Selecting between open surgical aortic valve replacement (AVR) and transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) disease remains clinically complex because early procedural risk and longer-term cardiovascular outcomes may differ between approaches. A propensity-matched analysis from the TriNetX Research Network, presented at the AATS 2026 meeting, compared early and medium-term outcomes after both procedures.

The analysis included 1,370 patients who underwent open AVR and 1,370 treated with TAVR after 1:1 propensity-score matching across 56 covariates from 50 centers. Outcomes were assessed during an early period (1–90 days) and a medium-term period (>90 days to 3 years). Primary endpoints included all-cause mortality and major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, cardiac arrest, heart failure, and unstable angina.

Findings

• During the first 90 days, all-cause mortality was higher after open AVR than TAVR (3.3% vs 1.3%; HR 2.54; p=0.001).
• Pericardial complications (7.1% vs 4.6%; HR 1.55; p=0.014), acute kidney injury (3.5% vs 1.6%; HR 2.17; p=0.007), and AF/AFL (11.1% vs 5.3%; HR 2.25; p<0.001) occurred more frequently with open AVR during early follow-up.
• Infection or sepsis occurred more frequently after open AVR in the early period (HR 2.04; log-rank p=0.048), although the risk difference did not reach statistical significance.
• No significant early differences were observed for MACE, bleeding, VT/VF, or endocarditis between treatment strategies.
• Beyond 90 days, open AVR was associated with lower all-cause mortality compared with TAVR (2.2% vs 4.7%; HR 0.51; p≤0.003).
• Medium-term follow-up also showed lower risks of MACE (HR 0.33; p<0.001), ischemic stroke (HR 0.41; p≤0.003), VT/VF (HR 0.54; p≤0.016), AF/AFL (HR 0.57; p=0.005), and valve-related thrombus (HR 0.47; p=0.035) with open AVR, while bleeding and endocarditis rates remained similar.

The analysis showed higher early procedural risk with open AVR but lower mortality and cardiovascular event rates beyond 90 days compared with TAVR in patients with BAV.