Currently, BAV stenosis and/or regurgitation is the most common indication for surgical aortic valve replacement in patients < 70 years of age. Nonetheless, 20 % of patients > 80 years of age have underlying bicuspid pathology. Over the past 10 years, transcatheter aortic valve replacement (TAVR) has become a standard procedure in elderly patients with severe inoperable aortic stenosis [
12]. Recently, a study by Mylotte et al., published in JACC [
13], evaluated the clinical value of TAVR in 139 BAV patients (mean age 78.0 ± 8.9 years) from 12 centres in Europe and Canada, being the largest collection of BAV patients treated with TAVR. Evaluation of the morphology of the aortic valve was performed using transoesophageal echocardiography in all patients; MSCT-based TAV sizing was used in 63.5 % of patients. Thirty-day device safety, success, and efficacy were noted in 79.1, 89.9, and 84.9 % of patients, respectively. There was a 30-day mortality rate of 5 %, a 30-day stoke rate of 2 %, and a device success rate of 90 %. One-year mortality was 17.5 %, and the patients were New York Hear Association functional class I or II. It was concluded that TAV-in-BAV is feasible with encouraging short- and intermediate-term clinical outcomes. However, a high incidence of post-implantation aortic regurgitation was observed of 28 %, which appears to be mitigated by MSCT-based TAV sizing (17 %). Since MSCT-based TAV sizing was clearly associated with reduced para-valvular regurgitation, MSCT should be considered a mandatory element of patient screening for TAV-in-BAV, certainly in view of the suboptimal echocardiographic results. In an accompanying Editorial by Colombo and Latib [
14], it was stated that the incidence of significant aortic regurgitation, even with full MSCT evaluation, is still too high to extend TAVR to BAV unless the patient is truly inoperable or has an unacceptably high surgical risk. On the other hand, the Editorial reports that the current study sets a benchmark for next-generation TAVR devices demonstrating the feasibility of TAV-in-BAV.
To summarise, to diagnose patients with BAV, echocardiography remains the first choice. However, when the echocardiograms are difficult to analyse or for careful evaluation of the progression of aortic diameters, CMR is very useful to come to a diagnosis. MSCT is increasingly being used to accurately size the aortic root diameters. The recent study by Mylotte et al. [
12] is the first large multicentre analysis of TAV implantation in patients with significant BAV stenosis or regurgitation. TAV-in-BAV proved to be feasible with encouraging short- and intermediate-term clinical outcomes, but the relatively high incidence (28 %) of post-implantation aortic regurgitation is of serious concern. Therefore, longer-term follow-up of a larger cohort of patients is required to more completely assess the efficacy and durability of TAV implantation in patients with bicuspid disease.