What is the management for a patient with symptomatic bicuspid aortic regurgitation (TAVR - Transcatheter Aortic Valve Replacement, mechanical valve replacement, FU - Follow-up)?

Management of Symptomatic Bicuspid Aortic Regurgitation

For a patient with symptomatic bicuspid aortic regurgitation, surgical aortic valve replacement (SAVR) is the definitive treatment, not TAVR or simple follow-up. 1

Why Surgery is Indicated

• Symptomatic severe aortic regurgitation is a Class I indication for surgical intervention regardless of left ventricular systolic function. 1
• Surgery is recommended when surgical risk is not prohibitive, which applies to most patients with isolated symptomatic AR. 1
• The presence of symptoms (dyspnea, angina, syncope, or heart failure) triggers the need for intervention to prevent irreversible left ventricular damage and improve survival. 1

Why TAVR is NOT Appropriate

• TAVR should not be performed in patients with isolated severe aortic regurgitation who have indications for SAVR and are surgical candidates. 1
• This is a Class III recommendation (meaning risk exceeds benefit) with Level B evidence. 1
• TAVR may only be considered in experienced centers for selected patients who are ineligible for SAVR due to prohibitive surgical risk. 1
• The calcified landing zone required for TAVR is typically absent in pure aortic regurgitation, making the procedure technically challenging with higher rates of paravalvular leak and device malposition. 1
• Bicuspid anatomy further complicates TAVR due to the elliptical annulus shape and calcified raphe. 2

Surgical Options: Replacement vs. Repair

Valve Replacement (Standard Approach)

• Aortic valve replacement with either a mechanical or bioprosthetic valve is the established first-line intervention for symptomatic bicuspid AR. 1, 3
• Mechanical valves are preferred in younger patients (<60-65 years) who can tolerate lifelong anticoagulation and desire to avoid reoperation. 1
• Bioprosthetic valves are reasonable in older patients, those with contraindications to anticoagulation, or patient preference despite higher reoperation risk. 1

Valve Repair (Selected Cases)

• Aortic valve repair may be considered in selected patients with favorable valve anatomy at experienced comprehensive valve centers. 1
• Repair is most successful when all pathologic components are addressed simultaneously: resection of median raphe, subcommissural annuloplasty, leaflet free edge reinforcement, and sinotubular junction plication. 4, 5
• Repair combined with root remodeling shows 90.5% freedom from reoperation at 10 years and 76.6% at 20 years. 6
• Cusp calcification beyond the raphe is a predictor of repair failure and should favor replacement over repair. 6
• Partial cusp replacement with pericardial patch is associated with increased reoperation risk. 6

Concomitant Aortic Root Management

• If the aortic root or ascending aorta is dilated ≥45 mm in a patient undergoing AVR for severe AR, replacement of the aortic sinuses and/or ascending aorta is reasonable when performed at a comprehensive valve center. 1
• Approximately 50% of bicuspid valve patients have aortic root involvement requiring evaluation with cardiac MRI or CT angiography. 3
• Root replacement with valve-sparing surgery may be considered in bicuspid patients at comprehensive valve centers if anatomy is favorable. 1

Why Follow-Up Alone is Inadequate

• Once symptoms develop in severe aortic regurgitation, medical management and observation are associated with poor outcomes and progressive irreversible left ventricular dysfunction. 1
• Symptomatic status mandates intervention to relieve symptoms and prolong survival. 1
• Follow-up is only appropriate for asymptomatic patients with preserved LV function and acceptable LV dimensions. 1

Critical Decision Algorithm

1. Confirm symptomatic status and severe AR severity via comprehensive echocardiography. 1
2. Assess surgical risk using STS-PROM or EuroSCORE II. 1
3. If surgical candidate (most patients): Proceed with SAVR ± root replacement if indicated. 1
4. Evaluate valve anatomy: If non-calcified with favorable anatomy at experienced center, consider repair; otherwise, replacement. 1, 6, 5
5. Choose prosthesis type: Mechanical for younger patients desiring durability; bioprosthetic for older patients or anticoagulation contraindications. 1
6. If prohibitive surgical risk only: Consider TAVR at experienced center, though outcomes are less established. 1

Common Pitfalls to Avoid

• Do not delay surgery once symptoms develop, as this leads to irreversible LV dysfunction and increased operative mortality. 1
• Do not attempt TAVR in standard surgical candidates with isolated AR, as this violates guideline recommendations and has inferior outcomes. 1
• Do not overlook aortic root dimensions, as concomitant root pathology is present in 50% of bicuspid valve patients and requires simultaneous treatment. 1, 3
• Do not attempt valve repair without addressing all pathologic components (annulus, leaflets, sinotubular junction), as incomplete repair leads to early failure. 4, 5