A classification system for the bicuspid aortic valve from 304 surgical specimens

The passability of delivery catheter system during self-expanding transcatheter aortic valve replacement: A CT-based prediction model

OBJECTIVE

Aortic anatomy may pose challenges to the advancement of the delivery catheter system (DCS) and affect the outcome of self-expanding transcatheter aortic valve replacement (SE-TAVR). This study aimed to develop a preprocedural CT-based nomogram to predict the passability of DCS and clinical SE-TAVR outcomes.

METHODS AND RESULTS

Data of 348 patients who underwent transfemoral SE-TAVR were retrospectively collected from May 2018 to December 2023. A number of 118 patients received snare catheter, indicating poor DCS passaibility. All patients were randomized to development (n = 244) and validation (n = 104) sets. A predictive model was constructed by logistic regression and presented as a nomogram, which indicated that larger aortic angle, severe calcification, larger ascending aorta diameter, coronary ostial height of ≤10 mm, and bicuspid aortic valve were independent anatomical risk factors for poor DCS passability during SE-TAVR. Subsequently, the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were depicted to assess the performance of the nomogram, revealing its good accuracy and concordance. This model also showed that patients with poor DCS passability were more likely to develop significant postprocedural paravalvular leak (PVL).

CONCLUSIONS

The model adequately predicts the DCS passability during SE-TAVR, which provides a comprehensive profile of risk factors for poor DCS passability and indicates coronary ostial height of ≤10 mm as a novel anatomical risk factor, in addition to the larger aortic angle, severe calcification, larger ascending aorta diameter, and bicuspid aortic valve. Patients with poor DCS passability are more likely to develop significant PVL.

Creation of bicuspid aortic valve for bicuspid annulus using Ozaki's neocuspidization technique, with indigenously developed valve templates

This study aimed to retrospectively analyze the early outcomes of bicuspid aortic valve (BAV) neocuspidization for Type 0 bicuspid aortic annulus. Bicuspid neo leaflets were created and surgically sutured using Ozaki's neocuspidization technique with indigenously developed valve templates. The study was conducted at the Department of Cardiothoracic and Vascular Surgery, GB Pant Postgraduate Institute of Medical Education and Research, New Delhi, for the patients operated between June 2022 and March 2024. Bicuspid neocuspidization was performed in patients with BAVs who required aortic valve replacement and were not candidates for tricuspid neocuspidization. A total of 8 patients were found to have Type 0 BAVs during the study period. In one of these patients, tricuspid neocuspidization was done, while in the remaining 7 patients, bicuspid neocuspidization was done. In 1 patient of bicuspid neocuspidization, concomitant root replacement was done and was excluded. The outcomes of 6 patients are hereby presented. There was no mortality. The mean postoperative gradient was 14.5 (+ / - 0.9) mm Hg. There was trivial aortic regurgitation in 2 cases of bicuspid neo valves while 4 cases of bicuspid neo valves had no neo aortic valve regurgitation. The average coaptation length of the neo valve was 14.8 (+ / - 0.5) mm.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01843-1.

Physical activity characteristics in adults with bicuspid aortic valve versus age- and sex-matched controls

BACKGROUND

A bicuspid aortic valve (BAV) is associated with a higher lifetime risk of cardiovascular morbidity. Management of modifiable risk factors, including physical (in)activity, is therefore key. However, little is known about physical activity (PA) and sedentary behavior (SB) characteristics in BAV individuals. Therefore, we compared objectively measured PA and SB characteristics between BAV individuals and controls.

METHODS AND RESULTS

100 BAV adults (45 ± 16 years; 59 % male) and 100 age- and sex-matched controls were recruited. SB and PA characteristics were objectively assessed for 8 consecutive days using thigh-worn accelerometers. SB was comparable between BAV and control groups (9.3 [8.5-10.2] vs. 9.3 [8.2-10.2] hrs/day, p = 0.84), but time spent in MVPA (72 [59-89] vs. 98 [75-116] min/day, p < 0.001) and step count (4826 [4004-5801] vs. 6252 [4784-7484] steps/day, p < 0.001) were markedly lower in BAV individuals. BAV individuals were categorized into none-to-mild (n = 46) or moderate-to-severe (n = 54) disease subgroups based on the presence of valvular dysfunction and/or aortic dilatation. A more prominent decrease in MVPA (-16.9 and - 27 min/day) and step count (-967 and - 1685 steps/day) was observed with increased BAV disease severity. PA characteristics were positively associated with mental QoL in BAV, whereas no association was found with cardiac anxiety. Forty-eight percent of BAV individuals expressed uncertainty regarding allowed PA levels and 56 % was interested in additional information on PA recommendations.

CONCLUSION

BAV individuals were less physically active compared to age- and sex-matched controls, as evidenced by a lower MVPA time and step count, with greater levels of physical inactivity among individuals with more severe disease.

Review Article: Contemporary Transcatheter Heart Valves for TAVI in Bicuspid Aortic Anatomy

Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5-2% of the population and often leading to early aortic valve degeneration. While surgical aortic valve replacement (SAVR) remains the gold standard for treating severe bicuspid aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) is emerging as a viable alternative in selected BAV anatomies. Initial experiences with first-generation transcatheter heart valves (THVs) showed the feasibility of this technique, but were associated with lower device success rates and higher complications, such as paravalvular leak (PVL) and pacemaker implantation. Advancements in second- and third- generation THVs, together with better pre-procedural imaging assessment and growing operator experience, have significantly enhanced TAVI outcomes in BAV patients, with results now comparable to those seen in tricuspid aortic valves (TAVs). Proper patient selection, pre-procedural sizing, and device implantation are key to improving TAVI success in BAV. Recent registry data on contemporary THV platforms demonstrate improved procedural success, hemodynamic performance, and the safety of TAVI in BAV. However, higher rates of PVL, pacemaker implantation, and strokes remain concerns. Ongoing advancements in THV design and procedural techniques will further enhance outcomes for this challenging population. Up to the present, there are no dedicated THVs for BAV, but the latest-generation THVs offer promising results.

Expanding Transcatheter Aortic Valve Replacement Use in Younger Patients and Bicuspid Valves: Risks, Evidence Gaps, and Regulatory Action

This expert review examines the expanding use of transcatheter aortic valve replacement (TAVR) in younger patients with bicuspid aortic valves (BAV), highlighting midterm outcomes, including elevated mortality, stroke, and pacemaker dependency, compared with surgical aortic valve replacement. The untested and unproven long-term effectiveness and durability of TAVR in patients aged <70 years and the growing use of "valve-in-valve" for surgical aortic valve replacement bioprosthetic degeneration and TAVR failure are also highlighted. Summarizing recent observational studies, registry data, and the limited randomized evidence available, the author calls for new rigorous, long-term randomized controlled trials before broader adoption of TAVR and valve-in-valve TAVR in these populations, and urges the United States Food and Drug Administration and Centers for Medicare and Medicaid Services to align policy with evidence challenging the erosion of guideline-directed care driven by market forces.

Diagnosis of bicuspid aortic valves: CT vs. TTE

Bicuspid aortic valfves (BAV) are a relatively common cardiac abnormality, with an associated risk of aortic stenosis, aortic regurgitation and aortopathy. First-line diagnosis is via transthoracic echocardiography (TTE), which may be impacted by valve calcification and operator variability. Electrocardiogram-gated computed tomography (CT) offers an alternative form of assessment. The aim of this systematic review and meta-analysis is to evaluate the diagnostic performance of TTE versus CT for BAV. Eligible studies were retrieved from inception through to March 2024 on OVID Medline, Embase and Cochrane Library. All primary studies regarding the diagnostic performance of TTE and/or CT with regards to BAV were included. The QUADAS-2 tool was utilized for quality assessment. Sensitivity and specificity data were statistically analyzed. Of 4698 records, 19 were eligible for inclusion, and 16 had sufficient data for inclusion in the meta-analysis. There was only data regarding TTE vs. retrospectively ECG-gated CT. There was a significant difference between the sensitivity of retrospectively ECG-gated cardiac CT (95.5% (95% CI: [91.3-97.5%]) and TTE (79.7%, 95% CI: [71.6-86.0%]) for identifying BAV. The specificity was high and not significantly different for both CT and TTE (96%, 95% CI: [92.5-98.2%] and 91.3%, 95% CI: [87.3-93.8%], respectively). Retrospectively ECG-gated CT demonstrates greater sensitivity for diagnosis of BAV compared to TTE. Both modalities are non-invasive and demonstrate good specificity for excluding BAV. Given that CT scans are easily accessible, they offer a reasonable second-line investigation for diagnosis of BAV when an initial TTE is inconclusive.

