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Transcatheter aortic valve implantation in patients with bicuspid valve morphology: a roadmap towards standardization

Abstract

Indications for transcatheter aortic valve implantation (TAVI) have expanded in many countries to include patients with aortic stenosis who are at low surgical risk, and a similar expansion to this cohort is anticipated elsewhere in the world, together with an increase in the proportion of patients with bicuspid aortic valve (BAV) morphology as the age of the patients being treated decreases. To date, patients with BAV have been excluded from major randomized trials of TAVI owing to anatomical considerations. As a consequence, BAV has been a relative contraindication to the use of TAVI in international guidelines. Although clinical experience and observational data are accumulating, BAV presents numerous anatomical challenges for successful TAVI, despite advances in device design. Furthermore, in those with BAV, substantial geographical variation exists in patient characteristics, clinical approach and procedural strategy. Therefore, in this Roadmap article, we summarize the existing evidence and provide consensus recommendations from an international group of experts on the application of TAVI in patients with BAV in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients.

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Fig. 1: Current classification schemes for BAV.
Fig. 2: Representative multi-slice CT images of bicuspid aortic valves with different anatomical features.
Fig. 3: Proportion of patients with BAV in large-scale, international registries of TAVI.
Fig. 4: Patterns of calcium deposition on bicuspid aortic valves.
Fig. 5: Proposed roadmap to address current knowledge gaps in the treatment of BAV stenosis with TAVI.

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Acknowledgements

We thank the National Natural Science Foundation of China (81970325, 82170375 and 82102129) and West China Hospital “1·3·5” Discipline of Excellence Project — “Percutaneous transcatheter aortic valve implantation” and “Mechanisms of aortic stenosis and the clinical applications” for supporting this project, and Yi Zhang (Department of Cardiology, West China Hospital, Sichuan University, China) for assistance with the literature review.

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In the author list, the authors from W.B. to W.-H.Y. are listed in alphabetical order by surname. All the authors participated in the Delphi development and evaluation process, which was coordinated by T.-Y.X. and M.C. T.-Y.X. and D.M. wrote the first draft of the Introduction. T.-Y.X. wrote the first draft of the Methodology. T.-Y.X. and A.S. wrote the first draft of the ‘Morphology and anatomy’ section. T.-Y.X. and K.H. wrote the first draft of the ‘Diagnosis and classification’ section. T.-Y.X., W.B., T.M. and L.S. wrote the first draft of the ‘Choice of treatment’ section. T.-Y.X. and N.P. wrote the first draft of the ‘TAVI sizing in BAV’ section. T.-Y.X. and S.R. wrote the first draft of the ‘Device selection’ section. T.-Y.X. and D.T. wrote the first draft of the ‘Intra-procedural considerations’ section. T.-Y.X. and A.L. wrote the first draft of the ‘Post-procedural management’ section. All the sections were edited by M.C., B.P. and D.M. before final review and revision by all the authors. Authors from different regions were encouraged to report local practices during the revisions.

Corresponding authors

Correspondence to Mao Chen, Bernard Prendergast or Darren Mylotte.

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Competing interests

Y.F. is a consultant/proctor for Peijia Medical and Venus MedTech. K.H. is a proctor for Edwards Lifesciences and Medtronic. H.J. is a consultant to Boston Scientific, Edwards Lifesciences and Medtronic, and has received grant and research support from Abbott Vascular, Edwards Lifesciences and Medtronic. A.L. is an advisory board member for Abbott and Medtronic. M.K.-Y.L. is a proctor for Edwards Lifesciences and Medtronic. M.B.L. has received institutional research support from Abbott, Boston Scientific, Edwards Lifesciences and Medtronic, and is a consultant or advisory board member for Abbott, Boston Scientific, Gore, Medtronic and Meril Life. R.R.M. has received research grants from Abbott, Boston Scientific, Edwards Lifesciences and Medtronic, and has received personal fees from Edwards Lifesciences for travel. T.M. is a consultant for Abbott, Boston Scientific, Cephea, Edwards Lifesciences, GE Healthcare, Medtronic and Microport, is a proctor for Medtronic, and receives speaker fees from Medtronic. C.N. has received lecture fees from Abbott Vascular, Boston Scientific and Medtronic, and has served on the advisory boards of Abbott Vascular and Boston Scientific. N.P. is a consultant and proctor for Medtronic and Peijia Medical. M.J.R. serves on an advisory board for Medtronic. S.R. has received speaker fees from Edwards Lifesciences and has served as an international advisory board member for Medtronic. A.S. is an adviser/speaker for Abbott Vascular, Boston Scientific, Medtronic and Meril Lifesciences, and is a proctor for Medtronic and Meril Lifesciences. L.S. has received consulting fees and institutional research grants from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic and Symetis. D.T. is a proctor for Boston Scientific, Edwards Lifesciences and Medtronic. M.C. is a consultant/proctor for Peijia Medical and Venus MedTech. B.P. has received institutional educational and research grants from Edwards Lifesciences and has received speaker/consultancy fees from Abbott, Anteris, Edwards Lifesciences, Medtronic and Microport. D.M. is a proctor and consultant for Medtronic and Microport and is a consultant for Boston Scientific. The other authors declare no competing interests.

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Nature Reviews Cardiology thanks Arturo Evangelista, Philippe Pibarot and Flavien Vincent for their contribution to the peer review of this work. Nature Reviews Cardiology also thanks Ottavio Alfieri, who co-reviewed with Nicola Buzzatti; Nicolas van Mieghem; and the other, anonymous, reviewer(s) for their contribution to the peer review of a previous version of this work.

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Xiong, TY., Ali, W.B., Feng, Y. et al. Transcatheter aortic valve implantation in patients with bicuspid valve morphology: a roadmap towards standardization. Nat Rev Cardiol (2022). https://doi.org/10.1038/s41569-022-00734-5

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