Latest Advances in the Treatment of Bicuspid Aortic Valve

Bicuspid aortic valve (BAV) is the most frequent congenital cardiac defect, and affects 0.5-2% of live births. Almost half of BAV subjects develop different degrees of valvular dysfunction during their lifetime. In both echocardiographic cohorts and surgical series, pure aortic regurgitation is significantly less common than stenosis. BAV also carries a higher risk of aortic aneurysm, aortic dissection or aortic valve endocarditis compared to the general population. Once aortic insufficiency reaches threshold criteria for surgical treatment, the valve has to be replaced (conventional aortic valve replacement, the outcomes of which are well established) or repaired. Repair techniques for regurgitant BAVs and valve-sparing surgery for BAV-related aneurysms have evolved remarkably over the past several decades. Improvements in our understanding of the mechanisms of normal and pathological BAV function and the development of criteria and techniques to address all the pathologic components of valve and root have supported better repair results. The more frequent stenotic BAV is treated by prosthetic valve replacement or, in recent years, by trans-catheter prosthetic replacement (TAVR), the application of which in the BAV setting is increasing, as with tricuspid aortic valve (TAV) stenosis, especially since indications are extended to medium-risk patients. It has been reported that the risk of paravalvular leak and/or prosthesis malposition is higher in BAV than in TAV stenosis, due to the more elliptical annulus and the calcified raphe of the bicuspid valve. New-generation balloon-expandable devices seem to be capable of lowering the rates of these complications. As research in this field keeps filling in the gaps in current knowledge about bicuspid malformation and its common complications, further advancements in their treatment are awaited.