Bicuspid Low Risk TAVR: Are We There Yet?

A 65-year-old female patient with a history of diabetes, hypertension, and a family history of bicuspid aortic valve presents with symptomatic severe aortic stenosis (AS) with New York Heart Association Class III symptoms of dyspnea on exertion and a recent heart failure hospitalization. Echocardiography shows left ventricular ejection fraction of 60%, aortic valve area of 0.7 cm2, and mean gradient of 52 mmHg and likely bicuspid valve. Computed tomography confirms a type zero bicuspid valve with moderate leaflet calcification, no significant left ventricular outflow tract or sinotubular junction calcification. There are adequate iliofemoral conduits for transcatheter aortic valve replacement (TAVR), and there is no ascending aortic aneurysm or dilatation. Coronary angiogram shows non-obstructive coronary artery disease. After heart team discussion, the patient is deemed low surgical risk for surgical aortic valve replacement (SAVR). The patient is very concerned about bleeding risk and prefers to avoid long-term anticoagulation.

Figure 1
(L): Cardiac Computed Tomography annular reconstruction and (R): view of leaflets/sinuses of Valsalva demonstrating a Sievers Type 0 bicuspid valve.

What treatment approach would you recommend for this patient?

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