Bicuspid aortic valve: long-term morbidity and mortality

Contribution of rare chromosome 22q11.2 copy number variants to non-syndromic bicuspid aortic valve

BACKGROUND

Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults, often leading to complications such as thoracic aortic aneurysms and aortic stenosis. While BAV is frequently associated with 22q11.2 deletion syndrome (22q11.2DS), the contribution of rare copy number variants (CNVs) in this region to non-syndromic BAV is less clear. This study is aimed to assess the role of rare 22q11.2 CNVs in patients with early-onset BAV (EBAV) and to determine whether these variants are linked to an increased risk of complications.

METHODS

Whole genome microarray genotyping was conducted on 272 patients with BAV with early onset valve or aortic disease (EBAV) and 272 biological relatives. CNVs were detected using three independent algorithms, focusing on the 22q11.2 region (18-24 Mb). CNV burden in the EBAV cohort was compared with unselected European ancestry controls.

RESULTS

Rare duplications and deletions within the 22q11.2 region, particularly involving genes associated with cardiac development, were identified in 7.4% of EBAV probands. These CNVs were significantly enriched compared with the general population and segregated with BAV in families. Individuals carrying rare 22q11.2 CNVs had a higher prevalence of psychiatric diagnoses and learning difficulties, although they did not exhibit the typical features of 22q11.2DS. Importantly, these CNVs were associated with early onset or complex BAV cases, underscoring their potential clinical relevance.

CONCLUSIONS

Rare 22q11.2 CNVs play a role in non-syndromic BAV, particularly in cases with early onset or complex presentations. CNV screening could be considered as part of risk stratification for patients with BAV, helping to predict complications and guide management.

TRIAL REGISTRATION NUMBER

NCT01823432.

Rate of Ascending Aortic Enlargement in a Large Echocardiographic Cohort: Associated Risk Factors and Adverse Aortic Events

BACKGROUND

Understanding ascending aortic aneurysm growth and associated risk factors is critical to advising appropriate echocardiographic follow-up intervals for patients. The aim of this study was to identify aortic aneurysm growth rate on serial echocardiography as well as the clinical and demographic variables that contribute to baseline aortic size and subsequent aortic growth.

METHODS

Patients identified with ascending aortic aneurysms and undergoing serial echocardiograms within 5 years were evaluated. Ascending aortic size was measured as part of routine echocardiographic examinations. Clinical and demographic variables including aortic valve type (trileaflet, bicuspid, or prosthetic) were evaluated for association with baseline aortic size as well as with aortic progression rate. Clinical events including aortic dissection and elective or emergent surgical repair were recorded.

RESULTS

A total of 3,639 patients were identified (78% men; median age, 69 years), 175 (4.8%) with bicuspid valves and 206 (5.6%) with prior aortic valve replacement. Patients with larger aortas at baseline were older, with higher tobacco use and prior prosthetic valves. Over a mean of 2.4 years, aortic growth was observed and differed by valve type (trileaflet valve, 0.08 mm/y; bicuspid valve, 0.4 mm/y; P < .001). In six patients who developed aortic dissection, the estimated average annual growth rate was 0.98 mm/y.

CONCLUSIONS

In a large echocardiographic cohort, aortic aneurysm growth rate was 0.08 mm/y, though it was higher in patients with bicuspid valves (0.4 mm/y), but initial aortic size did not correlate with change in the aortic progression rate. These data may help inform recommended echocardiographic surveillance intervals.

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.

Calcific Aortic Stenosis: A Review

Importance

Calcific aortic stenosis (AS) restricts the aortic valve opening during systole due to calcification and fibrosis of either a congenital bicuspid or a normal trileaflet aortic valve. In the US, AS affects 1% to 2% of adults older than 65 years and approximately 12% of adults older than 75 years. Worldwide, AS leads to more than 100 000 deaths annually.

Observations

Calcific AS is characterized by aortic valve leaflet lipid infiltration and inflammation with subsequent fibrosis and calcification. Symptoms due to severe AS, such as exercise intolerance, exertional dyspnea, and syncope, are associated with a 1-year mortality rate of up to 50% without aortic valve replacement. Echocardiography can detect AS and measure the severity of aortic valve dysfunction. Although progression rates vary, once aortic velocity is higher than 2 m/s, progression to severe AS occurs typically within 10 years. Severe AS is defined by an aortic velocity 4 m/s or higher, a mean gradient 40 mm Hg or higher, or a valve area less than or equal to 1.0 cm2. Management of mild to moderate AS and asymptomatic severe AS consists of patient education about the typical progression of disease; clinical and echocardiographic surveillance at intervals of 3 to 5 years for mild AS, 1 to 2 years for moderate AS, and 6 to 12 months for severe AS; and treatment of hypertension, hyperlipidemia, and cigarette smoking as indicated. When a patient with severe AS develops symptoms, surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) is recommended, which restores an average life expectancy; in patients aged older than 70 years with a low surgical risk, 10-year all-cause mortality was 62.7% with TAVI and 64.0% with SAVR. TAVI is associated with decreased length of hospitalization, more rapid return to normal activities, and less pain compared with SAVR. However, evidence supporting TAVI for patients aged younger than 65 years and long-term outcomes of TAVI are less well defined than for SAVR. For patients with symptomatic severe AS, the 2020 American College of Cardiology/American Heart Association guideline recommends SAVR for individuals aged 65 years and younger, SAVR or TAVI for those aged 66 to 79 years, and TAVI for individuals aged 80 years and older or those with an estimated surgical mortality of 8% or higher.

