Cardiovasc Interv 2019; 12(18): 1811–1822. https://doi.org/10.1016/j.jcin.2019.06.037

34.

Husso

Airaksinen

Juvonen

, et al. Transcatheter and surgical aortic valve replacement in patients with bicuspid aortic valve. Clin Res Cardiol 2021; 110(3): 429–439. https://doi.org/10.1007/s00392-020-01761-3

35.

Chen

Malas

Megna

, et al. Bicuspid aortic stenosis: national three-year outcomes of transcatheter versus surgical aortic valve replacement among medicare beneficiaries. J Thorac Cardiovasc Surg 2024; 168(4): 1035–1044. https://doi.org/10.1016/j.jtcvs.2023.12.002

36.

Sanaiha

Hadaya

Tran

, et al. Transcatheter and surgical aortic valve replacement in patients with bicuspid aortic valve stenosis. Ann Thorac Surg 2023; 115(3): 611–618. https://doi.org/10.1016/j.athoracsur.2022.06.030

37.

Chiariello

Di Mauro

Pasquini

, et al. Progression of the ascending aorta diameter after surgical or transcatheter bicuspid aortic valve replacement. Interdisciplinary CardioVascular and Thoracic Surgery 2024; 38(5): ivae100. https://doi.org/10.1093/icvts/ivae100

38.

Van Mieghem

Deeb

Søndergaard

, et al. Self-expanding transcatheter vs surgical aortic valve replacement in intermediate-risk patients: 5-Year outcomes of the SURTAVI randomized clinical trial. JAMA Cardiol 2022; 7(10): 1000–1008. https://doi.org/10.1001/jamacardio.2022.2695

39.

Webb

Altwegg

Boone

, et al. Transcatheter aortic valve implantation: impact on clinical and valve-related outcomes. Circulation 2009; 119(23): 3009–3016. https://doi.org/10.1161/CIRCULATIONAHA.108.837807

40.

Kovarovic

Rotman

Parikh

, et al. Mild paravalvular leak May pose an increased thrombogenic risk in transcatheter aortic valve replacement (TAVR) patients-insights from patient specific in vitro and in silico studies. Bioengineering 2023; 10(2): 188. https://doi.org/10.3390/bioengineering10020188

41.

Siontis

Jüni

Pilgrim

, et al. Predictors of permanent pacemaker implantation in patients with severe aortic stenosis undergoing TAVR: a meta-analysis. J Am Coll Cardiol 2014; 64(2): 129–140. https://doi.org/10.1016/j.jacc.2014.04.033

42.

Franzoni

Latib

Maisano

, et al. Comparison of incidence and predictors of left bundle branch block after transcatheter aortic valve implantation using the CoreValve versus the edwards valve. Am J Cardiol 2013; 112(4): 554–559. https://doi.org/10.1016/j.amjcard.2013.04.026

43.

Yousef

Simard

Webb

, et al. Transcatheter aortic valve implantation in patients with bicuspid aortic valve: a patient level multi-center analysis. Int J Cardiol 2015; 189: 282–288. https://doi.org/10.1016/j.ijcard.2015.04.066

44.

Vincent

Ternacle

Denimal

, et al. Transcatheter aortic valve replacement in bicuspid aortic valve stenosis. Circulation 2021; 143(10): 1043–1061. https://doi.org/10.1161/circulationaha.120.048048

45.

Attinger‐Toller

Bhindi

Perlman

, et al. Mid‐term outcome in patients with bicuspid aortic valve stenosis following transcatheter aortic valve replacement with a current generation device: a multicenter study. Cathet Cardiovasc Interv 2020; 95(6): 1186–1192. https://doi.org/10.1002/ccd.28475

46.

Ailawadi

LaPar

Speir

, et al. Contemporary costs associated with transcatheter aortic valve replacement: a propensity-matched cost analysis. Ann Thorac Surg 2016; 101(1): 154–161. https://doi.org/10.1016/j.athoracsur.2015.05.120

47.

Mantha

Juo

Morchi

, et al. Evolution of surgical aortic valve replacement in the era of transcatheter valve technology. JAMA Surg 2017; 152(11): 1080–1083. https://doi.org/10.1001/jamasurg.2017.2344

48.

Praz

Borger

Lanz

, et al. ESC/EACTS guidelines for the management of valvular heart disease: developed by the task force for the management of valvular heart disease of the European society of cardiology (ESC) and the european association for cardio-thoracic surgery (EACTS). Eur Heart J 2025; 29: ehaf194.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

2.78 MB