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Brain & Heart Modern imaging and management of bicuspid valves

calculation of mean gradients, and the estimation of AVA, subtype, the functional status of the valve, symptomatology,
allowing for a more precise grading of stenosis severity. dimensions and growth rate of the aortic root and arch,
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For AR, MRI can evaluate regurgitant volume, which coexisting hypertension, genetic predispositions, and
correlates directly with the severity of the condition. any family history of aortic dissection. For asymptomatic
Phase-contrast imaging allows for quantification of the individuals with preserved left ventricular ejection
regurgitant jet, measuring the volume of blood flowing fraction and stable aortic dimensions, a “watchful waiting”
backward from the aorta into the left ventricle during approach is typically endorsed. This strategy involves
diastole. 60,61 close monitoring through regular clinical evaluations and
imaging studies to track disease progression.
MRI can also help visualize the regurgitant jet and the
aortic root, which can assist in determining the degree Notably, medical therapies for BAV are limited,
of valve insufficiency and the corresponding impact on leaving many patients on a trajectory that necessitates
the left ventricle. MRI excels in imaging the aorta and surgical intervention. Angiotensin receptor blockers,
assessing aortic anatomy, including detecting aneurysms such as losartan, valsartan, and telmisartan, along with
and dissections. In patients with BAV or other forms beta-blockers, such as metoprolol, have been shown
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of aortic disease, MRI provides excellent visualization of in some observational studies to slow aortopathy
the ascending aorta, aortic arch, and descending aorta, progression, especially Marfan syndrome and BAV-
offering accurate measurements of aortic diameter and associated aortopathy. More than 50% of individuals
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identifying areas of dilation. MRI is particularly beneficial with BAV require AVR at some point in their lives, with
in monitoring the progression of aortic aneurysms, as it 25% undergoing procedures for dilation of the aortic root
provides precise measurements over time, which is essential or the ascending aorta. 26,67 This underscores the critical
for determining the need for surgical intervention. In importance of thorough patient counseling and the
addition, MRI helps assess aortic root dilation, a common formulation of individualized surgical strategies tailored
complication in patients with BAV that may increase the to the unique risks and needs of each patient and their
risk of rupture if left untreated. 58,63 families. Early, proactive planning is essential to optimize
outcomes and address the progressive nature of the disease
MRI is considered the gold standard for assessing left 68
ventricular size and function due to its high accuracy and effectively.
reproducibility. MRI can provide precise measurements of 4.1. Bicuspid valve AS
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left ventricular end-diastolic volume, end-systolic volume,
and ejection fraction, which are crucial for evaluating Patients with BAV constitute 50% of all patients who
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the impact of aortic valve disease, particularly in cases undergo surgical AVR (SAVR). These individuals are
of severe AS or regurgitation. Sustained hemodynamic often younger and have a lower left ventricular ejection
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stress, either from pressure overload in AS or volume fraction than those with tricuspid AS. Patients with
overload in AR, can lead to left ventricular hypertrophy severe bicuspid AS exhibit significant left ventricular
and dilation. MRI can quantify left ventricular wall remodeling, leading to higher post-operative heart failure
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thickness and end-diastolic diameter and assess global left admissions after AVR compared to tricuspid AS. However,
ventricular function, helping clinicians to monitor for the retrospective data indicate similar post-AVR survival
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development of heart failure or diastolic dysfunction. outcomes in both groups. The American College of
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MRI also plays a critical role in evaluating left ventricular Cardiology (ACC) and AHA guidelines align BAV surgical
remodeling, a process that occurs in response to chronic indications with those established for acquired aortic valve
aortic valve disease, providing essential data for clinical disease (i.e., in patients who are symptomatic or have
decision-making, including the timing of surgical evidence of left ventricular dysfunction). AVR remains
interventions. the preferred surgical treatment for older individuals
with severe stenosis, with decisions guided by the severity
One of the key advantages of MRI in cardiovascular of symptoms, valve hemodynamics, and left ventricular
imaging is its ability to provide high spatial and temporal function. Over the years, the Ross procedure has emerged
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resolution, offering a detailed assessment of heart and as the procedure for BAV patients needing surgical aortic
vessel anatomy with unparalleled precision. valve intervention.

4. Management 4.2. Bicuspid valve AR
The management of BAV presents a complex challenge in Patients with BAV typically develop AR one decade earlier
contemporary cardiovascular medicine. Clinicians must than AS and are more likely to be younger than patients
consider an array of factors, including the specific BAV with TAV-AR. 12,71 Girdauskas et al. found that 78%
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Volume 3 Issue 3 (2025) 7 doi: 10.36922/BH025050008