Transcatheter Aortic Valve Replacement for Severe Bicuspid Aortic Valve Stenosis: A Systematic Review and Meta-Analysis.

BACKGROUND: Comparative outcomes of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) stenosis remain uncertain. OBJECTIVES: The authors synthesized evidence comparing: 1) TAVR outcomes in BAV vs tricuspid aortic valve (TAV) stenosis; and 2) TAVR vs surgical aortic valve replacement (SAVR) among patients with BAV stenosis. METHODS: MEDLINE, Scopus, and Cochrane CENTRAL were searched through January 31, 2026 (CRD420261304542). Random-effects models pooled risk ratios (RRs) with 95% CIs. Exploratory meta-regression assessed study-level modifiers and temporal trends in 1-year mortality. RESULTS: Fifty-two studies were included. In 39 studies comparing TAVR in BAV vs TAV, BAV was associated with higher paravalvular leak (RR: 1.44; 95% CI: 1.18-1.77; P < 0.001), aortic root injury (RR: 1.83; 95% CI: 1.10-3.04; P = 0.020), 30-day stroke (RR: 1.27; 95% CI: 1.02-1.59; P = 0.035), and 30-day mortality (RR: 1.25; 95% CI: 1.00-1.55; P = 0.047), but lower 1-year mortality (RR: 0.84; 95% CI: 0.75-0.94; P = 0.002). The Society of Thoracic Surgeons score-but not BAV anatomy-predicted 1-year mortality (RR: 1.31; 95% CI: 1.08-1.59; P = 0.006). BAV outcomes improved in recent studies (RR per year, 0.93; 95% CI: 0.87-1.00; P = 0.048). In 13 studies comparing TAVR vs SAVR in BAV, TAVR had higher paravalvular leak (RR: 7.08; 95% CI: 2.28-21.98; P < 0.001) and lower major bleeding (RR: 0.27; 95% CI: 0.17-0.44; P < 0.001) but similar 30-day stroke (P = 0.288) and mortality (P = 0.452). CONCLUSIONS: TAVR for BAV stenosis was associated with procedural risk than TAVR for TAV stenosis but lower 1-year mortality. Compared with SAVR, TAVR showed procedural trade-offs without early mortality differences.