Tissue-specific lncRNA GATA6-AS1 and its ortholog Moshe as essential regulators of aortic valve development

Long noncoding RNAs (lncRNAs) are integral to epigenetic regulation during cardiogenesis; however, their role in aortic valve disease is not well characterized. Investigating lncRNAs present in the human embryonic heart and pinpointing their specific isoforms presents notable challenges due to both technical and ethical limitations. In our research, we identified GATA6- AS1 as a lncRNA predominantly found in the heart by analyzing publicly accessible RNA sequencing data derived from human embryonic tissues. Employing in vitro models along with CS17 embryonic heart tissue, we determined that isoforms 202 and 208 of GATA6-AS1 are uniquely expressed in cardiac neural crest lineage cells throughout the development of the aortic valve. We also identified Moshe, the murine ortholog of GATA6-AS1, whose expression occurs during aortic valve formation in mice. Notably, depletion of Moshe results in the development of bicuspid aortic valves (BAV), accompanied by a significant downregulation of genes associated with BAV, particularly those related to the Notch and TGF-β signaling pathways. These findings highlight the critical role of GATA6-AS1 in aortic valve development through the study of its mouse ortholog Moshe. They also suggest that lncRNAs, still underexplored in congenital heart disease research, may hold significant implications for BAV pathogenesis and potential therapeutic strategies. [BMB Reports 2025; 58(4): 175-182].

Asymptomatic giant ascending aortic aneurysm: a challenging surgical strategy for a silent bicuspid aortopathy

We report the case of an incidental finding of a giant aneurysm of the ascending aorta with a congenital bicuspid aortic valve type 0-lateral. This severe condition was totally unknown to the patient, who was asymptomatic for cardiovascular disease. The aneurysmal mass involved the entire mediastinum, altering the normal anatomical relations, so the operative strategy was modified intraoperatively, tailoring the surgical technique to the anatomical conditions found. Despite a delayed awakening, the patient had an uncomplicated postoperative course. Therefore, this case highlights the importance of not underestimating nonspecific, seemingly harmless symptoms and signs that may reveal potentially catastrophic pathologies while also focusing on the surgical technique used. The modified Cabrol procedure, while an underutilized technique, if present in the cardiac surgeon's "arsenal" can represent a life-saving strategy in complex cases requiring an aortic valve and ascending aorta replacement.

Prevalence, clinical characterization, management and evolution of bicuspid aortic valve classified according to the 2021 International Consensus Statement in a tertiary care hospital

OBJECTIVES

The 2021 International Consensus for the congenital bicuspid aortic valve (BAV) condition recognizes 3 morphologies of BAV (fused, two-sinus and partial-fusion) and 3 types of aortopathy (ascending, root and extended). The clinical impact of BAV phenotyping on aortopathy evolution has not been evaluated so far. The aims were to assess: (i) prevalence of BAV phenotypes; (ii) frequency of BAV-related aortic valve dysfunction and aortopathy; and (iii) inter-phenotypic differences in aortopathy progression in a real-world population.

METHODS

This was an observational cohort study on patients with BAV referred to our tertiary hospital between January 2018 and November 2022 to undergo a comprehensive transthoracic echocardiography. Baseline clinical, ultrasonographic and computed tomographic data were evaluated; even echocardiographic progression of aortic dilatation was assessed.

RESULTS

Three hundred and two patients were evaluated: 245 (81.1%) had fused, 41 (13.6%) two-sinus and 16 (5.3%) partial fusion BAV. Aortopathy was documented in 101 (33.6%) cases and it was prevalent among patients with the fused type. The prevalence of aortic valve dysfunction was instead similar among the 3 groups. Two hundred and twelve patients underwent invasive management of clinically relevant aortic valve or aortic disease. Non-operated fused type presented the highest progression rate of aortic dilatation, whilst, among the interventional subpopulation, a more pronounced evolution was observed in the two-sinus type, at a median follow-up of 2 years.

CONCLUSIONS

Fused type represented the BAV phenotype with the highest frequency and the most significant association with aortopathy. In terms of aortopathic progression, the mid-term growth rate of the thoracic aorta was more significant in the non-interventional fused BAVs.

Personalized Diagnoses for Those Born with Congenitally Malformed Hearts

Background/Objectives: It is increasingly realized that the advances in diagnosis and treatment for those born with congenitally malformed hearts have now resulted in avoidance of morbidity being equally as important as avoiding postoperative mortality. Detailed personalized diagnoses will now be key to achieve such improvements. Methods: We have reviewed our own experience in diagnosing major phenotypic variations on selected congenital cardiac malformations, showing that the ability to personalize the findings is at hand, although not always to date universally employed. Results: We have chosen four categories to illustrate how the definitions now provided by the International Nomenclature Society, and incorporated in the 11th iteration of the International Classification of Disease, make it possible to provide personalized diagnoses. The lesions chosen for review are the arrangement of the atrial appendages, the lesions permitting interatrial shunting, the options in the setting of deficient ventricular septation, and the abnormal morphology of the aortic root. We show that not all centers, as yet, are taking advances of these opportunities at hand to tailor the chosen treatments. Conclusions: Detailed phenotypic definitions have now been provided for all the major congenital cardiac malformations. Use of these definitions should now provide personalized medicine for all those born with malformed hearts. As yet, the definitions are not used to their full effect.

Transcatheter aortic valve implantation in bicuspid aortic valves: present and future

The prevalence of bicuspid aortic valves (BAV) in patients undergoing transcatheter aortic valve implantation (TAVI) is expected to gradually increase over the coming years. However, in the absence of dedicated randomized trials, TAVI outcomes in BAV patients have failed to match those obtained in trileaflet anatomies. This discrepancy is mainly due to varying degrees of valve morphology and calcification, aortic angulation, concomitant aortopathy, and the difficulties of achieving optimal preprocedural anatomic sizing and device selection in the BAV setting. In this review, we aim to outline the current state of knowledge in the BAV and TAVI field, evaluate the main challenges faced by TAVI operators when dealing with these anatomies, summarize novel approaches for sizing and preprocedural evaluation, and provide a glimpse into the future of this interesting and evolving field.

Development of a methodology for in vitro and in silico simulation of transcatheter aortic valve replacement using 3D-printed valve frames

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is experiencing continued growth as an option for the treatment of aortic stenosis. Both in vitro and in silico methods have proven reliable in assessing the performance of TAVI devices, which can be used in procedure planning and prototyping new concepts. 3D printing of TAVI frames has the potential for revolutionizing frame designs by making it possible to create more complex geometries. However, the mechanical performance of additively manufactured frames, in terms of crimping and deployment into an aortic root, needs to be verified if such frames are to provide a plausible and reliable method for benchtop testing.

METHODS

Having previously established a suitable set of process parameters for laser powder bed fusion (LPBF) manufacture of TAVI frames based on the SAPIEN S3 design, the deployment of such a frame into a patient-specific, 3D printed aortic root phantom was undertaken and assessed using a high resolution CT scan of the result. In parallel, a full computational model was developed to simulate the same deployment procedure and validated against the in vitro study. Further, an interesting case study was setup using this approach to assess deployment of the LPBF frame into the same aortic root phantom but with two of the leaflets fused together.

RESULTS

The LPBF-manufactured frame had sufficient radial strength to fully open the leaflets within the aortic root phantom and anchor the frame in place for both fused and non-fused leaflet cases. There was good agreement between the in vitro and in silico tests in terms of frame position with an average nodal position error of 0.37 mm and 1.29 mm for non-fused and fused cases respectively. Similarly, the frame diameter difference between the in vitro and in silico deployments were 1.01% for the non-fused and 3.17% for the fused cases.

CONCLUSION

Manufacture of a SAPIEN S3 type heart valve frame using LPBF has been shown to provide a viable procedure for producing frames for testing and assessment when crimped and deployed into a model of an aortic root. Further, the validated in silico model developed in this study can be used to computationally design and test novel frame concepts to be manufactured by LPBF.

Clinical value of aortic arch morphology in transfemoral TAVR: artificial intelligence evaluation

BACKGROUND

The impact of aortic arch (AA) morphology on the management of the procedural details and the clinical outcomes of the transfemoral artery (TF)-transcatheter aortic valve replacement (TAVR) has not been evaluated. The goal of this study was to evaluate the AA morphology of patients who had TF-TAVR using an artificial intelligence algorithm and then to evaluate its predictive value for clinical outcomes.

MATERIALS AND METHODS

A total of 1480 consecutive patients undergoing TF-TAVR using a new-generation transcatheter heart valve at 12 institutes were included in this retrospective study. The AA measurements were evaluated by deep learning, and then the approach index (I A ) was determined. The machine learning algorithm was used to construct the predictive model and was validated externally.

RESULTS

The area under the curve of the I A model using random forest and logistic regression was 0.675 [95% confidence interval (CI): 0.586-0.764] and 0.757 (95% CI: 0.665-0.849), respectively. The I A model was validated externally, and consistent distinctions were obtained. After we used a generalized propensity score matching method for continuous exposure, the I A was the strongest correlation factor for major procedural events (odds ratio: 3.87; 95% CI: 2.13-7.59, P < 0.001). When leaflet morphology or transcatheter heart valve type was an interactive item with I A , neither of them was statistically significant in terms of clinical outcomes.

CONCLUSION

I A may be used to identify the impact of AA morphology on procedural and clinical outcomes in patients having TF-TAVR and to help to predict the procedural complications.

