There is a limited experience with transcatheter aortic valve implantation (TAVI) in the setting of a bicuspid valve(BAV). Incomplete valve expansion or malposition are the most frequent problems in this setting. There is, therefore, a concern over scheduling these patients for TAVI due to the bulky and asymmetric leaflets in a BAV, which may result in hemodynamic disturbances, reduced durability, paravalvular leaks, or embolization. Here, we report a 79 years old patient with severe AS due to BAV who was not a candidate for open heart surgery and was finally treated with TAVI.

Procedure was performed under local anasthesia and sedation. Right femoral acess was obtained and percutaneous closure system was used. The aortic valve was severely calcified and after several attempts it became possible to pass the native aortic valve with guidewire.The Amplatz superstiff guidewire could not carry the baloon, therefore we used Back-up Meier 0.35, 260 cm super stiff support wire(Boston Scientific Corp., USA) for strength and stability to obtain enough support. Pre-implantation balloon valvuloplasty was done with a 25 mm balloon, and full balloon expansion could be achieved. Thereafter, 29 mm Edwards-Sapien XT valve (Edwards Lifesciences, Inc., Irvine, California) was thereafter successfully implanted(Video 1). Aortography revealed well-functioning valve with no aortic regurgitation (Video 2). The peak pressure gradients (PPG) and mean pressure gradients (MPG) by echocardiography decreased from 57mm Hg to 10 mm Hg and from 43 mm Hg to 6 mm Hg, respectively. No obvious aortic insufficiency was detected. A 30 day follow-up showed significant improvement in clinical and hemodynamic findings.

Transcatheter stent-valve implantation in stenotic congenital BAV is under debate. The recommendations against TAVI in patients with BAV are not based on well-designed clinical studies. Therefore, TAVI seems promising in the treatment of the severe stenosis of BAV, especially in high-risk patients.