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Case Discussion: Complex Bicuspid Aortic Valve — TAVR vs SAVR Decision
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Dr. Michael Torres
Feb 17, 2026 7:37 PM
Professor · Interventional Cardiology · Johns Hopkins Medicine
Case Discussion: Complex Bicuspid Aortic Valve — TAVR vs SAVR Decision
Presenting a challenging case from last week. 72-year-old male with severe bicuspid aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg). CT shows heavily calcified raphe with asymmetric leaflet morphology. STS score 3.2%.
Heart team discussion was split — surgery comfortable with their outcomes in bicuspid, but the patient strongly prefers transcatheter approach. Recent data from the BICUSPID registry shows promising results with newer-generation devices.
What would your approach be? Particularly interested in hearing from those with experience using the latest-generation self-expanding platforms in bicuspid anatomy.
Clinical discussion
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3 replies
Great case, Michael. We\'ve treated 28 bicuspid cases with the Evolut PRO+ over the past 18 months. Key considerations:
1. Annular sizing is critical — we always use MSCT with 3mensio and add 10-15% oversizing vs tricuspid
2. Implantation depth matters more — we aim for 3-5mm below the annulus
3. The raphe calcification pattern determines our approach
For your patient, I would lean toward TAVR if the CT measurements support it. Happy to review the images if you can share.
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From the surgical perspective — with an STS of 3.2%, the risk is low for either approach. Our institutional data shows excellent durability at 10 years for surgical bioprostheses in bicuspid patients. The lifetime management strategy should factor in here.
That said, if the anatomy is favorable on CT and the patient is well-informed about the trade-offs, I would support TAVR. The key is shared decision-making with realistic expectations about potential need for reintervention.
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We see similar cases frequently at Keio. One thing I\'d add — conduction disturbance risk is higher in bicuspid TAVR. Our pacemaker rate is ~18% in bicuspid vs ~10% in tricuspid. We always have EP standby and pre-procedural high-res CT assessment of the membranous septum length.
The patient\'s baseline conduction should factor into the TAVR vs SAVR discussion as well.
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