Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Aortic Valve Stenosis: Meta-Analysis and Systemic Review.

Because of its anatomic and procedural complexities, bicuspid aortic valve (BAV) has been excluded from previous trials investigating transcatheter aortic valve replacement (TAVR). We aimed to compare the clinical outcomes of TAVR in BAV and tricuspid aortic valve patients. We searched the databases systematically from inception until March 2023 for studies that reported the outcomes of TAVR in BAV and tricuspid aortic valve patients. The primary focus was all-cause mortality at 1 year. Additional outcomes included outcomes at 30-day follow-up. Secondary and subgroup analyses were performed on propensity-matched patients, patients at low surgical risk, and based on the type of transcatheter valve type. We included 30 studies with a total of 193,274 patients who underwent TAVR, of which 14,353 patients had BAV stenosis. The rate of 1-year mortality was lower in the BAV group compared with the tricuspid group with the results reaching statistical significance (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.75 to 0.98, p = 0.02). The rate of 30-day stroke, however, was higher in patients with BAV who underwent TAVR (OR 1.24, 95% CI 1.08 to 1.43, p <0.05). Other 30-day clinical outcomes were similar between the 2 groups. Similar outcomes were observed in secondary analysis of matched populations with less mortality and higher rate of stroke in patients with BAV (OR 0.84, 95% CI 0.72 to 0.96, p = 0.01, and OR 1.38, 95% CI 1.09 to 1.75, p <0.05, respectively). Comparing the outcomes for self-expandable and balloon-expandable valves resulted in similar results. Subgroup analysis of low-surgical-risk patients similarly showed lower 1-year mortality in patients with BAV (OR 0.67, 95% CI 0.50 to 0.91, p = 0.01), without difference in 30-day stroke between the 2 groups (OR 1.24, 95% CI 0.83 to 1.88, p = 0.30). In conclusion, this report indicates that TAVR is safe and feasible in patients with BAV, including patients at low surgical risk. The higher rate of 30-day stroke, however, warrants caution when pursuing TAVR in this population. More studies, specifically randomized trials, are still warranted to further assess the safety and the long-term outcomes in this group.

Case Report of High-Grade Atrioventricular Block and Takotsubo Cardiomyopathy.

INTRODUCTION: Takotsubo cardiomyopathy (TTC) is a condition with a good long-term prognosis. However, when the TTC is due to a life-threatening arrhythmia, such as atrioventricular block (AVB), several considerations must be made regarding treatment. CASE PRESENTATION: A 71-year-old woman with a history of ischemic stroke presented after a syncopal episode. Before passing out, the patient was walking, nauseous, lightheaded, dizzy, and short of breath. In the emergency department, the blood pressure was 230/120 mmHg, and the heart rate was 38 beats per minute, but the patient was asymptomatic. An electrocardiogram showed a new-onset 2:1 AVB, bifascicular block, and prolonged PR and corrected QT intervals. An echocardiogram revealed a new-onset ejection fraction of 30% to 35%; hypokinesis of the apex, mid-inferoseptum, mid-anterolateral, apical to mid-inferior, and apical to mid-anterior walls; and hyperkinesis of the basal segments. The cardiac catheterization illustrated normal coronary arteries without significant stenosis. Therefore, the patient was diagnosed with TTC and 2:1 AVB. She was treated with lisinopril and metoprolol succinate and received a dual-chamber pacemaker. At the follow-up visit, the patient's ejection fraction and hypokinetic segments improved. She denied any recurrence of syncope, and her pacemaker was functioning appropriately. CONCLUSION: When AVB or other arrhythmias initiate a TTC, the patient can experience sudden cardiac death and decompensate quickly. Therefore, clinicians should understand this rare but fatal complication because these patients require pacemakers and beta blockers.