Bicuspid aortic valve
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Bicuspid aortic valve (BAV) refers to a spectrum of deformed aortic valves with two functional leaflets or cusps which are often unequal in size.
They are most often congenital while an acquired bicuspid valve occurs when there is fibrous fusion between the right and left cusps of a pre-existing trileaflet aortic valve.
A congenitial biscuspid aortic valve is considered to be one of the most common causes of isolated aortic stenosis 4. It is considered a major cause of aortic valve disease in young adults.
The estimated incidence of a congenital bicuspid valve in the general population is thought to be ~2%. They may be more common in males.
dilatation of the proximal ascending aorta: most frequent association 9
other congenital cardiac diseases:
Turner syndrome: 10-12% of women with Turner syndrome 11
Bicuspid aortic valve refers to a spectrum of deformed aortic valves with two functional leaflets or cusps which are often unequal in size. Only two cusps, commissures and sinuses are seen in the less common "pure" bicuspid aortic valve subtype. The more common form of bicuspid aortic valve occurs in a valve with three cusps with underdevelopment of a commissure and fusion of two adjacent cusps to form a raphe 7. Over time, the abnormal stress across the valve leads to calcification, usually in adulthood.
Several classification have been proposed, with one of the more common being:
type Ia: raphe between right coronary cusp and left coronary cusp
type Ib: purely bicuspid with fusion between left and right coronary cusps
type IIa: raphe between right coronary cusp (RCC) and non-coronary cusp (NCC)
type IIb: purely bicuspid with fusion between non-coronary and right coronary cusps
type IIIa: raphe between left coronary cusp (LCC) and non-coronary cusp (NCC)
type IIIb: purely bicuspid with fusion between non-coronary and left coronary cusps
The usefulness of plain chest radiographs in the detection of a bicuspid valve is considered to be rather poor. Occasionally the presence of a single calcified raphe at the expected site of the bicuspid valve, which is best seen on the lateral view as the aortic valve is superimposed on the spine on frontal radiographs, as well as post-stenotic dilatation of the ascending aorta may suggest a bicuspid valve 4.
Transthoracic echocardiography is typically an adequate imaging modality for identifying the presence of a bicuspid aortic valve, with sensitivity and specificity approaching 92% and 96% respectively given the presence of adequate sonographic windows 19. It is also used to surveil the development of valvular dysfunction and the associated aortopathy.
The parasternal windows are best to evaluate the morphology of the valve, defining the number and location of the commissures, valve excursion and mobility, and the presence and location of a raphe. Evaluation of the aortic root diameter often requires additional views to be obtained in more cephalad intercostal spaces. Color flow Doppler interrogation may reveal flow turbulence and valvular regurgitation. Features that may suggest the presence of a bicuspid aortic valve include 16:
systolic "doming" of the valve leaflets
morphologically normal aortic valve leaflets assume a parallel orientation when maximally open in mid-systole
the restricted excursion in bicuspid valves results in leaflets that assume a concave (in respect to the valvular orifice) midsystolic posture
eccentric closure line (M-mode)
as the valve cusps may be markedly asymmetric in size, valve closure may deviate from the mid-position of the aortic lumen
may also occur in normal, tricuspid aortic valves
diastolic leaflet prolapse
often associated with eccentric aortic regurgitation
ellipsoid valvular orifice in systole
short axis views of a tricuspid aortic valve should demonstrate a triangular orifice with straight leaflet margins
cusp fusion with a raphe
an echoic thickening at the free margin of the valve leaflets corresponding to the location of cusp fusion
may give the false appearance (in diastole) of a tricuspid valve
abnormal number and orientation of the valve commissures 15
typically located at the 10, 2, and 6 o'clock positions
the most common variant (fusion of the right and left coronary cusps) has two commissures that divide the valve horizontally, appearing approximately at the 4 and 10 o'clock positions
this imparts an anteroposterior division to the valve
fusion of the right and non-coronary cusps results in a more vertical division, a result of the commissure orientation at roughly 12 and 6 o'clock
The presence of associated cardiac malformations and complications should also be sought, using both standard and extended windows to evaluate for the presence and significance of:
most common manifestation of valvular dysfunction
imaging from the suprasternal notch with spectral Doppler may assist in an assessment of severity
associated with severe hemodynamic compromise 17
often requires surgical intervention
bicuspid aortic valve aortopathy
dilation of the ascending aorta distal to the sinotubular junction is characteristic, with relative sparing of the aortic root
significantly increased risk of thoracic aortic dissection
At the time of writing, CT has a much higher reported detection rate for bicuspid valves and includes 6:
positive predictive value: 100%
negative predictive value: 97%
The characteristic “fish-mouth” shape of the open valve in systole is noted on ECG-gated cardiac CT 7.
There is often earlier leaflet calcification.
Cardiac MRI has the advantage of demonstrating the dynamic motion of the bicuspid valve when heavily calcified valves make echocardiography difficult to interpret. Furthermore, MRI can provide non-invasive assessment of the ascending aortic diameter and the presence of coarctation in a single study.
Experimental 4D MRI studies have suggested a "hurricane aorta" like flow pattern 13.
Treatment and prognosis
A minority of patients develop aortic regurgitation as a young adult but the majority have progressive valve stenosis, with only about 1% maintaining normal valve function over their lifetime 10.
High blood pressure should be controlled.
Symptomatic children have very little calcification and are treated by balloon valvuloplasty. Also, insertion of a valve in a child is not advisable, as the child will continue to grow.
In adults, aortic valve replacement is performed and occurs in a younger age group than in patients with tri-leaflet valve stenosis. Aortic root replacement is also required in 30% of patients undergoing valve replacement 9.