Incidence and predictors of continued ascending aortic dilatation after TAVI in patients with bicuspid aortic stenosis

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) for bicuspid aortic stenosis (AS) frequently present with ascending aortic (AAo) dilatation which is left untreated. The objective of this study was to study the natural progression and underlying mechanisms of AAo dilatation after TAVI for bicuspid AS.

METHODS

Patients with a native bicuspid AS and a baseline AAo maximum diameter > 40 mm treated by TAVI and in whom post-TAVI computed tomography (CT) scans beyond 1 year were available were included. AAo dilatation was deemed to be either continuous (≥ 2 mm increase) or stable (< 2 mm increase or decrease). Uni- and multivariate logistic regression analysis was utilized in order to identify factors associated with continuous AAo dilatation post-TAVI.

RESULTS

A total of 61 patients with a mean AAo maximum diameter of 45.6 ± 3.9 mm at baseline were evaluated. At a median follow-up of 2.9 years, AAo dimensions remained stable in 85% of patients. Continuous AAo dilatation was observed in 15% of patients at a rate of 1.4 mm/year. Factors associated with continuous AAo dilatation were raphe length/annulus mean diameter ratio (OR 4.09, 95% CI [1.40-16.7], p = 0.022), TAV eccentricity at the leaflet outflow level (OR 2.11, 95%CI [1.12-4.53], p = 0.031) and maximum transprosthetic gradient (OR 1.30, 95%CI [0.99-1.73], p = 0.058).

CONCLUSIONS

Ascending aortic dilatation in patients undergoing TAVI for bicuspid AS remains stable in the majority of patients. Factors influencing TAV stent frame geometry and function were identified to be associated with continuous AAo dilatation after TAVI; this should be confirmed in future larger cohort studies.

Incidence and Prognosis of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement for Bicuspid Aortic Stenosis

BACKGROUND

Evidence regarding the incidence of prosthesis-patient mismatch (PPM) and long-term mortality after transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve stenosis (AS) is scarce.

OBJECTIVES

This study sought to assess the incidence and prognostic impact of PPM after TAVR for bicuspid AS compared with that for tricuspid AS.

METHODS

In total, 7,393 patients who underwent TAVR were prospectively enrolled in the OCEAN-TAVI (Optimized Catheter Valvular Intervention Transcatheter Aortic Valve Implantation) registry, an ongoing Japanese, multicenter registry. We analyzed 7,051 patients (median age = 85 years, 68.4% women) and identified 503 (7.1%) with bicuspid AS. We compared the incidence of PPM and long-term mortality in 497 patients with and 497 without bicuspid AS after one-to-one propensity score matching analysis.

RESULTS

Among the 7,051 patients, moderate and severe PPM were observed in 756 (10.7%) and 92 (1.3%) patients, respectively. Upon Kaplan-Meier curve analysis of the overall cohort, severe PPM appeared to be associated with long-term mortality (log-rank test, P = 0.065). After propensity score matching analysis, moderate and severe PPM were more frequently observed among patients with tricuspid AS than patients with bicuspid AS (moderate PPM, 11.7% vs 4.4%; severe PPM, 1.4% vs 1.0%; P = 0.0001).

CONCLUSIONS

Severe PPM appeared to be associated with all-cause mortality. Moderate and severe PPM were more frequently observed in patients with tricuspid AS than patients with bicuspid AS.

Valve-sparing aortic root replacement in bicuspid aortic valves-the reimplantation technique: A multicenter study

OBJECTIVE

Reported outcomes in patients with bicuspid aortic valves (BAVs) undergoing valve-sparing aortic root replacement (VSRR) are scarce. This study aims to evaluate outcomes in patients with BAV using the reimplantation (David) technique.

METHODS

Consecutive adult patients with BAV, aortic root aneurysm, and/or aortic valve insufficiency (AI) undergoing VSRR (reimplantation) were included from 5 centers experienced in reimplantation procedures. Patients were subcategorized into 2 groups with different primary indications for operation: (1) aneurysm, and (2) isolated AI. Exclusion criteria included acute aortic dissection, endocarditis, and valvular-stenosis.

RESULTS

In total, 498 patients were included. Mean age was 45.4 years (±11.8 years); median follow-up was 5.4 years (interquartile range, 2.3-8.7 years). Group 1 included aneurysm (n = 144) and group 2 included AI (n = 354). There was 1 in-hospital death. Survival (overall) was 93.4% (95% confidence interval [CI], 92-97%) at 10 years, with no difference between groups (P = .93) observed. Freedom from reintervention at 1 year was 99.1% (95% CI, 99%-100%), at 5 years 95.4% (95% CI, 93%-97%), and at 10 years 89.2% (95% CI, 86%-93%) for patients with aneurysm 100% at 1 year and 95.4% (95% CI, 92%-98%) at 10 years; and for AI 98.9% (95% CI, 98%-99%) at 1 year and 86.4% (95% CI, 83%-91%) at 10 years. Cusp fenestrations (P = .01), prolapse (P = .04), and isolated AI (0.03) were associated with greater hazard of reintervention.

CONCLUSIONS

This multicenter study shows excellent results after VSRR reimplantation procedure in patients with BAV and aortic aneurysm and/or valve insufficiency. Isolated AI and cusp abnormalities are associated with greater reintervention rates and may reflect more advanced leaflet disease. The reimplantation technique, when performed in expert centers, appears to be an excellent treatment strategy in BAV.

Conduction Disturbances and Outcome After Surgical Aortic Valve Replacement in Patients With Bicuspid and Tricuspid Aortic Stenosis

BACKGROUND

This study aimed to compare the incidence and prognostic implications of new-onset conduction disturbances after surgical aortic valve replacement (SAVR) in patients with bicuspid aortic valve (BAV) aortic stenosis (AS) versus patients with tricuspid aortic valve (TAV) AS (ie, BAV-AS and TAV-AS, respectively). Additionally, the study included stratification of BAV patients according to subtype.

METHODS

In this cohort study, the incidence of postoperative third-degree atrioventricular (AV) block with subsequent permanent pacemaker requirement and new-onset left bundle-branch block (LBBB) was investigated in 1147 consecutive patients without preoperative conduction disorder who underwent isolated SAVR (with or without ascending aortic surgery) between January 1, 2005, and December 31, 2022. The groups were stratified by aortic valve morphology (BAV, n=589; TAV, n=558). The outcomes of interests were new-onset third-degree AV block or new-onset LBBB during the index hospitalization. The impact of new-onset postoperative conduction disturbances on survival was investigated in BAV-AS and TAV-AS patients during a median follow-up of 8.2 years. BAV morphology was further categorized according to the Sievers and Schmidtke classification system (possible in 307 BAV-AS patients) to explore association between BAV subtypes and new-onset conduction disturbances after SAVR.

RESULTS

The overall incidence of third-degree AV block and new-onset LBBB after SAVR was 4.5% and 7.8%, respectively. BAV-AS patients had a higher incidence of both new-onset third-degree AV block (6.5% versus 2.5%; P=0.001) and new-onset LBBB (9.7% versus 5.7%; P=0.013) compared with TAV-AS patients. New-onset LBBB was associated with an increased all-cause mortality during follow-up (adjusted hazard ratio, 1.60 [95% CI, 1.12-2.30]; P=0.011), whereas new-onset third-degree AV block was not associated with worse prognosis. Subgroup analysis of the BAV cohort revealed that BAV-AS patients with fusion of the right- and non-coronary cusps had the highest risk of new-onset third-degree AV block (adjusted odds ratio [aOR], 8.33 [95% CI, 3.31-20.97]; P<0.001, with TAV as reference group) and new-onset LBBB (aOR, 4.03 [95% CI, 1.84-8.82]; P<0.001, with TAV as reference group), whereas no significant association was observed for the other BAV subtypes.

CONCLUSIONS

New-onset LBBB after SAVR is associated with increased all-cause mortality during follow-up, and is more frequent complication in BAV AS patients compared with TAV-AS patients. BAV-AS patients with fusion of the right- and non-coronary cusps have an increased risk for conduction disturbances after SAVR. This should be taken into consideration when managing these patients.

Transcatheter Aortic Valve Implantation (TAVI) in Bicuspid Anatomy

Bicuspid aortic valve (BAV) stenosis, a common congenital condition, presents unique challenges for transcatheter aortic valve replacement (TAVI) due to anatomical variations like cusp morphology, coexisting aortopathy and calcification. TAVI offers a viable option for BAV patients with refinements in technique and technology, though ongoing research is essential to optimize patient-specific approaches and long-term results. Key considerations for TAVI in BAV include precise valve sizing, positioning, and the need for rigorous pre-procedural imaging to mitigate risks such as paravalvular leak and stroke. Early results show TAVI's safety and efficacy are comparable to surgery, though BAV patients undergoing TAVI often are exposed to higher rates of post-procedural pacemaker implantation. Emerging data on next-generation self-expandable (SE) and balloon-expandable (BE) valves reveal that while both offer success in this complex anatomical aortic valve variation, gaps remain in the long-term durability and management of BAV-related aortopathy. This review examines the latest advancements in TAVI for BAV, emphasizing how specialized approaches and device selection address BAV's complexities.

