What is the next step in managing a 77-year-old female with a likely bicuspid (bicuspid aortic valve) aortic valve, calcification, and restricted opening, aneurysmal (abnormal bulging of the atrial septum) atrial septum, and hypokinetic (reduced movement) base to mid inferior wall?

Management of a 77-Year-Old Female with Bicuspid Aortic Valve and Associated Cardiac Abnormalities

The next step in management should be comprehensive cardiac imaging with ECG-gated multidetector computed tomography (MDCT) of the thoracic aorta to fully evaluate the bicuspid aortic valve, calcification, aortic dimensions, and coronary anatomy. 1

Assessment of Bicuspid Aortic Valve and Associated Conditions

Initial Findings and Concerns

The patient presents with multiple significant cardiac findings:

• Likely bicuspid aortic valve with calcification and restricted opening (suggesting aortic stenosis)
• Aneurysmal atrial septum
• Hypokinetic base to mid inferior wall (suggesting coronary artery disease or prior infarction)

Diagnostic Approach

Step 1: Complete Echocardiographic Evaluation

• Ensure transthoracic echocardiography (TTE) has been performed to:
  • Confirm bicuspid valve morphology
  • Assess severity of aortic stenosis using:
    • Peak velocity
    • Mean gradient
    • Valve area calculation
  • Evaluate for aortic regurgitation
  • Measure left ventricular function (LVEF)
  • Assess wall motion abnormalities, particularly the hypokinetic inferior wall

Step 2: Advanced Imaging (Key Next Step)

• ECG-gated MDCT of the thoracic aorta is indicated 1
  • This is crucial when TTE cannot fully assess aortic valve morphology and the dimensions of the aortic root and ascending aorta 1
  • Class I recommendation for patients with bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be fully assessed by echocardiography 1

Step 3: Evaluate for Associated Conditions

• Assess for coarctation of the aorta (associated with bicuspid valve) 1
• Evaluate coronary anatomy (especially given the hypokinetic inferior wall)
• Consider cardiac MRI if MDCT is contraindicated 1

Comprehensive Assessment Parameters

Aortic Valve and Root Measurements

The MDCT should include detailed measurements of:

• Aortic valve morphology and calcification
• Aortic annulus dimensions
• Aortic root and ascending aorta dimensions
• Sinotubular junction
• Coronary artery height and anatomy 1

Specific Measurements to Request

1. Aortic valve:

   • Calcium score using Agatston technique
   • Number of valve cusps
   • Valve opening assessment

2. Left ventricular outflow tract:

   • Diameter, perimeter, and area
   • Assessment of calcification

3. Aortic root:

   • Sinus of Valsalva measurements
   • Height from annulus to coronary arteries
   • Aortic root angulation

4. Ascending aorta and arch:

   • Diameters at multiple levels
   • Assessment for aneurysmal dilation

5. Coronary arteries:

   • Evaluation of stenosis
   • Relationship to valve apparatus 1

Clinical Implications and Follow-up Plan

Risk Assessment

• Bicuspid aortic valves are associated with increased risk of:
  • Aortic stenosis or regurgitation progression
  • Aortic dilation and potential dissection
  • Endocarditis 1

Management Decision Points

• If severe aortic stenosis is confirmed:

  • Assess symptom status
  • Consider aortic valve replacement (surgical or transcatheter) based on:
    • Severity of stenosis
    • Symptoms
    • LV function
    • Comorbidities

• If significant aortic dilation is present:

  • Consider combined valve and aortic replacement when diameter exceeds 4.5 cm 1

• For the hypokinetic inferior wall:

  • Coronary angiography may be needed to assess for significant coronary artery disease

Common Pitfalls to Avoid

1. Underestimating aortic dimensions in patients with bicuspid valves
2. Focusing only on valve pathology while missing associated aortopathy
3. Failing to evaluate for coarctation of the aorta
4. Neglecting to assess coronary anatomy before intervention
5. Delaying intervention in elderly patients with severe stenosis

Family Screening Considerations

• First-degree relatives should be evaluated for bicuspid aortic valve and aortopathy 1
• This is a Class I recommendation as bicuspid aortic valve can be inherited in families as an autosomal dominant condition 1

By following this systematic approach with comprehensive imaging as the next step, you will be able to fully characterize this patient's cardiac condition and determine the optimal management strategy.