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Real-world Accuracy of Transthoracic Echocardiography in Diagnosing Bicuspid Aortic Valve Morphology: A Single Center UK Experience

Artery Research volume 26, pages 21–26 (2020)Cite this article

Abstract

Objectives

The aim of this study was to compare the diagnostic accuracy of Transthoracic Echocardiography (TTE) in assessing Bicuspid Aortic Valve (BAV) morphology.

Methods

Case notes of 408 patients (>18 years old) undergoing elective Aortic Valve (AV) surgery over a 2-year period were retrospectively reviewed. Aortic valve data was collected from preoperative TTE reports and intraoperative records. The diagnostic accuracy of TTE for identifying AV morphology was assessed using intraoperative findings as the gold standard. One-hundred-and-eighty-nine (46.3%) patients had a recent TTE with complete morphological assessment of the AV and an operation note documenting AV morphology. Cases that were ‘unable to be determined’ on TTE were included as false negatives.

Results

TTE correctly identified AV morphology in 165 of the patients, equating to an accuracy of 79.1% (sensitivity = 72.4%, specificity = 87.3%). For BAV patients alone, accuracy was 81.3% (sensitivity = 65.8%, specificity = 90.0%), and for Tricuspid Aortic Valve (TAV) patients, accuracy was 77.1% (sensitivity = 75.5%, specificity = 81.4%). There was no significant difference in diagnostic accuracy of TTE for BAV and TAV (p = 0.464), nor was there any difference between valve calcification (p = 0.196) and functional disease (p = 0.088).

Conclusion

Our data suggests that identification of BAV from TTE requires expertise and therefore it is operator dependent. A larger study is required to confirm our findings.

References

  1. Roberts WC. The congenitally bicuspid aortic valve. A study of 85 autopsy cases. Am J Cardiol 1970;26:72–83.

    Google Scholar 

  2. Basso C, Boschello M, Perrone C, Mecenero A, Cera A, Bicego D, et al. An echocardiographic survey of primary school children for bicuspid aortic valve. Am J Cardiol 2004;93:661–3.

    Google Scholar 

  3. Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 1984;53:849–55.

    Google Scholar 

  4. Joziasse IC, Vink A, Cramer MJ, van Oosterhout MFM, van Herwerden LA, Heijmen R, et al.: Bicuspid stenotic aortic valves: clinical characteristics and morphological assessment using MRI and echocardiography. Neth Heart J 2011;19:119–25.

    Google Scholar 

  5. Huntington K, Hunter AG, Chan KL. A prospective study to assess the frequency of familial clustering of congenital bicuspid aortic valve. J Am Coll Cardiol 1997;30:1809–12.

    Google Scholar 

  6. Jain R, Engleka KA, Rentschler SL, Manderfield LJ, Li L, Yuan L, et al. Cardiac neural crest orchestrates remodeling and functional maturation of mouse semilunar valves. J Clin Invest 2011;121:422–30.

    Google Scholar 

  7. Garg V, Muth AN, Ransom JF, Schluterman MK, Barnes R, King IN, et al. Mutations in NOTCH1 cause aortic valve disease. Nature 2005;437:270–4.

    Google Scholar 

  8. Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007;133:1226–33.

    Google Scholar 

  9. Horstkotte D, Loogen F. The natural history of aortic valve stenosis. Eur Heart J 1988;9:57–64.

    Google Scholar 

  10. McKellar SH, Michelena HI, Li Z, Schaff HV, Sundt TM. Long-term risk of aortic events following aortic valve replacement in patients with bicuspid aortic valves. Am J Cardiol 2010;106:1626–33.

    Google Scholar 

  11. Beppu S, Suzuki S, Matsuda H, Ohmori F, Nagata S, Miyatake K. Rapidity of progression of aortic stenosis in patients with congenital bicuspid aortic valves. Am J Cardiol 1993;71:322–7.

    Google Scholar 

  12. Subramanian R, Olson LJ, Edwards WD. Surgical pathology of pure aortic stenosis: a study of 374 cases. Mayo Clin Proc 1984;59:683–90.

    Google Scholar 

  13. Sadee AS, Becker AE, Verheul HA, Bouma B, Hoedemaker G. Aortic valve regurgitation and the congenitally bicuspid aortic valve: a clinico-pathological correlation. Br Heart J 1992;67:439–41.

    Google Scholar 

  14. Della Corte A, Bancone C, Quarto C, Dialetto G, Covino FE, Scardone M, et al. Predictors of ascending aortic dilatation with bicuspid aortic valve: a wide spectrum of disease expression. Eur J Cardiothorac Surg 2007;31:397–405.

    Google Scholar 

  15. Jackson V, Petrini J, Caidahl K, Eriksson MJ, Liska J, Eriksson P, et al. Bicuspid aortic valve leaflet morphology in relation to aortic root morphology: a study of 300 patients undergoing open-heart surgery. Eur J Cardiothorac Surg 2011;40:e118–e24.

    Google Scholar 

  16. Michelena HI, Khanna AD, Mahoney D, Margaryan E, Topilsky Y, Suri RM, et al. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA 2011;306:1104–12.

    Google Scholar 

  17. Novaro GM, Tiong IY, Pearce GL, Grimm RA, Smedira N, Griffin BP. Features and predictors of ascending aortic dilatation in association with a congenital bicuspid aortic valve. Am J Cardiol 2003;92:99–101.

    Google Scholar 

  18. Borger MA, Preston M, Ivanov J, Fedak PWM, Davierwala P, Armstrong S, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004;128:677–83.