Interventions for adult congenital heart disease

Advances in imaging diagnostics, surgical techniques and transcatheter interventions for paediatric patients with severe congenital heart disease (CHD) have substantially reduced mortality, thereby extending the lifespan of these individuals and increasing the number of adults with complex CHD. Transcatheter interventions have emerged as an alternative to traditional open-heart surgery to mitigate congenital defects. The evolution of techniques, the introduction of new devices and the growing experience of operators have enabled the treatment of patients with progressively more complex conditions. The general cardiology community might be less aware of contemporary interventions for adult CHD, their clinical indications and associated outcomes than interventional cardiologists and congenital heart specialists. In this Review, we provide a comprehensive evaluation of the available transcatheter interventions for adult patients with CHD.

TAVI with the ACURATE neo2 in severe bicuspid aortic valve stenosis: the Neo2 BAV Registry

BACKGROUND

The ACURATE neo2 is a contemporary transcatheter aortic valve implantation (TAVI) system approved for the treatment of severe aortic stenosis in Europe. The ACURATE neo2 has not been evaluated in bicuspid aortic valve (BAV) stenosis.

AIMS

We sought to evaluate the safety and efficacy of ACURATE neo2 in patients with BAV stenosis.

METHODS

We retrospectively analysed consecutive severe BAV stenosis patients undergoing TAVI with ACURATE neo2 at 10 European centres. Imaging data from preprocedural multislice computed tomography, pre- and postprocedural echocardiography, and procedural cinefluoroscopy were evaluated by a core laboratory. Valve Academic Research Consortium 3 (VARC-3)-defined 30-day procedure safety and efficacy were the primary endpoints. Adverse events were site-reported according to VARC-3 criteria.

RESULTS

Among 181 patients with BAV stenosis treated with the ACURATE neo2, the mean age was 77.5±7.2 years, 58.0% were female, and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 2.3% (1.6-3.7%). Most procedures were transfemoral, and predilatation was performed in all cases. A second valve was required in 4 cases (2.2%). VARC-3-defined technical success was 95.6%. The primary endpoints of device success and early safety occurred in 90.6% and 82.3%, respectively. At 30 days, cardiovascular death occurred in 2.2% (N=4) and stroke in 1.6% (N=3). Core laboratory-adjudicated echocardiography reported an effective orifice area of 2.0 (1.7-2.5) cm2 and a mean transvalvular gradient of 6.5 (4.6-9.0) mmHg. Half of all cases (51.2%) had no paravalvular leak, while moderate leak occurred in 4.3%. A new permanent pacemaker was required in 11 patients (6.5%).

CONCLUSIONS

The ACURATE neo2 demonstrated favourable clinical outcomes and bioprosthetic valve performance at 30 days in selected patients with severe BAV stenosis.

Role of miRNAs in Regulating Ascending Aortic Dilation in Bicuspid Aortic Valve Patients Operated for Aortic Stenosis

Deregulation of micro-RNAs (miRNAs) may contribute to mechanisms of injury in the bicuspid aortic valve (BAV). Our objective was to investigate the expression of miRNAs in aortic tissue from patients who underwent aortic valve replacement for aortic stenosis and its relationship with aortic dilatation. The study included 78 patients, 40 with bicuspid aortic valve (BAV) and 38 with tricuspid aortic valve (TAV). The expression of miRNA-17-5p, hsa-let-7e, and miRNA-196a-5p in human aortic tissue was evaluated by a reverse transcriptase polymerase chain reaction (RT-qPCR). Comparative analysis between patients with BAV and controls with TAV explored the association between the miRNAs and aortic dilatation (AD), calcification, valve dysfunction, and stenosis. The results showed that the expression levels of miRNA-Let-7e-5p and miRNA-196-5p were mostly increased in patients with BAV and aortic dilatation (p = 0.01 and p = 0.01), respectively. In contrast, the levels of miRNA-17a-5p (p < 0.20) were lower but without a statistically significant difference. The downregulation of miRNA-17a-5p and the upregulation of miR-Let-7e-5p and miR-196-5p were related to an increased risk of AD risk. Subjects with BAVs with or without double aortic lesions had higher expression levels of Let-7e-5p and miRNA-17a-5p vs. TAV. In all patients, we found an inverse correlation of MiRNA-196-5p with High-Density Lipoprotein-Cholesterol (HDL-C) and indexed valvular area. In subjects with a higher expression of miRNA196, lower levels of HDL-C correlation (r2) [r2 0.27 (p = 0.02)] and a lower indexed valvular area [r2 0.28 (p = 0.05)] were observed. In the specific analysis for each patient group, it was found that in control subjects with tricuspid aortic valve (TAV), miRNA-196-5p had a positive correlation with valvular calcification (r2 = 0.60, p = 0.02). Deregulation of miRNAs in the aortic tissue of a BAV may influence valvular stenosis, dysfunction, and concomitant aortic dilation. This information could help to define potential therapeutic target strategies to improve the prognosis and treatment of BAV.

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve Disease: A Review of the Existing Literature

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure used to replace a damaged aortic valve with a prosthetic valve. TAVR has exceeded surgical aortic valve replacement (SAVR) due to shorter procedures and recovery times. Though initially approved for patients with aortic stenosis at a high surgical risk, TAVR's indications have now broadened to include high, intermediate, and low-risk patients. This review focuses on the evolving role of TAVR in patients with bicuspid aortic valves (BAV). We examine the anatomical and hemodynamic differences between tricuspid aortic valve and BAV, highlighting the unique challenges TAVR faces in BAV patients.

The impact of bicuspid valve morphology on the selection of transcatheter aortic valve implantation devices: an in silico study

Aims

Bicuspid aortic valve (BAV) represents a challenge for transcatheter aortic valve implantation (TAVI). Few data are reported about the procedural implications of BAV using different self-expandable devices. The aim of this study is to investigate how BAV and tricuspid aortic valve (TAV) morphologies influence device selection and their impact on the potential development of post-operative conduction disturbances, using a novel in silico approach.

Methods and results

Five patients with BAV undergoing TAVI were enrolled. TAVs were virtually modelled within each BAV patient-specific anatomy, resulting in 10 virtual patients. Acurate Neo2 and Evolut R implantations were subsequently simulated across all cases. Post-implantation stresses exerted on both the stent and aortic root were measured, allowing a comparative analysis of the impact of the two valve morphologies. Comparing stent stresses between BAV and TAV configurations, the stress gap increased by 21.96 ± 5.35% (P = 0.01) in Acurate Neo2 cases (n = 6) compared with Evolut R cases (n = 4). The analysis of aortic root stresses showed no significant differences between BAV (n = 5) and TAV (n = 5) configurations, with a mean stress difference of 5.1 ± 8.17% (P > 0.05).

Conclusion

Our patient-specific model shows that high radial force devices, such as Evolut R, demonstrate consistent expansion regardless of valve morphology, without increasing the risk of post-implantation conduction disturbances, hence resulting more suitable for BAV cases. Incorporating this methodology into pre-operative planning could support clinicians in selecting the most suitable device with a patient-specific approach.

CharActeristics, sizing anD outcomes of stenotic, tapered, rapHe-type bicuspid aOrtic valves treated with trans-catheter device implantation: Insights the AD HOC registry

BACKGROUND

Raphe-type bicuspid aortic valve (BAV) is a potential hostile scenario in trans-catheter aortic valve replacement (TAVR) due to pronounced calcium burden, possibly associated with tapered valve configuration. Trans-Catheter heart valve (THV) sizing strategy (annular vs. supra-annular) is controversial in this valve subtype.

OBJECTIVES

To describe the phenotypical characteristics of severe, tapered, raphe-type, BAV stenosis undergoing TAVR and to explore safety and efficacy of modern-generation THVs, analysing the impact of annular and supra-annular sizing strategies on short- and mid-terms outcomes.

METHODS

This is a retrospective, multicenter registry enrolling consecutive stenotic Sievers type 1 BAV treated with TAVR. Study population was divided into tapered and non-tapered configuration according to MSCT analysis. Matched comparison between annular and supra-annular sizing groups was performed in tapered population.

RESULTS

From January 2016 to June 2023, 897 patients were enrolled. Of them, 696 patients displayed a tapered configuration. Of those, 510 received a THV according to annular sizing. After propensity score matching 186 matched pairs were selected. Technical success (96.2 % vs 94.1 %, OR 1.61 [0.61-4.24], p = 0.34), 30-day device success (83.6 % in both groups, OR 1.42 [0.78-2.57], p = 0.25) and 30-day early safety (71.8 % vs 70.5 %, OR 1.07 [0.68-1.68], p = 0.78) were similar between the annular and supra-annular sizing groups; a higher post-TAVR gradient was observed in supra-annular group, although it was only 2 mmHg mean. At mid-term follow-up, the rate of clinical efficacy was 84.7 %.

CONCLUSIONS

TAVR with modern-generation devices is safe and effective for tapered raphe-type BAV, showing comparable results for annular and supra-annular sizing strategies.

