The Puzzle of TAVR for Bicuspid AS: Still Missing a Piece?

Transcatheter aortic valve replacement (TAVR) was introduced as a therapy reserved for patients with severe, symptomatic and inopearable aortic stenosis (AS) almost 20 years ago. Currently, TAVR is a therapeutic option for patients with severe AS at any degree of estimated surgical risk. TAVR procedures have proliferated as interventional imaging, proceduralists’ experience and expertise, and requisite TAVR equipment (vascular access sheaths, steering guides, valves, etc) have improved and advanced; multicenter clinical trials have accompanied the investigations seeking to expand TAVR indications, resulting in a robust foundation in procedural success rates, description of complications, and tracked outcomes over time. In 2019, two pivotal trials fueled the Conformite Europeenne (CE) and the United States’ Food and Drug Administration (FDA) approval for TAVR as a therapeutic option in the low-surgical risk patient with severe, symptomatic AS.^1,2 Both of these trials showed TAVR to be non-inferior to surgical aortic valve replacement (SAVR) in the low-surgical risk patient, with regard to the primary outcome of death or disabling stroke.^1,2 Despite the aforementioned investigations, at present both the European Society of Cardiologists/European Association for Cardio-Thoracic Surgery (ESC/EACTS) and the American College of Cardiology/American Heart Association (ACC/AHA) offer Class 1 recommendations for SAVR - instead of TAVR - to younger individuals (i.e.: <75 years old per European guidelines and <65 years old per American guidelines) at low-surgical risk with symptomatic AS whom require aortic valve replacement. These recommendations are deferential to the excellent, reliable outcomes with SAVR in young, low-risk patients.^3,4