Leaflet Modification for Bicuspid Aortic Valve Tricuspidalization Enabling Implantation of Larger Transcatheter Heart Valves

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.