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Comparative Study
. 2025 May 12;18(9):1174-1185.
doi: 10.1016/j.jcin.2025.02.016.

Risk of Coronary Obstruction in Redo-Transcatheter Aortic Valve Replacement Between Bicuspid and Tricuspid Aortic Valves

Atsushi Okada  1 , Syed Zaid  2 , Miho Fukui  3 , Evan Walser-Kuntz  1 , Larissa I Stanberry  1 , Marcus R Burns  4 , John R Lesser  5 , João L Cavalcante  6 , Paul Sorajja  5 , Vinayak N Bapat  7
Affiliations
Comparative Study

Risk of Coronary Obstruction in Redo-Transcatheter Aortic Valve Replacement Between Bicuspid and Tricuspid Aortic Valves

Atsushi Okada et al. JACC Cardiovasc Interv. .

Abstract

Background: Transcatheter aortic valve replacement (TAVR) is approved across all risk profiles, including patients with bicuspid aortic valves. These patients are generally younger, with a higher chance of reintervention.

Objectives: The aim of this study was to compare the feasibility of redo transcatheter aortic valve (TAV) between bicuspid and tricuspid aortic valves.

Methods: A computed tomographic (CT) simulation of redo-TAV was conducted using 913 post-TAVR CT studies from patients who underwent TAVR with SAPIEN 3 or SAPIEN 3 Ultra (S3; n = 623) or Evolut R, Evolut PRO, or Evolut PRO+ (Evolut; n = 290) valves. Fifty-nine cases were for bicuspid valves. Four redo-TAV scenarios-S3-in-S3, Evolut-in-S3, S3-in-Evolut, and Evolut-in-Evolut-were simulated. Second TAV size was determined from the averaged stent areas in the landing zone, except for Evolut-in-Evolut, for which same size was simulated. Redo-TAV feasibility (risk to coronary arteries) was estimated by the relationship between neoskirt plane and coronary risk plane or sinotubular junction and the narrowest valve-to-aorta distances.

Results: Patients with bicuspid valves, compared with those with tricuspid valves, were younger with lower surgical risk and had larger annular areas (522 mm2 [Q1-Q3: 461-597 mm2] vs 479 mm2 [Q1-Q3: 416-551 mm2]), sinus of Valsalva diameters (34 mm [Q1-Q3: 31-36 mm] vs 32 mm [Q1-Q3: 30-35 mm]), and sinotubular junction diameters (30 mm [Q1-Q3: 28-33 mm] vs 29 mm [Q1-Q3: 27-31 mm]) (P < 0.05 for all). Narrowest valve-to-aorta distances were longer in bicuspid cases, resulting in higher redo-TAV feasibility for S3-in-S3 and Evolut-in-S3 scenarios. Similar trends were observed for S3-in-Evolut and Evolut-in-Evolut, for which the feasibility tended to be higher in bicuspid cases.

Conclusions: Redo-TAV simulation using post-TAVR CT imaging performed at 30 days suggested higher redo-TAV feasibility in patients with bicuspid aortic valves compared with tricuspid aortic valves.

Keywords: TAV-in-TAV; feasibility; neoskirt; redo-TAV; sinus sequestration.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Fukui has served as a consultant for Anteris and Edwards Lifesciences. Dr Bapat has received consulting fees from Abbott Structural, Medtronic, Boston Scientific, and Edwards Lifesciences. Dr Cavalcante has received consulting fees from 4C Medical, Abbott Structural, Anteris, AriaCV, Boston Scientific, Edwards Lifesciences, HighLife, Medtronic, VDyne, W.L. Gore, and Xylocor; and has received research grant support from Abbott Northwestern Hospital Foundation. Dr Sorajja has received consulting fees from 4C Medical, Abbott Structural, Adona, Boston Scientific, Edwards Lifesciences, Evolution Medical, Foldax, GE Medical, Laza, Medtronic, Phillips, W.L. Gore, vDyne, and xDot; and has received institutional research grant support from Abbott Structural, Edwards Lifesciences, Medtronic, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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