Perspective:

TAVR is increasingly used for the treatment of severe calcific aortic stenosis, with expanding indications for patients at progressively lower predicted operative risk. However, patients with BAV were excluded from all TAVR pivotal trials, so the performance of TAVR among patients with BAV has been less well studied. This study used a multicenter registry to address echocardiographic and clinical outcomes after TAVR in patients with bicuspid aortic stenosis. Although CT images were interpreted at a central core laboratory, echocardiograms were not. The major findings are that leaflet and raphe calcification were predictors of all-cause mortality, aortic root injury, and paravalvular aortic regurgitation. There were a small number of patients (n = 107 [10%]) with Sievers type 0 BAV (no raphe), potentially limiting the ability to test for outcome differences based on that morphologic feature. In terms of applying the data to populations outside this registry cohort, it would have been helpful to define excess leaflet calcification using an objective criterion rather than the median for this registry population. There is no doubt that TAVR will be used among patients with BAV; based on this study, substantial leaflet and raphe calcification might be taken as potential markers of worse outcomes.