Clinical Outcomes of Patients With Bicuspid Aortic Valve Undergoing a Targeted Transcatheter Aortic Valve Replacement Approach: The LIRA Method

BACKGROUND

Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) disease is still burdened by a non-negligible rate of stroke and permanent pacemaker implantation (PPI). These suboptimal results, possibly related to the unique BAV anatomy, may suggest the use of a different sizing method in this setting. The aim of our study is to evaluate whether the application of the supra-annular LIRA method may improve clinical outcomes in this population.

METHODS

In this single-center retrospective study, we enrolled consecutive patients with severe aortic stenosis and raphe-type BAV undergone TAVR with the implantation of supra-annular self-expanding prostheses sized according to the LIRA method. The primary endpoint was the device success. Secondary endpoints were in-hospital and 30-day safety outcomes and 1-year clinical efficacy. All study endpoints were adjudicated according to the Valve Academic Research Consortium 3 criteria.

RESULTS

A total of 104 patients (mean age, 79.8 ± 5.83 years) were enrolled in our study. The mean Society of Thoracic Surgeons score was 4.96 ± 4.73%. Use of the LIRA method led to prosthesis downsizing in 85.6% of patients. Device success was 94.2%. All-cause death was 0%, conversion to surgery was 0%, and an extremely low rate of stroke (1.9%) and PPI (9.6%) was observed. The intended performance of the valve was attained in 96.1% of patients and it was maintained at 1-year follow-up. Clinical efficacy at 1 year was reached in 90.6% of patients.

CONCLUSIONS

The LIRA method represents an alternative option for prosthesis sizing in patients with type 1 and type 2 BAV undergoing TAVR with promising early and midterm outcomes.

New systemic inflammatory indices as predictors of ascending aortic dilation in children with bicuspid aortic valve: A retrospective cross-sectional study

Systemic inflammatory indices, originally developed to predict the prognosis of cancer patients, have found increasing application in various medical areas, including cardiovascular research. This study aimed to investigate the relationship between ascending aortic dilatation in bicuspid aortic valve patients and systemic inflammatory indices. This retrospective cross-sectional study included 122 patients with bicuspid aortic valves. These patients were divided into 2 groups based on the presence or absence of dilatation according to ascending aorta z-scores. Complete blood counts were analyzed, focusing on leukocyte, neutrophil, lymphocyte, monocyte, and platelet counts. Additionally, systemic inflammatory indices including neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio (PLR), Systemic Immune-Inflammation Index (SII), Systemic Inflammatory Response Index (SIRI), and monocyte-to-lymphocyte ratio (MLR) and pan-immune-inflammation value (PIV) were calculated from these parameters. MLR, SIRI, and PIV demonstrated acceptable diagnostic power in detecting ascending aortic dilatation in bicuspid aortic valve patients, with area under the curve (AUC) values of 0.709, 0.741, and 0.779, respectively. PLR and SII exhibited fair diagnostic power, with AUC values of 0.673 and 0.688, respectively. According to the receiver operating characteristic analysis, PIV had the highest AUC value of 0.779 (95% confidence interval [CI] = 0.69-0.86), with a sensitivity of 70.9% and specificity of 70.8% at a cutoff value of 224.93. A relationship exists between PLR, MLR, SII, SIRI, PIV, and ascending aorta dilatation in pediatric patients with bicuspid aortic valves. These findings suggest that inflammation may play a role in the dilatation of the ascending aorta in bicuspid aortic valve patients.

Long-Term Durability of Transcatheter Aortic Valve Prostheses in Patients With Bicuspid Versus Tricuspid Aortic Valve

BACKGROUND

Currently, there is a lack of evidence for the long-term bioprosthetic valve durability of patients with bicuspid aortic valve (BAV) following transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

This study aimed to evaluate hemodynamic outcome, structural valve deterioration, and bioprosthetic valve failure during long-term follow-up after TAVR in patients with BAV versus patients with tricuspid aortic valve (TAV). Patients with BAV and TAV who underwent TAVR between 2012 and 2020, with echocardiography followed for at least 3 years, were included. Baseline characteristics, long-term valve hemodynamic performance, structural valve deterioration, and bioprosthetic valve failure were compared between patients with BAV and TAV. A total of 170 patients with BAV and 145 patients with TAV were included. The mean duration of follow-up for patients with BAV and TAV was 5.2±1.8 and 5.0±1.7 years. No significant differences were observed in the rates of structural valve deterioration and bioprosthetic valve failure between patients with BAV and TAV: structural valve deterioration, BAV 20 (11.8%) versus TAV 16 (11.0%) at last follow-up (P=0.861); bioprosthetic valve failure, BAV 3 (1.8%) versus TAV 7 (4.8%) at last follow-up (P=0.196). More than moderate intravalvular aortic regurgitation (1.8% versus 4.8%, P=0.196) and paravalvular leak (6.5% versus 3.4%, P=0.305) were rare in both patients with BAV and patients with TAV.

CONCLUSIONS

This study indicated satisfactory long-term valve durability of TAVR in patients with BAV. Comparable hemodynamic outcome, structural valve deterioration, and bioprosthetic valve failure could be achieved in patients with BAV and TAV during long-term follow-up after TAVR.

Transcatheter Aortic Valve Replacement Versus Surgical Aortic Valve Replacement in Bicuspid Aortic Valve Stenosis-We Need a Well-Designed Randomized Control Trial

Bicuspid aortic stenosis is a common pathology, typically seen in patients a decade younger than those with tricuspid valves. Surgical aortic valve replacement has been the mainstay treatment for bicuspid disease, especially considering the prevalence of concomitant aortic aneurysmal pathology. Transcatheter aortic valve replacement has shown equivalent results in bicuspid compared to tricuspid pathology in highly selected patient populations in single-arm registries and observational studies. For older patients with favorable bicuspid pathology, TAVR is reasonable. However, as younger patients with longer life expectancy are now being treated with TAVR, what is "best" is a question only answered by a well-designed randomized controlled trial. Herein, we describe the current evidence for treating bicuspid aortic stenosis and provide a framework for future trials. Yet, the question of equipoise remains, and who will we enroll?

Management of bicuspid aortic valve disease in the transcatheter aortic valve implantation era

In an era of rapidly expanding use of transcatheter aortic valve implantation (TAVI), the management of patients with bicuspid aortic valve (BAV) disease is far less well established than in those with trileaflet anatomy. Results of isolated surgical aortic valve replacement are excellent in suitable patients, and surgery also allows treatment of concomitant pathology of the aortic root and ascending aorta that is frequently encountered in this cohort. Conversely, TAVI provides an excellent alternative in older patients who may be unsuitable for surgery, although outcomes in BAV disease have only been reported in relatively small non-randomised series. Here, we discuss the pertinent literature on this topic and outline contemporary interventional treatment options in this challenging setting.

Bicuspid Aortic Valve in Children and Young Adults for Cardiologists and Cardiac Surgeons: State-of-the-Art of Literature Review

Bicuspid aortic valve disease is the most prevalent congenital heart disease, affecting up to 2% of the general population. The presentation of symptoms may vary based on the patient's anatomy of fusion, with transthoracic echocardiography being the primary diagnostic tool. Bicuspid aortic valves may also appear with concomitant aortopathy, featuring fundamental structural changes which can lead to valve dysfunction and/or aortic dilatation over time. This article seeks to give a comprehensive overview of the presentation, treatment possibilities and long-term effects of this condition. The databases MEDLINE, Embase, and the Cochrane Library were searched using the terms "endocarditis" or "bicuspid aortic valve" in combination with "epidemiology", "pathogenesis", "manifestations", "imaging", "treatment", or "surgery" to retrieve relevant articles. We have identified two types of bicuspid aortic valve disease: aortic stenosis and aortic regurgitation. Valve replacement or repair is often necessary. Patients need to be informed about the benefits and drawbacks of different valve substitutes, particularly with regard to life-long anticoagulation and female patients of childbearing age. Depending on the expertise of the surgeon and institution, the Ross procedure may be a viable alternative. Management of these patients should take into account the likelihood of somatic growth, risk of re-intervention, and anticoagulation risks that are specific to the patient, alongside the expertise of the surgeon or centre. Further research is required on the secondary prevention of patients with bicuspid aortic valve (BAV), such as lifestyle advice and antibiotics to prevent infections, as the guidelines are unclear and lack strong evidence.

Bicuspid Valve Aortopathy: Is It Reasonable to Define a Different Surgical Cutoff Based on Different Aortic Wall Mechanical Properties Compared to Those of the Tricuspid Valve?

BACKGROUND

In this study, we examined and compared ex vivo mechanical properties of aortic walls in patients with bicuspid (BAV) and tricuspid (TAV) aortic valve aortopathy to investigate if the anatomical peculiarities in the BAV group are related to an increased frailty of the aortic wall and, therefore, if a different surgical cutoff point for ascending aortic replacement could be reasonable in such patients.

METHODS

Ultimate stress tests were performed on fresh aortic wall specimens harvested during elective aortic surgery in BAV (n. 33) and TAV (n. 77) patients. Three mechanical parameters were evaluated at the failure point, under both longitudinal and circumferential forces: the peak strain (Pstr), peak stress (PS), and maximum elastic modulus (EM). The relationships between the three mechanical parameters and preoperative characteristics were evaluated, with a special focus on evaluating potential risk factors for severely impaired mechanical properties, cumulatively and comparatively (BAV vs. TAV groups).