    Google Scholar 

  19. Barker AJ, Lanning C, Shandas R. Quantification of hemodynamic wall shear stress in patients with bicuspid aortic valve using phase-contrast MRI. Ann Biomed Eng 2010;38:788–800.

    Google Scholar 

  20. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;70:252–89.

    Google Scholar 

  21. Panayotova R, Macnab A, Waterworth PD. A pilot project of familial screening in patients with bicuspid aortic valve disease. J Heart Valve Dis 2013;22:150–5.

    Google Scholar 

  22. Piccoli G, Slavich G, Gianfagna P, Gasparini D. Cardiovascular flashlight. Cleft bicuspid aortic valve: the Achilles’ heel of echocardiography? Eur Heart J 2010;31:2140.

    Google Scholar 

  23. Tirrito SJ, Kerut EK. How not to miss a bicuspid aortic valve in the echocardiography laboratory. Echocardiography 2005;22: 53–5.

    Google Scholar 

  24. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014:63:2438–88.

    Google Scholar 

  25. Schaefer BM, Lewin MB, Stout KK, Gill E, Prueitt A, Byers PH, et al. The bicuspid aortic valve: an integrated phenotypic classification of leaflet morphology and aortic root shape. Heart 2008;94:1634–8.

    Google Scholar 

  26. Russo CF, Cannata A, Lanfranconi M, Vitali E, Garatti A, Bonacina E. Is aortic wall degeneration related to bicuspid aortic valve anatomy in patients with valvular disease? J Thorac Cardiovasc Surg 2008;136:937–42.

    Google Scholar 

  27. Ruzmetov M, Shah JJ, Fortuna RS, Welke KF. The association between aortic valve leaflet morphology and patterns of aortic dilation in patients with bicuspid aortic valves. Ann Thorac Surg 2015;99:2101–8.

    Google Scholar 

  28. Yousry M, Rickenlund A, Petrini J, Jenner J, Liska J, Eriksson P, et al. Aortic valve type and calcification as assessed by transthoracic and transoesophageal echocardiography. Clin Physiol Funct Imaging 2015;35:306–13.

    Google Scholar 

  29. Malaisrie SC, Carr J, Mikati I, Rigolin V, Yip BK, Lapin B, et al. Cardiac magnetic resonance imaging is more diagnostic than 2-dimensional echocardiography in determining the presence of bicuspid aortic valve. J Thorac Cardiovasc Surg 2012;144:370–6.

    Google Scholar 

  30. Hayashida K, Bouvier E, Lefèvre T, Chevalier B, Hovasse T, Romano M, et al. Transcatheter aortic valve implantation for patients with severe bicuspid aortic valve stenosis. Circ Cardiovasc Interv 2013;6:284–91.

    Google Scholar 

  31. Takeda H, Muro T, Saito T, Hyodo E, Ehara S, Hanatani A, et al. Diagnostic accuracy of transthoracic and transesophageal echocardiography for the diagnosis of bicuspid aortic valve: comparison with operative findings. Osaka City Med J 2013;59:69–78.

    Google Scholar 

  32. Ayad RF, Grayburn PA, Ko JM, Filardo G, Roberts WC. Accuracy of two-dimensional echocardiography in determining aortic valve structure in patients >50 years of age having aortic valve replacement for aortic stenosis. Am J Cardiol 2011;108:1589–99.

    Google Scholar 

  33. Tanaka R, Yoshioka K, Niinuma H, Ohsawa S, Okabayashi H, Ehara S. Diagnostic value of cardiac CT in the evaluation of bicuspid aortic stenosis: comparison with echocardiography and operative findings. AJR Am J Roentgenol 2010;195:895–9.

    Google Scholar 

  34. Alegret JM, Palazón O, Duran I, Vernis JM. Aortic valve morphology definition with transthoracic combined with transesophageal echocardiography in a population with high prevalence of bicuspid aortic valve. Int J Cardiovasc Imaging 2005;21:213–17.

    Google Scholar 

  35. Tsai SF, Trivedi M, Daniels CJ. Comparing imaging modalities for screening aortic complications in patients with bicuspid aortic valve. Congenit Heart Dis 2012;7:372–7.

    Google Scholar 

  36. Barker AJ, Markl M, Bürk J, Lorenz R, Bock J, Bauer S, et al. Bicuspid aortic valve is associated with altered wall shear stress in the ascending aorta. Circ Cardiovasc Imaging 2012;5:457–66.

    Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, University Hospital Southampton, UK

    Oliver James Harrison, Abdul Badran, Daniel Muller & Sunil K. Ohri

  2. Institute of Developmental Sciences, University of Southampton, UK

    Oliver James Harrison & Abdul Badran

  3. Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK

    Amer Harky

  4. Department of Echocardiography, University Hospital Southampton, UK

    Benoy N. Shah

Authors
  1. Oliver James Harrison
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  2. Abdul Badran
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  3. Amer Harky
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  4. Daniel Muller
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Corresponding author

Correspondence to Abdul Badran.

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Peer review under responsibility of the Association for Research into Arterial Structure and Physiology

Data availability statement: The data that support the findings of this study are available from the corresponding author, [AB], upon reasonable request.

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This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).

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Harrison, O.J., Badran, A., Harky, A. et al. Real-world Accuracy of Transthoracic Echocardiography in Diagnosing Bicuspid Aortic Valve Morphology: A Single Center UK Experience. Artery Res 26, 21–26 (2020). https://doi.org/10.2991/artres.k.191219.001

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  • DOI: https://doi.org/10.2991/artres.k.191219.001

Keywords

Artery Research

ISSN: 1876-4401

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