TAVI for Bicuspid Aortic Valve: Addressing Technical Challenges and Optimizing Outcomes

Bicuspid aortic valve (BAV) is the most common congenital valvular anomaly, affecting roughly 1-2% of the population and predisposing to premature aortic stenosis and thoracic aortopathy. Surgical aortic valve replacement (SAVR) remains the standard therapy, while transcatheter aortic valve implantation (TAVI) is increasingly adopted across a broader range of risk profiles due to accumulating evidence and advancements in device technology. Observational registries and early trial data indicate that TAVI is technically feasible in selected BAV anatomies, with device-success rates exceeding 90%. Nonetheless, bicuspid morphology is still technically demanding, with several possible pitfalls during transcatheter procedure and pre-procedural planning compared with tricuspid valve. The rates of moderate-to-severe paravalvular leak (PVL), permanent pacemaker implantation (PPI), and annular complications remain high, especially in the presence of extensive calcifications with raphe or tapered roots, underscoring the importance of meticulous multimodality imaging, dedicated sizing algorithms, and device-specific strategies. Long-term durability signals are encouraging but remain limited, underlining the need for prospective trials with extended follow-up. This review summarizes current knowledge on BAV anatomy and its management, exploring the available evidence supporting the role of transcatheter approach in this challenging and unique scenario.