Comparison between severe R-L and R-NC raphe-type bicuspid aortic valve stenosis treated with TAVI: insights from the international AD HOC Registry

Background: Sievers type 1 bicuspid aortic valve (BAV) stenosis presents unique challenges for trans-catheter aortic valve implantation (TAVI), particularly when calcified raphe is present. The impact of raphe localization on TAVI outcomes remains unclear. Objectives: This study aimed to compare procedural and clinical outcomes in patients with right-left (R-L) and right-non coronary (R-NC) raphe-type BAV treated with TAVI. Methods: Between January 2016 and October 2023, 956 consecutive patients with severe Sievers type 1 BAV stenosis underwent trans-femoral (TF)-TAVI across 24 tertiary centers. Pre-procedural computed tomography was retrospectively analyzed. To address the non-randomized study's design, 2:1 propensity score matching (PSM) was performed between R-L and R-NC groups. Primary endpoints included VARC-3 technical success, 30-day device success, early safety, and mid-term major adverse events (death, stroke, or heart failure hospitalization at the last follow-up). Results: 825 had R-L raphe whereas 131 had R-NC pattern. After PSM, 251 R-L and 128 R-NC were analyzed. Baseline clinical, electrocardiographic, echocardiographic, computed tomography and procedural features were similar. Technical success was high in both groups (92.8 % vs 96.1 %; OR 0.53; 95%CI 0.19–1.45; p = 0.215), with comparable short- and mid-term outcomes. However, permanent pacemaker implantation (PPI) incidence was 3 times higher in R-L compared to R-NC (16.1 % vs. 6.7 %; OR 0.37, CI 0.16–0.89). Conclusions: Raphe localization in Sievers type 1 BAV does not affect major TAVI outcomes except for PPI risk, which is 3-fold higher in R-L patients.