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Brain & Heart Modern imaging and management of bicuspid valves

Table 3. Strengths and limitations by modality of bicuspid aortic valve intervention
Intervention Strengths Limitations
Bioprosthetic • Reduced need for lifelong anticoagulation, lowering the • Limited durability and shorter valve life
replacement risk of bleeding • High risk for structural deterioration/failure
• Suitable for patients with contraindication to • Higher chance of reoperation and less suitable for younger patients
anticoagulation
Mechanical • Superior durability • Requires lifelong anticoagulation, and hence the risk of bleeding
replacement • Suitable for younger patients • Higher risk of thromboembolism
Valvular repair • Preserves native valve, maintaining natural hemodynamics • Limited applicability; not all valves are suitable for repair
• Reduced risk of prosthesis‑related complications • Durability concerns: repaired valves may deteriorate and need
• No need for anticoagulation future interventions
• Requires specialized surgical expertise
Ross procedure • Excellent hemodynamic performance as the patient’s • Complex procedure and long operative times
pulmonary valve is used • Risk of complications in both aortic and pulmonic positions
• No need for long‑term anticoagulation • Potential for future reintervention due to valve failure
Ozaki procedure • Constructs new valve cusps from pericardium; hence, • Limited long‑term data on durability and outcomes
tailored to suit patients’ anatomy • Technically complex procedure requiring surgical expertise
• Avoids prosthetic material, so no need for long‑term • Potential for calcification and degeneration of pericardial tissue
anticoagulation
Transcatheter • Minimally invasive, shorter hospital stays • Relatively new, limited long‑term data on durability, especially in
aortic valve • Suitable for high‑risk patients young patients
replacement • Expanding indications to lower‑risk populations • Potential for paravalvular leak and need for pacemaker implantation
• Not suitable for all anatomical variations
• Not suitable for all valvular pathologies

were categorized by BAV phenotype on CT as type 0 (no the elderly, and athletes. 112-114 Pregnancy forces many
raphe) or type 1 (one raphe). The primary endpoint was physiological changes in the cardiovascular system,
the success of the Valve Academic Research Consortium-2 which compounds the existing risks in the setting of a
(VARC-2) device. Type 0 BAV showed a tendency toward BAV. Cardiac output increases till it peaks at 36 weeks of
lower VARC-2 device success and higher rates of mean gestation. This increases wall stress and shearing forces
transprosthetic gradients ≥20 mmHg compared to type 1. on the valve and the aorta. Women with BAV usually
108
115
In another subgroup analysis, the aortic annular diameter experience safe pregnancies and have no significant post-
was found to potentially influence procedural outcomes partum events. 116,117 Multiple studies showed that BAV
among different transcatheter heart valve types. Notably, patients with no aortopathy have had outcomes similar
a larger aortic annulus was linked to a significantly higher to the general population, but the data remain sparse
incidence of paravalvular leak in self-expanding valves and should be addressed in future research. Outcomes of
compared to balloon-expandable valves. 109 pregnancies for women with BAV depend mainly on the
Overall, TAVR is a viable option for BAV patients who presence of aortic pathology stratified according to aortic
are not suitable candidates for traditional surgery. 110,111 In diameter. 118,119 Prophylactic treatment for BAV patients
the 2020 ACC/AHA guidelines, TAVR carries a class IIb planning for pregnancy is recommended when the aortic
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recommendation (Level of Evidence B) under specific diameter is ≥5 cm. Surgery during pregnancy is typically
conditions for bicuspid valve patients. Nonetheless, not recommended for valvular problems, regardless
3
randomized clinical trials are needed to determine of the cause, unless it is causing severe morbidity and
3
whether a percutaneous approach offers superior outcomes hemodynamic deterioration. The emergence of life-
compared to surgery for patients with bicuspid valve threatening situations like acute type A dissections is
anatomy. among the rare cases when surgery is recommended
during pregnancy. In some circumstances, surgery may be
6. BAV in special populations advocated in the setting of progressive aortic dilation, but
this is done on a case-to-case basis. 74
6.1. BAV in pregnant women
The BAV has a significant presence in all special populations, 6.2. BAV in children
especially those with hemodynamic considerations, such BAV is usually diagnosed at around 30 years of age. As a
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as in women during pregnancy, pediatrics, adolescents, result, pediatrics and adolescents present a special group to

Volume 3 Issue 3 (2025) 12 doi: 10.36922/BH025050008