What are the implications of a bicuspid aortic valve (BAV) with mild aortic regurgitation and no aortic stenosis, in the presence of a nondilated aorta?

From the Guidelines

The patient with a bicuspid aortic valve and mild regurgitation, without stenosis or aortic dilation, should undergo regular cardiac monitoring with echocardiograms every 1-2 years to track any progression of the regurgitation or development of aortic dilation. This approach is based on the guidelines for the management of patients with valvular heart disease, as outlined in the 2014 AHA/ACC guideline 1 and the 2007 European Society of Cardiology guidelines 1. The current condition of the patient falls under Stage A, where the patient is at risk of aortic regurgitation (AR) due to the presence of a bicuspid aortic valve, but currently has no significant hemodynamic consequences.

Key considerations for management include:

• Regular echocardiographic monitoring to assess for progression of regurgitation or aortic dilation
• No specific medication is required at this stage, given the mild nature of the regurgitation and absence of stenosis or aortic dilation
• Endocarditis prophylaxis may be considered before certain dental or invasive procedures, although guidelines on this have evolved
• Maintaining good dental hygiene to reduce the risk of endocarditis
• Regular follow-up with a cardiologist is crucial, as bicuspid aortic valves can deteriorate over time and may require intervention if regurgitation worsens or if the aorta begins to dilate

It's also important to note that moderate aerobic exercise is generally safe for patients with bicuspid aortic valves, but extreme competitive or isometric exercises should be discussed with a cardiologist. The patient's condition, while currently stable, requires ongoing monitoring to ensure early intervention if needed, as bicuspid aortic valves can affect approximately 1-2% of the population and have the potential for deterioration over time.

From the Research

Bicuspid Aortic Valve with Mild Regurgitation and No Stenosis

• The patient has a bicuspid aortic valve with mild regurgitation and no stenosis, and the aorta is nondilated 2.
• In this case, the management approach would involve yearly surveillance transthoracic echocardiography to monitor left ventricular function, jet velocity, gradient, and valve area, as well as yearly clinical evaluation for change in symptom status or functional capacity 2.
• The use of NT-pro BNP levels may also be helpful in assessing patients with bicuspid aortic valve, particularly those with mismatch between anatomic severity and clinical symptoms 2.
• Since the aorta is nondilated, echocardiography may be sufficient for follow-up, and cardiac MRI or CT angiography may not be necessary unless there are changes in the patient's condition 2.

Role of Multimodality Imaging

• Multimodality imaging, including echocardiography, cardiac MRI, cardiac CT, and advanced technologies such as 4D flow and strain imaging, may be useful in evaluating aortic regurgitation in patients with bicuspid aortic valve 3.
• This approach can help quantify regurgitation and select patients suitable for valve replacement 3.
• The choice of imaging modality depends on the individual patient's condition and the availability of resources 3.

Surgical Options

• For patients with bicuspid aortic valve and aortic regurgitation, surgical repair or replacement may be necessary 4, 5.
• The surgical approach depends on the severity of the regurgitation, the presence of aortic dilation, and other individual patient factors 4, 5.
• In some cases, repair of the bicuspid aortic valve may be possible, while in others, replacement with a prosthetic valve may be necessary 4, 5.