RESULTS

The patient populations were inhomogeneous, as BAV patients reached surgical indication, according to the maximum aortic dilatation, at a younger age (58 ± 15 vs. 64 ± 13; p = 0.0294). The extent of the maximum aortic dilatation was, conversely, similar in the two groups (52 ± 4 vs. 54 ± 7; p = 0.2331), as well as the incidences of different phenotypes of aortic dilatation (with the ascending aorta phenotype being the most frequent in 81% and 66% of the BAV and TAV patients, respectively (p = 0.1134). Cumulatively, the mechanical properties of the aortic wall were influenced mainly by the orientation of the force applied, as both PS and EM were impaired under longitudinal stress. An age of >66 and a maximum dilatation of >52 mm were shown to predict severe Pstr reduction in the overall population. Comparative analysis revealed a trend of increased mechanical properties in the BAV group, regardless of the position, the force orientation, and the phenotype of the aortic dilatation.

CONCLUSIONS

BAV aortopathy is not correlated with impaired mechanical properties of the aortic wall as such. Different surgical cutoff points for BAV aortopathy, therefore, seem to be unjustified. An age of >66 and a maximum aortic dilatation of >52 mm, however, seem to significantly influence the mechanical properties of the aortic wall in both groups. These findings, therefore, could suggest the need for more accurate monitoring and evaluation in such conditions.

Four-dimensional computed tomography analysis of bicuspid aortic valves

Objectives

To evaluate the role of 4-dimensional (4D; 3-dimensional [3D] + time) analysis using multiphase cardiac computed tomography (MCCT) in the description of the aortic annulus (AA) of bicuspid aortic valves (BAV) with regard to the latest expert consensus classification.

Methods

Electrocardiography-gated MCCT of 15 patients with BAV were analyzed using in-house software and compared to 15 patients with normal tricuspid aortic valve (TAV). The AA border was pinpointed on 9 reconstructed planes, and the 3D coordinates of the 18 consecutive points were interpolated in 3D using a cubic spline to calculate 3D areas, perimeters, diameters, eccentricity indexes, and global height. Measurements were repeated throughout the cardiac cycle (10 phases). Three additional planes were generated at the level of the left ventricular outflow tract (LVOT), the sinus of Valsalva, and the sinotubular junction.

Results

The annulus area was significantly larger in BAV compared to TAV (mean indexed 3D area, 5.64 ± 0.84 cm2/m2 vs 4.3 ± 0.38 cm2/m2, respectively; P < .001). The AA was also larger in BAV in terms of perimeter, diameters, and height (P < .001). The Valsalva sinuses and sinotubular junction also were significantly larger in BAV compared to TAV (mean area in end-diastole, 6.06 ± 1.00 cm2 vs 4.69 ± 1.00 cm2 [P < .001] and 5.13 ± 1.62 cm2 vs 3.62 ± 0.99 cm2 [P < .001], respectively). In BAV, 3D AA shape analysis helps distinguish the 3 types of BAV: the 2-sinus type (symmetrical), the fused type, and the partial-fusion type or "form fruste" (both asymmetrical). It also allows determination of the position and height of the nonfunctional commissure. In symmetrical BAV, the nonfunctional commissure was significantly lower than the other commissures (6.01 ± 4.27 mm vs 18.24 ± 3.20 mm vs 17.15 ± 3.60 mm; P < .001), whereas in asymmetrical BAV, the 3 commissures were of comparable height (16.38 ± 0.86 mm vs 15.88 ± 1.69 mm vs 15.37 ± 0.88 mm; P = .316). There was no difference in AA eccentricity indices between TAV and BAV in all phases of the cardiac cycle; however, there was a spectrum of ellipticity for the other components of the aortic root among the different types of valves: going from TAV to asymmetrical BAV to symmetrical BAV, at end-diastole, the LVOT became more circular and the sinuses of Valsalva became more elliptical.

Conclusions

3D morphometric analysis of the BAV using MCCT allows identification of the type of BAV and the position and height of the nonfunctional commissure. There are significant differences in the morphology of the aortic root between TAV and the different types of BAV. Further studies are needed to evaluate the impact of 3D analysis on the procedural planning for pathologic BAV.

Multiscale structure and function of the aortic valve apparatus

Whereas studying the aortic valve in isolation has facilitated the development of life-saving procedures and technologies, the dynamic interplay of the aortic valve and its surrounding structures is vital to preserving their function across the wide range of conditions encountered in an active lifestyle. Our view is that these structures should be viewed as an integrated functional unit, here referred to as the aortic valve apparatus (AVA). The coupling of the aortic valve and root, left ventricular outflow tract, and blood circulation is crucial for AVA's functions: unidirectional flow out of the left ventricle, coronary perfusion, reservoir function, and support of left ventricular function. In this review, we explore the multiscale biological and physical phenomena that underlie the simultaneous fulfillment of these functions. A brief overview of the tools used to investigate the AVA, such as medical imaging modalities, experimental methods, and computational modeling, specifically fluid-structure interaction (FSI) simulations, is included. Some pathologies affecting the AVA are explored, and insights are provided on treatments and interventions that aim to maintain quality of life. The concepts explained in this article support the idea of AVA being an integrated functional unit and help identify unanswered research questions. Incorporating phenomena through the molecular, micro, meso, and whole tissue scales is crucial for understanding the sophisticated normal functions and diseases of the AVA.

Balloon-Expandable vs Self-Expanding Valves for Transcatheter Treatment of Sievers Type 1 Bicuspid Aortic Stenosis

BACKGROUND

Balloon-expandable valves (BEVs) and self-expanding valves (SEVs) have different features that may impact the outcomes of patients with Sievers type 1 bicuspid aortic valve (BAV) stenosis undergoing transcatheter aortic valve replacement.

OBJECTIVES

This study sought to compare procedural and clinical outcomes of BEVs and SEVs in Sievers type 1 BAV stenosis.

METHODS

AD-HOC (Characteristics, Sizing, and Outcomes of Stenotic Raphe-Type Bicuspid Aortic Valves Treated With Transcatheter Device Implantation) is an observational registry enrolling patients with Sievers type 1 BAV stenosis undergoing transcatheter aortic valve replacement with current-generation BEVs and SEVs at 24 international centers. A 1:1 propensity score matching analysis was performed to adjust for baseline imbalances. The primary endpoint was midterm major adverse events, defined as a composite of all-cause death, neurologic events, or hospitalization for heart failure.

RESULTS

Among 955 eligible patients, propensity score matching resulted in 301 pairs. At a median follow-up of 1.3 years, BEVs and SEVs had a similar risk of major adverse events (BEV vs SEV: HR: 0.75; 95% CI: 0.49-1.16; P = 0.200). Technical success was similar (OR: 1.38; 95% CI: 0.63-3.04; P = 0.421). At 30 days, BEVs were associated with a lower risk of new permanent pacemaker implantation (OR: 0.42; 95% CI: 0.24-0.72; P = 0.002) and moderate or greater paravalvular regurgitation (OR: 0.16; 95% CI: 0.05-0.48; P = 0.001) but a higher risk of severe patient-prosthesis mismatch (OR: 3.03; 95% CI 1.02-8.95; P = 0.045).

CONCLUSIONS

Current-generation BEVs and SEVs proved similar technical success and midterm clinical efficacy in Sievers type 1 BAV stenosis. Compared to SEVs, BEVs were associated with less permanent pacemaker implantation and moderate or greater paravalvular regurgitation but with more severe patient-prosthesis mismatch.

Two-year follow-up of transcatheter aortic valve replacement in low-risk patients with symptomatic severe bicuspid aortic valve stenosis

BACKGROUND

In 2019, the US Food and Drug Administration (FDA) approved transcatheter aortic valve replacement (TAVR) for low-risk patients with symptomatic severe tricuspid aortic stenosis. However, bicuspid aortic valve (BAV) patients were included only in single-arm registries of pivotal low-risk TAVR trials, resulting in limited data for this subgroup.

METHODS

The LRT (Low Risk TAVR) trial was an investigator-initiated, prospective, multicenter study and the first FDA-approved investigational device exemption trial to evaluate the feasibility of TAVR with balloon-expandable or self-expanding valves in low-risk patients with symptomatic severe BAV stenosis. This analysis reports 2-year follow-up, assessing the primary outcome of all-cause mortality and evaluating clinical outcomes.

RESULTS

From 2016 to 2019, a total of 72 low-risk patients diagnosed with symptomatic, severe BAV stenosis underwent TAVR across six centers. Six patients were lost to follow-up. At 2-year follow-up, mortality was 1.5% (1 of 66 patients). Among the remaining 65 patients, four experienced nondisabling strokes (6.2%), while 2 (3.1%) developed infective endocarditis. No new permanent pacemakers were required beyond the 30-day follow-up, and no patients, including those with endocarditis, needed aortic valve re-intervention. At the 2-year echocardiography follow-up (n = 65), 27.8% of BAV patients showed mild aortic regurgitation, with none exhibiting moderate or severe regurgitation. The mean aortic gradient was 12.1 ± 4.1 mmHg, and the mean valve area was 1.7 ± 0.5 cm².

