Researchers reveal that patients with bicuspid aortic valves may have a higher chance of successful repeat transcatheter aortic valve replacement (redo-TAVR) compared to those with tricuspid valves. Writing in the May 12 issue of JACC: Cardiovascular Interventions, the findings of the retrospective computed tomography (CT) simulation study are due to a more favorable relationship to coronary arteries with differences in frame expansion of index TAV. “Redo-TAVR is an important consideration as more patients receive transcatheter valves at younger ages," said the paper’s authors, led by Atsushi Okada, MD, PhD, from the Minneapolis Heart Institute Foundation. "Our findings suggest that bicuspid anatomy may offer advantages in future interventions." Main findings Researchers found that 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]). The narrowest valve-to-aorta distances were longer in bicuspid cases, resulting in higher redo-TAV feasibility for SAPIEN 3 or SAPIEN 3 Ultra (S3-in-S3) and Evolut R, Evolut PRO or Evolut PRO+ (Evolut-in-S3) valve scenarios. Similar trends were observed for S3-in-Evolut and Evolut-in-Evolut, for which the feasibility tended to be higher in bicuspid cases. “The longer distances translated into more space between the neoskirt and the coronary arteries, which reduces obstruction risk," said the paper’s authors. Validation required Despite the promising results, the authors caution that clinical validation was needed. “Our simulations matched real-world outcomes in four patients who underwent redo-TAVR, but larger follow-up studies are essential,” they said. With transcatheter valve therapy expanding to lower-risk and younger patients, these findings could have lasting implications. “This study gives new hope that bicuspid patients can be safely managed over their lifetimes with TAVR,” said the authors. “It may shape how we choose initial valve strategies moving forward.” In their editorial Stephan Windecker MD and Daijiro Tomii MD, from the University of Bern in Switzerland, highlighted that redo-TAVR was more complex than TAVR for failed surgical bioprostheses and how younger bicuspid patients showed a greater frequency of low coronary obstruction risk. The editorial supported the study’s finding that larger aortic root dimensions in bicuspid patients increased the feasibility of redo-TAVR. However, they warned that the extrapolation of 30-day CT findings to long-term redo-TAVR scenarios remained uncertain, urging individualized patient planning for lifetime valve care. Methodology The study used a retrospective CT simulation design using 913 post-TAVR CT studies from patients who underwent TAVR with S3 (n=623) or Evolut (n=290) valves. Fifty-nine patients (6.5%) of which 59% were male were for bicuspid valves and 854 patients (93.5%) of which 58% were male were for tricuspid valves. The median age for the bicuspid group was 77 years and 82 years for the tricuspid group. The primary endpoint was defined as the risk of coronary obstruction, stratified as low, intermediate, or high. Sources: Okada A, Zaid S, Fukui M, et al. Risk of Coronary Obstruction in Redo-Transcatheter Aortic Valve Replacement Between Bicuspid and Tricuspid Aortic Valves. JACC Cardiovasc. Interv. 2025;18:1174–1185. Windecker S, Tomii D. Planning for the Future: CT-Based Insights into Redo-TAVR and Lifetime Aortic Valve Care. JACC Cardiovasc. Interv. 2025;18:1186–1189. Image Credit: Sebastian Kaulitzki – stock.adobe.com