Transcatheter versus Surgical Aortic Valve Replacement in Bicuspid Aortic Valves

Background: Recent approval of transcatheter aortic valve replacement (TAVR) in patients at lower risk profiles has resulted in a real-world expansion in patients with Bicuspid Aortic Valves (BAV), otherwise excluded from trials comparing TAVR to surgical aortic valve replacement (SAVR). Compare perioperative and longitudinal outcomes between BAV patients undergoing TAVR vs. SAVR.

Methods: Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries with BAV undergoing isolated SAVR or TAVR (2018-2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk-adjustment using inverse probability weighting, multilevel regression models, and competing-risk time to event analysis. Subgroup analysis evaluated patients < 75 years with low surgical risk (< 4%).

Results: A total of 11,289 BAV patients (8,123 SAVR, 3,166 TAVR) were included. Accounting for age, comorbidities, and frailty, TAVR was associated with lower procedural mortality (OR 0.40, p<0.001), but higher pacemaker (12.4% vs 2.3%, OR 5.4, p<0.001), longitudinal stroke (2.4% vs 1.5%, HR 1.35, p<0.001) and all-cause mortality (8.8% vs 5.7%, HR 1.49, p<0.001) compared to SAVR. The young low-risk subgroup (5,393 SAVR, 1,731 TAVR) highlighted similar findings with TAVR associated with higher longitudinal stroke (2.1% vs 1.7%, HR 1.22, p=0.017) and composite stroke, valve reintervention or death (8.1% vs 5.9%, HR 1.37, p<0.001) compared to SAVR.

Conclusions: Among Medicare beneficiaries with BAV, TAVR was associated with lower index in-hospital mortality, but also lower 5-year risk-adjusted freedom from longitudinal stroke compared to SAVR even in the youngest low-risk patients.