CONCLUSION

The 2-year follow-up confirms commendable clinical outcomes of TAVR in patients with bicuspid aortic stenosis, establishing its evident safety.

Simulation-based design of bicuspidization of the aortic valve

OBJECTIVE

Severe congenital aortic valve pathology in the growing patient remains a challenging clinical scenario. Bicuspidization of the diseased aortic valve has proven to be a promising repair technique with acceptable durability. However, most understanding of the procedure is empirical and retrospective. This work seeks to design the optimal gross morphology associated with surgical bicuspidization with simulations based on the hypothesis that modifications to the free edge length cause or relieve stenosis.

METHODS

Model bicuspid valves were constructed with varying free edge lengths and gross morphology. Fluid-structure interaction simulations were conducted in a single patient-specific model geometry. The models were evaluated for primary targets of stenosis and regurgitation. Secondary targets were assessed and included qualitative hemodynamics, geometric height, effective height, orifice area, and billow.

RESULTS

Stenosis decreased with increasing free edge length and was pronounced with free edge length less than or equal to 1.3 times the annular diameter d. With free edge length 1.5d or greater, no stenosis occurred. All models were free of regurgitation. Substantial billow occurred with free edge length 1.7d or greater.

CONCLUSIONS

Free edge length 1.5d or greater was required to avoid aortic stenosis in simulations. Cases with free edge length 1.7d or greater showed excessive billow and other changes in gross morphology. Cases with free edge length 1.5d to 1.6d have a total free edge length approximately equal to the annular circumference and appeared optimal. These effects should be studied in vitro and in animal studies.

Bicuspid Aortic Valve Disease: From Pathophysiology to Treatment

The Bicuspid Aortic Valve (BAV) is the most common congenital anomaly in adults, with a global incidence of 1.3%. Despite being well documented, BAV presents significant clinical challenges due to its phenotypic heterogeneity, diverse clinical manifestations, and variable outcomes. Pathophysiologically, BAV differs from tricuspid valves in calcification patterns and hemodynamic effects, leading to increased shear stress and aortic root dilatation, while it is influenced by genetic and hemodynamic factors. This is why therapeutically, BAV presents challenges for both surgical and transcatheter interventions, with surgical approaches being traditionally preferred, especially when aortopathy is present. However, transcatheter aortic valve implantation (TAVI) has emerged as a viable option, with studies showing comparable outcomes to surgery in selected patients, while advancements in TAVI and a better understanding of BAV's genetic and pathophysiological nuances are expanding treatment options. The choice between mechanical and bioprosthetic valves also presents considerations, particularly regarding long-term durability and the need for anticoagulation. Future research should focus on long-term registries and genetic studies to refine therapeutic strategies and improve patient outcomes. This review aims to evaluate current approaches in the surgical and interventional management of BAV, focusing on its anatomy, pathogenesis, pathophysiology, and therapeutic strategies.

Practical guidance and clinical applications of transoesophageal echocardiography. A position paper of the working group of echocardiography of the Hellenic Society of Cardiology

Transoesophageal echocardiography (TOE) is a well-established imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for a wide spectrum cardiac and extra-cardiac diseases. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Cardiology Society to state the essential steps of the typical TOE exam performed in echo lab. This is an educational text, describing the minimal requirements and the preparation of a meticulous TOE examination. Most importantly, it gives practical instructions to obtain and optimize TOE views and analyses the implementation of a combined two-and multi-dimensional protocol for the imaging of the most common cardiac structures during a TOE. In the second part of the article a comprehensive review of the contemporary use of TOE in a wide spectrum of valvular and non-valvular cardiac diseases is provided, based on the current guidelines and the experience of the WG members.

3D Characterization of the Aortic Valve and Aortic Arch in Bicuspid Aortic Valve Patients

Patients with bicuspid aortic valve (BAV) commonly have associated aortic stenosis and aortopathy. The geometry of the aortic arch and BAV is not well defined quantitatively, which makes clinical classifications subjective or reliant on limited 2D measurements. The goal of this study was to characterize the 3D geometry of the aortic arch and BAV using objective and quantitative techniques. Pre-TAVR computed tomography angiogram (CTA) in patients with BAV and aortic stenosis (AS) were analyzed (n = 59) by assessing valve commissural angle, presence of a fused region, percent of fusion, and calcium volume. The ascending aorta and aortic arch were reconstructed from patient-specific imaging segmentation to generate a centerline and calculate maximum curvature and maximum area change for the ascending aorta and the descending aorta. Aortic valve commissural angle signified a bimodal distribution suggesting tricuspid-like (≤ 150°, 52.5% of patients) and bicuspid-like (> 150°, 47.5%) morphologies. Tricuspid like was further classified by partial (10.2%) or full (42.4%) fusion, and bicuspid like was further classified into valves with fused region (27.1%) or no fused region (20.3%). Qualitatively, the aortic arch was found to have complex patient-specific variations in its 3D shape with some showing extreme diameter changes and kinks. Quantitatively, subgroups were established using maximum curvature threshold of 0.04 and maximum area change of 30% independently for the ascending and descending aorta. These findings provide insight into the geometric structure of the aortic valve and aortic arch in patients presenting with BAV and AS where 3D characterization allows for quantitative classification of these complex anatomic structures.

Incidence, Predictors, and Outcomes of Paravalvular Regurgitation After TAVR in Sievers Type 1 Bicuspid Aortic Valves

BACKGROUND

Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) stenosis is technically challenging and is burdened by an increased risk of paravalvular regurgitation (PVR).

OBJECTIVES

The aim of this study was to identify the incidence, predictors, and clinical outcomes of PVR after TAVR in Sievers type 1 BAV stenosis.

METHODS

Consecutive patients with Sievers type 1 BAV stenosis undergoing TAVR with current-generation transcatheter heart valves (THVs) in 24 international centers were enrolled. PVR was graded as none/trace, mild, moderate, and severe according to echocardiographic criteria. The endpoint of major adverse events (MAEs), defined as a composite of all-cause death, stroke, or hospitalization for heart failure, was assessed at the last available follow-up.

RESULTS

A total of 946 patients were enrolled. PVR occurred in 423 patients (44.7%)-mild, moderate, and severe in 387 (40.9%), 32 (3.4%), and 4 (0.4%) patients, respectively. Independent predictors of moderate or severe PVR were a larger virtual raphe ring perimeter (adjusted OR: 1.07; 95% CI: 1.02-1.13), severe annular or left ventricular outflow tract calcification (adjusted OR: 5.21; 95% CI: 1.45-18.77), a self-expanding valve (adjusted OR: 9.01; 95% CI: 2.09-38.86), and intentional supra-annular THV positioning (adjusted OR: 3.31; 95% CI: 1.04-10.54). At a median follow-up of 1.3 years (Q1-Q3: 0.5-2.4 years), moderate or severe PVR was associated with an increased risk of MAEs (adjusted HR: 2.52; 95% CI: 1.24-5.09).

CONCLUSIONS

After TAVR with current-generation THVs in Sievers type 1 BAV stenosis, moderate or severe PVR occurred in about 4% of cases and was associated with an increased risk of MAEs during follow-up.

Ascending Aortic Progression After Isolated Aortic Valve Replacement Among Patients with Bicuspid and Tricuspid Aortic Valves

OBJECTIVES

The aims of the present study were to compare the long-term outcomes for ascending aortic dilatation and adverse aortic events after isolated aortic valve replacement between patients with bicuspid aortic valve (BAV) and tricuspid aortic valve ( TAV).

METHODS

This retrospective study included 310 patients who had undergone isolated aortic valve replacement with an ascending aorta diameter ≤ 45 mm between January 2010 and September 2021. The patients were divided into BAV group (n=90) and TAV group (n=220). The differences in the dilation rate of the ascending aorta and long-term outcomes were analyzed.

RESULTS

Overall survival was 89 ± 4% in the BAV group vs. 75 ± 6% in the TAV group at 10 years postoperatively (P=0.007), yet this difference disappeared after adjusting exclusively for age (P=0.343). The mean annual growth rate of the ascending aorta was similar between the two groups during follow-up (0.5 ± 0.6 mm/year vs. 0.4 ± 0.5 mm/year; P=0.498). Ten-year freedom from adverse aortic events was 98.1% in the BAV group vs. 95.0% in the TAV group (P=0.636). Multivariable analysis revealed preoperative ascending aorta diameter to be a significant predictor of adverse aortic events (hazard ratio: 1.76; 95% confidence interval: 1.33 to 2.38; P<0.001).

CONCLUSION

Our study revealed that the long-term survival and the risks of adverse aortic events between BAV and TAV patients were similar after isolated aortic valve replacement. BAV was not a risk factor of adverse aortic events.

Pro-angiogenic cytokine features of left ventricular remodeling in patients with bicuspid aortic valve

OBJECTIVE

Bicuspid aortic valve (BAV) is prone to promote left ventricular remodeling (LVR), which is associated with adverse clinical outcomes. Although the association between angiogenic activity and LVR has been established, pro-angiogenic cytokine features and potential biomarker candidates for LVR in patients with BAV remain to be clarified.

