Transcatheter Aortic Valve Implantation in Complex Anatomy: An Anatomy-Driven Framework for Bicuspid Stenosis, Pure Aortic Regurgitation, and the Small Annulus in the Era of Lifetime Management

Background

Transcatheter aortic valve implantation is established for severe calcific tricuspid aortic stenosis, but its application in bicuspid aortic valve (BAV) stenosis, pure native aortic regurgitation (AR), and small aortic annulus anatomy remains limited by heterogeneous morphology, device-specific constraints, and uncertain long-term outcomes. These settings require decisions that extend beyond immediate procedural success to encompass coronary access, reintervention, valve durability, and associated aortopathy. This review synthesizes current evidence and proposes an anatomy-driven framework integrating imaging, device selection, procedural planning, and lifetime management.