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Brain & Heart Modern imaging and management of bicuspid valves

evaluations (Figure 2). Color Doppler imaging is used to are common in patients with BAV and can lead to life-
visualize the regurgitant jet, with the jet width and area threatening complications if not managed appropriately.
helping to estimate the severity of the regurgitation. In By visualizing the aorta and its branches, CTA helps guide
mild AR, the jet is narrow, while in severe cases, the jet is treatment decisions, including surgical intervention and
large and extends significantly into the left ventricle. In provides critical information for ongoing monitoring.
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addition, Doppler techniques can estimate the regurgitant CT is recommended for evaluating aortic
volume, which correlates with the severity of AR. Another root dimensions and aneurysmal anatomy when
key aspect of AR assessment is the evaluation of left echocardiographic findings are inconclusive, particularly
ventricular dimensions and function. Chronic AR leads in scenarios involving unexplained dilation of the aortic
45
to volume overload, causing left ventricular dilation, sinus or ascending aorta, eccentric AR, significant
which can be quantified using echocardiography. Recent calcification that limits accurate leaflet evaluation, or the
advancements in three-dimensional echocardiography need to investigate additional lesions. Multidetector
3,48
have enhanced spatial and temporal resolution, improving CT (MDCT) demonstrates 94% sensitivity and 100%
the assessment of the aortic valve and aortic root. Dynamic specificity. 49,50
three-dimensional imaging enables precise evaluation
of the aortic valve complex’s spatial and functional Furthermore, given the increased prevalence of
relationships. Multiplane reconstruction facilitates optimal coronary anomalies in patients with BAV, it is crucial to
visualization of the three-dimensional cusp anatomy, assess coronary anatomy in these patients, especially in
the context of surgical interventions, such as AVR or
coaptation lines, and their geometric interrelationship TAVR. MDCT plays a crucial role in the preoperative
3,51
with the aortic root. However, widespread clinical use of planning and evaluation for coronary anomalies in patients
three-dimensional TEE remains limited due to equipment with BAV, such as high-take-off coronary arteries and
availability and incomplete knowledge of imaging paracommissural orifices, which are more common in BAV
options. The measurement of left ventricular end- patients and may complicate aortic valve interventions. 52,53
46
diastolic diameter and ejection fraction helps determine MDCT is particularly valuable due to its superior spatial
the impact of regurgitation on the heart’s function. 41,47 resolution, allowing for detailed coronary artery anatomy
The strengths of echocardiography include its non- assessment.
invasive nature, real-time imaging capabilities, and However, radiation and iodinated contrast exposures
ability to assess both the aortic valve and left ventricle. are major limitations when using CT for surveillance.
However, limitations include the difficulty in accurately
assessing regurgitant volume in extreme cases of AR, 3.3. MRI
challenges in evaluating eccentric jets, and the potential MRI offers a non-invasive and highly informative
for misclassification of AR severity due to poor Doppler approach to the detailed assessment of BAV morphology,
signal quality or suboptimal imaging windows. Overall, associated aortopathy, and coexisting cardiomyopathy.
echocardiography remains an essential tool, although MRI can precisely assess the morphology of the aortic
careful interpretation is necessary for accurate severity valve, identifying the number and structure of leaflets and
assessment. 44,45 any associated commissural fusion. It provides detailed
3.2. CT angiography (CTA) imaging of the aortic root, where BAV-related dilation
often occurs. In addition, MRI can track aortic dilation
CTA is an important imaging tool for assessing BAV over time, which is important in determining the risk
morphology and related complications. CTA provides of aortic dissection or rupture, a major complication
detailed, high-resolution images of the aortic valve, associated with BAV. 54-57
allowing clinicians to evaluate its structure, including the
presence of two leaflets instead of the usual three. This MRI offers advanced capabilities in quantifying the
can help determine valve function and identify associated severity of both AS and AR, two major complications
conditions, such as aortic valve calcifications, leading to associated with BAV. For AS, MRI can utilize phase-
stenosis and impaired valve movement. contrast imaging to measure blood flow velocities across
the aortic valve, providing accurate estimations of pressure
In addition, CTA enables valve area planimetry, an gradients and AVA. Unlike Doppler echocardiography,
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essential assessment for quantifying the severity of stenosis which can be influenced by factors such as low-flow states
in BAV. It also plays a critical role in evaluating the aortic or poor acoustic windows, MRI offers more consistent and
anatomy, identifying aneurysms, dissections, or signs reliable measurements. MRI’s flow quantification technique
of acute aortic syndrome. Aortic dilation or aneurysms measures blood velocity across the valve, enabling the

Volume 3 Issue 3 (2025) 6 doi: 10.36922/BH025050008