Conclusions

Calcific AS is a common chronic progressive condition among older adults and is diagnosed via echocardiography. Symptomatic patients with severe AS have a mortality rate of up to 50% after 1 year, but treatment with SAVR or TAVI reduces mortality to that of age-matched control patients. The type and timing of valve replacement should be built on evidence-based guidelines, shared decision-making, and involvement of a multidisciplinary heart valve team.

Infective endocarditis causing recurrent cerebral infarction, cerebral hemorrhage and septic meningitis: A case report

RATIONALE

We reported a rare case of recurrent cerebral infarction, intracerebral hemorrhage, and purulent meningitis, culminating in the diagnosis of a young patient with infective endocarditis who had been treated in 3 hospitals for a long course of illness for 8 months prior to diagnosis. It aims to enhance clinicians' understanding of the neurological complications caused by infective endocarditis.

PATIENT CONCERNS

A 25-year-old male, student, was hospitalized for an 8-hour history of speech impairment and drooling with dysphagia. Magnetic resonance imaging (MRI) showed massive cerebral infarction in the right frontotemporal and insular lobes, and the first diagnosis was "cerebral infarction." Later, the patient developed recurrent cerebral infarction, intracerebral hemorrhage, and purulent meningitis.

DIAGNOSES

Recurrent cerebral infarction, intracerebral hemorrhage, and purulent meningitis were confirmed to be caused by infective endocarditis.

INTERVENTIONS

The patient was treated with antiplatelet drugs such as aspirin and clopidogrel, mannitol to reduce intracranial pressure, and ceftriaxone and vancomycin to fight infection, and the patient's condition improved.

OUTCOMES

The patient was diagnosed with infective endocarditis after 8 months without a clear diagnosis, and the patient was finally diagnosed with infective endocarditis during the final follow-up.

LESSONS

Febrile patients should be aware of infective endocarditis, particularly if the fever is persistent of unknown origin or structural changes in the heart with neurologic lesions. Cardiogenic neurological diseases are relatively more severe, have a worse prognosis, and have a higher recurrence rate than primary neurological diseases, so early diagnosis and treatment are more urgently needed.

Adults with congenital heart disease: what every cardiologist should know about their care

As patients with congenital heart disease (CHD) continue to enjoy longer lives, non-congenital cardiologists and other healthcare professionals are increasingly encountering them in their practice and are challenged by their specific needs. Most under- and post-graduate medical training tends to overlook this common pathology, resulting in insufficient awareness of post-repair or post-palliation residual lesions and sequelae from previous interventions. In a strive towards improving the quality of care for this ever-growing cardiovascular patient cohort, it is prudent to outline the areas of concern and specific management needs pertaining to adult patients with CHD and share it with non-CHD professionals. The purpose of this paper is to offer essential guidance to physicians, including cardiologists, when they encounter a patient with CHD in a non-congenital healthcare 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.

Whole-exome sequencing uncovers the genetic complexity of bicuspid aortic valve in families with early-onset complications

Bicuspid aortic valve (BAV) is the most common congenital heart lesion with an estimated population prevalence of 1%. We hypothesize that specific gene variants predispose to early-onset complications of BAV (EBAV). We analyzed whole-exome sequences (WESs) to identify rare coding variants that contribute to BAV disease in 215 EBAV-affected families. Predicted damaging variants in candidate genes with moderate or strong supportive evidence to cause developmental cardiac phenotypes were present in 107 EBAV-affected families (50% of total), including genes that cause BAV (9%) or heritable thoracic aortic disease (HTAD, 19%). After appropriate filtration, we also identified 129 variants in 54 candidate genes that are associated with autosomal-dominant congenital heart phenotypes, including recurrent deleterious variation of FBN2, MYH6, channelopathy genes, and type 1 and 5 collagen genes. These findings confirm our hypothesis that unique rare genetic variants drive early-onset presentations of BAV disease.

