From the Guidelines
Patients with bicuspid aortic valve (BAV) should undergo surgical intervention when the maximum aortic diameter is ≥55 mm, or ≥50 mm for those with the root phenotype, as recommended by the 2024 ESC guidelines 1. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life for patients with BAV. The management of BAV involves regular monitoring and surveillance to assess valve function and aortic dimensions. Key aspects of management include:
- Initial transthoracic echocardiography (TTE) to assess aortic diameters at several levels when BAV is first diagnosed 1
- Surgical intervention for bicuspid aortopathy when the maximum aortic diameter meets the specified thresholds 1
- Use of computed tomography (CT) or cardiac magnetic resonance (CMR) for imaging the entire thoracic aorta at first diagnosis, or when discrepancies in measurements are found between subsequent TTE controls during surveillance, or when the diameter of the aorta exceeds 45 mm 1
- Screening by TTE in first-degree relatives (FDRs) of BAV patients with root phenotype aortopathy and/or isolated aortic regurgitation 1
- Surveillance serial imaging by TTE in BAV patients with a maximum aortic diameter >40 mm, either with no indication for surgery or after isolated aortic valve surgery, after 1 year, then if stability is observed, every 2–3 years 1 The 2024 ESC guidelines provide the most recent and highest-quality evidence for the management of BAV, superseding previous recommendations 1.
From the Research
Bicuspid Aortic Valve Overview
- Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality, occurring in 1% to 2% of the total population 2.
- It has a wide spectrum of clinical manifestations, including aortic regurgitation (AR), aortic stenosis, and an associated aortopathy with a small but increased risk of aortic dissection 2.
Diagnosis and Surveillance
- Patients with a BAV should have evaluation of the aorta with a MRI or CT angiography at some point, as 50% of BAV patients have aortic root involvement 3.
- Cardiac MRI is preferred unless there is a contraindication, particularly in younger patients, given the cumulative radiation exposure from surveillance CT scans 3.
- Yearly surveillance transthoracic echocardiography is recommended for patients with moderate valve dysfunction (AS or AR) to monitor left ventricular function, jet velocity, gradient, and valve area 3.
Treatment Options
- For young adult patients with isolated aortic stenosis, balloon aortic valvuloplasty is often an effective and temporizing treatment option 3.
- For older patients with aortic stenosis or those with AR, aortic valve replacement, with or without surgery on the aorta, is the preferred management strategy 3.
- Transcatheter aortic valve replacement (TAVR) is also considered as an alternative option with good results, especially for patients with bicuspid aortic stenosis 4, 5, 6.
Outcomes of Transcatheter versus Surgical Aortic Valve Replacement
- A study comparing 3-year outcomes of TAVR versus surgical aortic valve replacement in patients with bicuspid aortic stenosis found that TAVR was associated with a similar mortality risk compared with surgical aortic valve replacement within the first 6 months, but a higher mortality risk between 6 months and 3 years 5.
- TAVR was also associated with a lower risk of heart failure readmissions before 6 months, but a higher risk between 6 months and 3 years 5.
Risk Stratification and Treatment Strategies
- Understanding the pathophysiology and the altered hemodynamics is a key component for the diagnosis, risk stratification, and treatment of BAV disease 6.
- Treatment strategies vary depending on the severity of the disease, particularly the dilation of the aorta playing a major role 6.
- Risk stratification and treatment strategies should be individualized based on the patient's specific condition and needs 3, 2, 6.