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Challenges of recognizing bicuspid aortic valve in elderly patients undergoing TAVR


Recognition of bicuspid aortic valve (BAV) may be challenging in elderly patients with heavily calcified aortic valves undergoing transcatheter aortic valve replacement (TAVR). In this subset, the diagnostic value of pre-procedural echocardiography in clinical routine is unknown. From a total of 2583 patients undergoing TAVR in our center, we determined the rate of BAV detected by routine echocardiography as documented in the medical records. Pre-procedural multidetector computed tomography (MDCT) images were retrospectively analyzed for the presence of BAV and served as reference standard. Using MDCT criteria, BAV was found in 235 (9.1%) (age 80.1 years [interquartile range 76.4; 83.4], 44.3% female). Of these, only 27/235 (11.5%) had been identified as BAV according to echocardiography reports, whereas 6/2348 (0.3%) with TAV had been wrongly diagnosed as BAV (p < 0.001; sensitivity 11.5%, specificity 99.7%). Correct diagnosis of BAV by echocardiography was more likely when transesophageal echocardiography was available (odds ratio (OR) 5.12 [95% confidence interval (CI) 2.22; 11.80]; p < 0.001) and the reader was experienced (OR 5.28 [95% CI 1.55; 18.04]; p = 0.008). Furthermore, correct diagnosis of BAV was more likely in bicommissural-type BAV (OR 2.22 [95% CI 0.90; 5.48]; p = 0.08), whereas heavy aortic valve calcification lead to misdiagnosis (OR 0.39 [95% CI 0.14; 1.06]; p = 0.07). In elderly patients with severe aortic stenosis that are candidates for TAVR, the presence of BAV may be considerably underestimated when relying solely on routine echocardiography. This underlines the value of MDCT for the screening of BAV in this patient population.

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We thank Elizabeth Martinson, Ph.D., from the KHFI Editorial Office for her editorial assistance.

Financial disclosures

Won-Keun Kim: Proctor for Symetis SA, St. Jude Medical/Abbott, Lecture Honoraria from Symetis SA, St. Jude Medical/Abbott. Christoph Liebetrau: Lecture Honoraria from Abbott, Astra Zeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Daiichi-Sankyio, and Pfizer—Bristol-Myers Squibb; travel accommodation/meeting expenses from Bayer and Daiichi-Sankyo. Matthias Renker: Lecture Honoraria from St. Jude Medical/Abbott. Andreas Rolf: Lecture Honoraria from Astra Zeneca, Boehringer, Pfizer, MSD, Bristol Myers Squibb. Mirko Doss: Proctor for St. Jude Medical/Abbott. Christian W. Hamm: Advisory Board Medtronic. Helge Möllmann: Proctor Fees and/or Speaker Honoraria from Abbott, Biotronic, Edwards Lifesciences, St. Jude Medical, Symetis SA.

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Correspondence to Won-Keun Kim.

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Kim, W., Liebetrau, C., Fischer-Rasokat, U. et al. Challenges of recognizing bicuspid aortic valve in elderly patients undergoing TAVR. Int J Cardiovasc Imaging 36, 251–256 (2020). https://doi.org/10.1007/s10554-019-01704-8

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  • Aortic stenosis
  • Bicuspid aortic valve
  • Echocardiography
  • MDCT
  • TAVR