Assessing the Performance of ChatGPT in Answering Patients' Questions Regarding Congenital Bicuspid Aortic Valve

AIM

Artificial intelligence (AI) models, such as ChatGPT, are widely being used in academia as well as by the common public. In the field of medicine, the information obtained by the professionals as well as by the patients from the AI tools has significant advantages while at the same time posing valid concerns regarding the validity and adequacy of information regarding healthcare delivery and utilization. Therefore, it is important to vet these AI tools through the prism of practicing physicians.

METHODS

To demonstrate the immense utility as well as potential concerns of using ChatGPT to gather medical information, a set of questions were posed to the chatbot regarding a hypothetical patient with a congenital bicuspid aortic valve (BAV), and the answers were recorded and reviewed based on three criteria: (i) readability/technicality; (ii) adequacy/completeness; and (iii) accuracy/authenticity.

RESULTS

While the ChatGPT provided detailed information about clinical pictures, treatment, and outcomes regarding BAV, the information was generic and brief, and the utility was limited due to a lack of specific information based on an individual patient's clinical status. The authenticity of the information could not be verified due to a lack of citations. Further, human aspects that would normally emerge in nuanced doctor-patient communication were missing in the ChatGPT output.

CONCLUSION

Although the performance of AI in medical care is expected to grow, imperfections and ethical concerns may remain a huge challenge in utilizing information from the chatbots alone without adequate communications with health providers, despite having numerous advantages of this technology to society in many walks of human life.

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.

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.

Filamin A heart valve disease as a genetic cause of inherited bicuspid and tricuspid aortic valve disease

OBJECTIVE

Variants in the FLNA gene have been associated with mitral valve dystrophy (MVD), and even polyvalvular disease has been reported. This study aimed to analyse the aortic valve and root involvement in FLNA-MVD families and its impact on outcomes.

METHODS

262 subjects (37 (18-53) years, 140 male, 79 carriers: FLNA+) from 4 FLNA-MVD families were included. Echocardiography was performed in 185 patients and histological analysis in 3 explanted aortic valves. The outcomes were defined as aortic valve surgery or all-cause mortality.

RESULTS

Aortic valve alterations were found in 58% of FLNA+ compared with 6% of FLNA- (p<0.001). 9 (13.4%) FLNA+ had bicuspid aortic valve compared with 4 (3.4%) FLNA- (p=0.03). Overall, the transvalvular mean gradient was slightly increased in FLNA+ (4.8 (4.1-6.1) vs 4.0 (2.9-4.9) mm Hg, p=0.02). The sinuses of Valsalva and sinotubular junction diameters were enlarged in FLNA+ subjects (all p<0.05). 8 FLNA+ patients underwent aortic valve surgery (0 in relatives; p<0.001). Myxomatous remodelling with an infiltration of immune cells was observed. Overall survival was similar between FLNA+ versus FLNA- subjects (86±5% vs 85±6%, p=0.36). There was no statistical evidence for an interaction between genetic status and sex (p=0.15), but the survival tended to be impaired in FLNA+ men (p=0.06) whereas not in women (p=0.71).

CONCLUSION

The patients with FLNA variants present frequent aortic valve disease and worse outcomes. Bicuspid aortic valve is more frequent in patients carrying the FLNA-MVD variants. These unique features should be factored into the management of patients with dystrophic and/or bicuspid aortic valve.

Bicuspid Aortic Valve Disease With Early Onset Complications: Characteristics And Aortic Outcomes

Bicuspid aortic valve (BAV) is the most common congenital heart malformation in adults but can also cause childhood-onset complications. In multicenter study, we found that adults who experience significant complications of BAV disease before age 30 are distinguished from the majority of BAV cases that manifest after age 50 by a relatively severe clinical course, with higher rates of surgical interventions, more frequent second interventions, and a greater burden of congenital heart malformations. These observations highlight the need for prompt recognition, regular lifelong surveillance, and targeted interventions to address the significant health burdens of patients with early onset BAV complications.

Whole Exome Sequencing Uncovers the Genetic Complexity of Bicuspid Aortic Valve in Families with Early Onset Complications

Bicuspid Aortic Valve (BAV) is the most common adult congenital heart lesion with an estimated population prevalence of 1%. We hypothesize that early onset complications of BAV (EBAV) are driven by specific impactful genetic variants. We analyzed whole exome sequences (WES) to identify rare coding variants that contribute to BAV disease in 215 EBAV families. Predicted pathogenic variants of causal genes were present in 111 EBAV families (51% of total), including genes that cause BAV (8%) or heritable thoracic aortic disease (HTAD, 17%). After appropriate filtration, we also identified 93 variants in 26 novel genes that are associated with autosomal dominant congenital heart phenotypes, including recurrent deleterious variation of FBN2, MYH6, channelopathy genes, and type 1 and 5 collagen genes. These findings confirm our hypothesis that unique rare genetic variants contribute to early onset complications of BAV disease.