Transcatheter aortic valve replacement in bicuspid versus tricuspid aortic valves among patients with mixed aortic valve disease

Mixed aortic valve disease (MAVD), defined as the coexistence of significant aortic stenosis (AS) and aortic regurgitation (AR), presents unique diagnostic and therapeutic challenges. Prior studies rarely distinguished bicuspid valve morphology in MAVD populations, and no study has evaluated long-term transcatheter aortic valve replacement (TAVR) outcomes between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients in this setting. The aim is to investigate the clinical outcomes of BAV versus TAV morphology in patients with MAVD undergoing TAVR. Between March 2013 and December 2024, 610 MAVD patients undergoing TAVR were included. Patients with severe AS and concomitant presence of moderate or more severe aortic regurgitation were defined as the MAVD. Clinical outcomes, functional status and echocardiography were followed and compared. A total of 610 patients were included in this study, 220 (36.1%) of whom were BAV morphology. BAV patients were younger (73 vs. 75 years, p < 0.001) and had a lower Society of Thoracic Surgeons (STS) score (3.47% vs. 4.15%, p < 0.001) compared to TAV patients. The five-year mortality rate was lower in bicuspid than tricuspid patients (10.5% vs. 18.7%, log-rank p = 0.014), while Cox regression analysis did not indicate BAV as an independent predictor of five-year all-cause mortality after multivariable adjustment (hazard ratio [HR] 0.75, 95% confidence interval [CI]: 0.47–1.22, p = 0.253). During the one-year follow-up after procedure, BAV patients exhibited a greater increase in AVA and LVEF (p for interaction = 0.012 and 0.011, respectively), and a greater reduction in mean gradient and peak velocity (both p for interaction < 0.001). Meanwhile, similar left ventricular reverse remodelling was found during follow-up (both p for trend < 0.001). In MAVD patients undergoing TAVR, bicuspid and tricuspid valve morphologies demonstrated comparable long-term clinical outcomes. BAV patients demonstrated greater improvements in left ventricular function and transvalvular hemodynamics, suggesting that bicuspid morphology itself does not confer an adverse long-term prognostic effect in appropriately selected patients with MAVD undergoing TAVR. NCT02803294.