METHODS

From November 2018 to May 2019, patients with BAV diagnosed by transthoracic echocardiography at our institution were included. LVR was diagnosed on the basis of echocardiographic calculations of relative wall thickness (RWT) and left ventricular mass index (LVMI). A multiplex ELISA array was used to measure the plasma levels of 60 angiogenesis-related cytokines.

RESULTS

Among 103 patients with BAV, 71 were categorized into the LVR group and 32 into the normal left ventricular (LV) geometry group. BAV patients with LVR demonstrated increased LVMI, elevated prevalence of moderate to severe aortic stenosis and aortic regurgitation, and decreased LV ejection fraction (LVEF). Plasma levels of angiopoietin-1 were elevated in BAV patients with or without LVR compared with healthy controls (P = 0.001, P < 0.001, respectively), and were negatively correlated with RWT (r = -0.222, P = 0.027). Plasma levels of angiopoietin-2 were elevated in the LVR group (P = 0.001) compared with the normal LV geometry group, and were negatively correlated with LVEF (r = -0.330, P = 0.002).

CONCLUSION

Decreased angiogenesis plays a crucial role in the occurrence and progression of LVR in patients with BAV. Disturbance in the pro- and anti-angiogenesis equilibrium in BAV patients with LVR may reflect the aggravation of endothelial injury and dysfunction.

Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe

AIM

To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)].

METHODS

Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation.

RESULTS

Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001).

CONCLUSIONS

Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

Intricate MIB1-NOTCH-GATA6 Interactions in Cardiac Valvular and Septal Development

Genome-wide association studies and experimental mouse models implicate the MIB1 and GATA6 genes in congenital heart disease (CHD). Their close physical proximity and conserved synteny suggest that these two genes might be involved in analogous cardiac developmental processes. Heterozygous Gata6 loss-of-function mutations alone or humanized Mib1 mutations in a NOTCH1-sensitized genetic background cause bicuspid aortic valve (BAV) and a membranous ventricular septal defect (VSD), consistent with MIB1 and NOTCH1 functioning in the same pathway. To determine if MIB1-NOTCH and GATA6 interact in valvular and septal development, we generated compound heterozygote mice carrying different Mib1 missense (Mib1K735R and Mib1V943F) or nonsense (Mib1R530X) mutations with the Gata6STOP/+ heterozygous null mutation. Combining Mib1R530X/+ or Mib1K735R/+ with Gata6STOP/+ does not affect Gata6STOP/+ single mutant phenotypes. In contrast, combining Mib1V943F/+ with Gata6STOP/+ decreases the incidence of BAV and VSD by 50%, suggesting a suppressive effect of Mib1V943F/+ on Gata6STOP/+. Transcriptomic and functional analyses revealed that while the EMT pathway term is depleted in the Gata6STOP/+ mutant, introducing the Mib1V943F variant robustly enriches this term, consistent with the Mib1V943F/+ phenotypic suppression of Gata6STOP/+. Interestingly, combined Notch1 and Gata6 insufficiency led to a nearly fully penetrant VSD but did not affect the BAV phenotype, underscoring the complex functional relationship between MIB1, NOTCH, and GATA6 in valvular and septal development.

Bicuspid Aortic Valve Function and Aortopathy on Presentation and Progression in Children: Does Sex Difference Have Any Implications?

Bicuspid aortic valve (BAV) is the most common congenital heart defect. It can be accompanied by aortic regurgitation or stenosis with aortopathies. Studies in adults showed a sex difference, but there are limited number of reports in the pediatric population. To evaluate the difference in bicuspid aortic valve morphology and functionality between sexes, and the presence and progression of aortopathies, a retrospective chart review study was performed at a tertiary referral care center in the Midwest. In our study, we analyzed a cohort of 476 pediatric patients diagnosed with BAV who presented between January 2007 and February 2018. During the follow-up period spanning 2 to 10 years, male patients (n = 314, 66%) had larger aortic valve annulus (AVA) and sinus of Valsalva (SOV) at the time of initial presentation with more likelihood for progression. In the subgroup analysis, the larger SOV in males was observed in isolated BAV patients without genetic syndromes or cardiac malformations, and there were no significant differences between both sexes in the ascending aorta dimension, valve functionality, valve morphology, and the need for intervention in any of the studied groups. As such, these findings may alter the follow-up focus and frequency for patients with BAV, particularly before adulthood, and warrant further studies.

Aortic Regurgitation in Bicuspid Aortic Valve: The Role of Multimodality Imaging

The evaluation of aortic regurgitation (AR) in bicuspid valve (BAV) is still a challenge because of the eccentricity of the jet, which may under/overestimate the regurgitation. The commonly used echocardiography parameters (such as vena contracta, pressure half-time, etc.) may not be useful in this kind of patient. A multimodality approach combining echocardiography, cardiac MRI, cardiac CT, and advanced technologies applied to non-invasive cardiac imaging (e.g., 4D flow and strain imaging) may be useful to better quantify regurgitation and to select patients suitable for valve replacement. This review provides an overview of the most recent insights about cardiovascular imaging tools and their utility in BAV evaluation, focusing on chronic regurgitation. We describe the role of multimodality imaging in both diagnosis and risk assessment of this disease, pointing out the advantages and disadvantages of the imaging techniques, aiming to provide a guide to clinicians and cardiovascular imaging specialists in choosing the best imaging tools to use.

Effect of deletion of the protein kinase PRKD1 on development of the mouse embryonic heart

Congenital heart disease (CHD) is the most common congenital anomaly, with an overall incidence of approximately 1% in the United Kingdom. Exome sequencing in large CHD cohorts has been performed to provide insights into the genetic aetiology of CHD. This includes a study of 1891 probands by our group in collaboration with others, which identified three novel genes-CDK13, PRKD1, and CHD4, in patients with syndromic CHD. PRKD1 encodes a serine/threonine protein kinase, which is important in a variety of fundamental cellular functions. Individuals with a heterozygous mutation in PRKD1 may have facial dysmorphism, ectodermal dysplasia and may have CHDs such as pulmonary stenosis, atrioventricular septal defects, coarctation of the aorta and bicuspid aortic valve. To obtain a greater appreciation for the role that this essential protein kinase plays in cardiogenesis and CHD, we have analysed a Prkd1 transgenic mouse model (Prkd1em1) carrying deletion of exon 2, causing loss of function. High-resolution episcopic microscopy affords detailed morphological 3D analysis of the developing heart and provides evidence for an essential role of Prkd1 in both normal cardiac development and CHD. We show that homozygous deletion of Prkd1 is associated with complex forms of CHD such as atrioventricular septal defects, and bicuspid aortic and pulmonary valves, and is lethal. Even in heterozygotes, cardiac differences occur. However, given that 97% of Prkd1 heterozygous mice display normal heart development, it is likely that one normal allele is sufficient, with the defects seen most likely to represent sporadic events. Moreover, mRNA and protein expression levels were investigated by RT-qPCR and western immunoblotting, respectively. A significant reduction in Prkd1 mRNA levels was seen in homozygotes, but not heterozygotes, compared to WT littermates. While a trend towards lower PRKD1 protein expression was seen in the heterozygotes, the difference was only significant in the homozygotes. There was no compensation by the related Prkd2 and Prkd3 at transcript level, as evidenced by RT-qPCR. Overall, we demonstrate a vital role of Prkd1 in heart development and the aetiology of CHD.

Surgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis

This systematic review and meta-analysis aim to provide a comprehensive analysis of the literature directly comparing the outcomes of surgical aortic valve replacement (SAVR) and TAVR in patients with BAV stenosis. Medline, PubMed, and Scopus were systematically searched for articles published between 2000 and 2023, 1862 studies were screened, and 6 retrospective studies met the inclusion criteria. We included 6550 patients in the final analyses: 3,292 and 3,258 in the SAVR and TAVR groups, respectively. Both groups have similar rates of in-hospital mortality (odds ratio (OR) 1.11; 95% CI 0.59-2.10; p = 0.75) and stroke (OR 1.25; 95% CI 0.85-1.86; p = 0.26. Patients who underwent SAVR experienced lower rates of permanent pacemaker implantation (OR 0.54; 95% CI 0.35-0.83; p = 0.005) and paravalvular leak (OR 0.47; 95% CI 0.26-0.86; p = 0.02). On the other hand, patients who underwent TAVR displayed lower rates of acute kidney injury (OR 1.81; 95% CI 1.15-2.84; p = 0.010), major bleeding (OR 3.76; 95% CI 2.18-6.49; p < 0.00001), and pulmonary complications (OR 7.68; 95% CI 1.21-48.84; p = 0.03). Despite the early mortality data suggesting that TAVR may be a reasonable strategy for patients with bicuspid AS with low to intermediate surgical risk, the increased risk of PPI and PVL is concerning. A prospective, randomized, controlled trial reporting long-term outcomes with pre-defined subgroup analyses based on BAV morphology is paramount. In the interim, caution should be exercised in the widespread adoption of TAVR in lower surgical-risk patients.