Recognized complications include:
this is secondary to leaflet calcification which occurs earlier (around age 40) than in patients with tri-leaflet aortic valves
turbulent flow across the valve predisposes to leaflet calcification
in children: incompetence develops secondary to redundant valve leaflets, endocarditis, or following balloon valvuloplasty
in adults: dilatation of the ascending aorta can lead to regurgitation
an aortopathy is present irrespective of the valve function; aortic dilatation (and dissection) is due to abnormal media; as such, bicuspid aortic valve can be considered a disease of both the valve and ascending aorta, and this should be a consideration in surgical decision making
aortic dissection: secondary to aortopathy and abnormal media
infective endocarditis: due to turbulent flow
- 1. Hope MD, Hope TA, Meadows AK et-al. Bicuspid aortic valve: four-dimensional MR evaluation of ascending aortic systolic flow patterns. Radiology. 2010;255 (1): 53-61. doi:10.1148/radiol.09091437 - Pubmed citation
- 2. Seibert JJ, James CA. Pediatric Radiology Casebase. George Thieme Verlag. (1998) ISBN:0865776970. Read it at Google Books - Find it at Amazon
- 3. Ko SM, Song MG, Hwang HK. Bicuspid aortic valve: spectrum of imaging findings at cardiac MDCT and cardiovascular MRI. AJR Am J Roentgenol. 2012;198 (1): 89-97. doi:10.2214/AJR.10.6084 - Pubmed citation
- 4. Spindola-franco H, Fish BG, Dachman A et-al. Recognition of bicuspid aortic valve by plain film calcification. AJR Am J Roentgenol. 1982;139 (5): 867-72. AJR Am J Roentgenol (abstract) - Pubmed citation
- 5. Girdauskas E, Borger MA, Kuntze T et-al. Aortopathy in bicuspid aortic valve disease: is it really congenital? Radiology. 2010;256 (3): 1015-6. doi:10.1148/radiol.101046 - Pubmed citation
- 6. Tanaka R, Yoshioka K, Niinuma H et-al. Diagnostic value of cardiac CT in the evaluation of bicuspid aortic stenosis: comparison with echocardiography and operative findings. AJR Am J Roentgenol. 2010;195 (4): 895-9. doi:10.2214/AJR.09.3164 - Pubmed citation
- 7. Agarwal PP, Wells SA, Kolias TJ. AJR teaching file: aortic valve abnormality in a woman with progressive shortness of breath. AJR Am J Roentgenol. 2010;195 (6): S70-2. doi:10.2214/AJR.09.7172 - Pubmed citation
- 8. Chen JJ, Manning MA, Frazier AA et-al. CT angiography of the cardiac valves: normal, diseased, and postoperative appearances. Radiographics. 29 (5): 1393-412. doi:10.1148/rg.295095002 - Pubmed citation
- 9. Siu SC, Silversides CK. Bicuspid aortic valve disease. J. Am. Coll. Cardiol. 2010;55 (25): 2789-800. doi:10.1016/j.jacc.2009.12.068 - Pubmed citation
- 10. Otto CM. Calcification of bicuspid aortic valves. Heart. 2002;88 (4): 321-2. Free text at pubmed - Pubmed citation
- 11. Lewin MB, Otto CM. The bicuspid aortic valve: adverse outcomes from infancy to old age. Circulation. 2005;111 (7): 832-4. doi:10.1161/01.CIR.0000157137.59691.0B - Pubmed citation
- 12. Popma JJ, Ramadan R. CT Imaging of Bicuspid Aortic Valve Disease for TAVR. JACC Cardiovasc Imaging. 2016;9 (10): 1159-1163. doi:10.1016/j.jcmg.2016.02.028 - Pubmed citation
- 13. Manka R, Binter C, Kozerke S. Hurricane aorta. Lancet (London, England). 384 (9960): 2141. doi:10.1016/S0140-6736(14)60752-2 - Pubmed
- 14. Yuan SM, Jing H, Lavee J. The bicuspid aortic valve and its relation to aortic dilation. (2010) Clinics (Sao Paulo, Brazil). 65 (5): 497-505. doi:10.1590/S1807-59322010000500007 - Pubmed
- 15. Evangelista, Arturo, Flachskampf, Frank A., Erbel, Raimund, Antonini-Canterin, Francesco, Vlachopoulos, Charalambos, Rocchi, Guido, Sicari, Rosa, Nihoyannopoulos, Petros, Zamorano, Jose, Pepi, Mauro, Breithardt, Ole-A., Plońska-Gościniak, Edyta. Echocardiography in aortic diseases: EAE recommendations for clinical practice. (2010) European Journal of Echocardiography. 11 (8): 645. doi:10.1093/ejechocard/jeq056 - Pubmed
- 16. Steven A Goldstein, Itzhak Kronzon, Bijoy K Khandheria, Victor Mor-Avi. ASE’s Comprehensive Echocardiography E-Book. (2015) ISBN: 9780323327343
- 17. Lamas, Cristiane C., Eykyn, Susannah J.. Bicuspid Aortic Valve—A Silent Danger: Analysis of 50 Cases of Infective Endocarditis. (2000) Clinical Infectious Diseases. 30 (2): 336. doi:10.1086/313646 - Pubmed
- 18. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (2014) Circulation. 129 (23): 2440-92. doi:10.1161/CIR.0000000000000029 - Pubmed
- 19. Chan KL, Stinson WA, Veinot JP. Reliability of transthoracic echocardiography in the assessment of aortic valve morphology: pathological correlation in 178 patients. (1999) The Canadian journal of cardiology. 15 (1): 48-52. Pubmed