Severe raphe calcification in bicuspid aortic valve (BAV) remains a major challenge for transcatheter aortic valve replacement (TAVR), often leading to asymmetric valve expansion, residual gradients, and suboptimal durability. We report a case of intentional leaflet modification to enable functional “tricuspidalization” of BAV anatomy and facilitate implantation of a larger transcatheter heart valve (THV). In a 76-year-old high-risk patient with severe aortic stenosis and heavily calcified raphe, a modified UNICORN electrosurgical laceration technique was used to split the fused cusps. This approach allowed annular-based sizing and successful implantation of a 23-mm THV, with optimal expansion, no residual gradient, and preserved coronary access. This strategy may improve TAVR outcomes in selected BAV patients. Larger studies are warranted to confirm the safety, reproducibility, and clinical efficacy of this approach.
Severe raphe calcification in bicuspid aortic valve (BAV) anatomy remains one of the most challenging scenarios for transcatheter aortic valve replacement (TAVR). Current guidelines preferentially recommend surgical aortic valve replacement in low-risk patients with BAV stenosis, largely due to concerns regarding asymmetric transcatheter heart valve (THV) expansion, residual transvalvular gradients, paravalvular regurgitation, and long-term durability. In the presence of a tapered aortic root, supra-annular sizing strategies frequently require THV undersizing relative to the annular dimensions. This approach may predispose to suboptimal prosthesis geometry, patient–prosthesis mismatch, leaflet thrombosis, and early structural valve degeneration. These concerns are particularly relevant in younger patients, in whom valve durability is paramount.
In addition, BAV anatomy is characterized by a wide spectrum of morphological variability, including differences in raphe length, calcification burden, and cusp fusion patterns, all of which may significantly impact procedural planning and outcomes. The presence of a heavily calcified raphe often acts as a rigid constraint, preventing uniform valve expansion and increasing the risk of eccentric deployment. This, in turn, may lead to suboptimal hemodynamics and potentially compromise long-term valve performance. Despite growing operator experience and improvements in device technology, these anatomical challenges continue to limit the reproducibility and predictability of TAVR results in this specific population.
To date, leaflet modification techniques have primarily been developed to prevent coronary obstruction and have been largely applied in the context of degenerated bioprosthetic valves. However, leaflet modification in native aortic valves—particularly in heavily calcified BAV with a rigid raphe that restricts THV expansion—remains largely unexplored. No dedicated strategy has yet been specifically designed to intentionally “tricuspidalize” BAV anatomy in order to optimize THV expansion, improve prosthetic geometry, and enhance hemodynamic performance. In this context, exploring novel approaches aimed at modifying native leaflet and raphe constraints may represent a promising step toward expanding the applicability of TAVR in complex BAV anatomies.
We report the case of a 76-year-old patient with symptomatic severe aortic stenosis and high surgical risk in the setting of BAV with a heavily calcified raphe between the right and left cusps. Computed tomography (CT) revealed a small aortic root with low coronary take-off and a markedly tapered configuration, with a mean diameter of 20 mm at the raphe level versus 23 mm at the annulus ( Figure 1 , Panel A). Supra-annular sizing would therefore have required THV down-sizing (SAPIEN 3 Ultra Resilia 20 mm instead of 23 mm), carrying a high anticipated risk of PPM and limiting the feasibility of future redo-TAVR within a lifetime management strategy.
Intentional transcatheter bicuspid aortic valve remodeling. Panel A. Procedural planning. 1. Pre-procedural CT-scan analysis demonstrating a tapered configuration of the bicuspid aortic valve (BAV) anatomy. Supra-annular measurements suggest a supra-annular sizing strategy, leading to selection of a down-sized transcatheter heart valve (THV) (20-mm). 2. Conceptual alternative of intentional BAV remodeling, with electro-surgical splitting of the fused cusps to “tricuspidalize” the valve, enabling implantation of a larger THV (23-mm) based on annular sizing. Panel B. Procedure. Fluoroscopic (lateral and frontal views) and transesophageal echocardiography (TEE X-plane view) guide-controlled puncture at the raphe, followed by progressive dilation of the created fenestration. This remodeling step enables implantation of a 23-mm Sapien 3 Ultra Resilia THV. Panel C. Results. Final procedural results showing fluoroscopic evidence of appropriate THV expansion with preserved access to the left coronary artery (LCA) demonstrated by selective coronary cannulation, and absence of residual gradient. Transesophageal echocardiography with color-Doppler confirming maintained flow into the LCA (white asterisk). Post-procedural computed tomography imaging demonstrating adequate prosthesis expansion and geometry. Abbreviations: AL-2 = Amplatz Left-2; CT = computed tomography; BAV = bicuspid aortic valve; Fr = French; LCC = left coronary cusp; MPA = multi-purpose A; NC = non-compliant; NCC = non-coronary cusp; RCC = right coronary cusp; TEE = trans-oesophageal echocardiography; THV = transcatheter heart valve. White asterisks indicate the position of AL-2 catheter.
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