Diagnostic accuracy study of routine echocardiography for bicuspid aortic valve: a retrospective study and meta-analysis

Abstract

Background: Transthoracic echocardiography (TTE) is the standard procedure to distinguish tricuspid aortic valve (TAV) from bicuspid aortic valve (BAV). Published studies assessed the accuracy of TTE for BAV under ideal conditions. Conversely, we aimed at assessing accuracy of TTE for BAV under routine conditions.Methods: This retrospective, cross-sectional study of 216 adults included 132 men aged 62±14 years.Of these, 108 had BAV and 108 were age-matched individuals with TAV. All diagnoses were confirmed at surgery. We assessed TTE in two patient groups. First, in the (I) group of all 216 individuals, where we assessed accuracy for BAV according to the original diagnoses as documented by the primary investigators during original TTE examination. Second, we assessed accuracy for BAV according to expert re-evaluation in (II) all 158 TTE with availability of original recordings. Third, we performed a meta-analysis of published results on the accuracy of TTE for BAV according to PRISMA standards.Results: Sensitivity, specificity and accuracy of (I) primary investigators was 46.3%, 97.2, and 71.8% as compared to (II) expert re-evaluation with 59.7%, 93%, and 77.8%, respectively. Sensitivity was significantly higher at re-evaluation (P<0.001). TTE at a non-tertiary care center (P=0.012), presence of aortic aneurysm (P=0.001) and presence of severe aortic valve calcification (P=0.003) predicted an inaccurate diagnosis of BAV. Conversely, meta-analysis of published TTE studies identified a pooled sensitivity of 87.7% and a pooled specificity of 88.3% for BAV.Conclusions: The current study shows that TTE yields almost ideal diagnostic accuracy when ideal investigators examine ideal patients. However, the study also shows that TTE yields suboptimal diagnostic accuracy under routine conditions. TTE in non-tertiary care settings, concomitant aortic aneurysm, and presence of severe aortic valve calcification predict an inaccurate diagnosis of BAV.

The Value of Circulating Biomarkers in Bicuspid Aortic Valve-Associated Aortopathy

“…Transthoracic echocardiography (TTE) is the most widely used cardiac imaging modality but is limited by intra-and interobserver variabilities. 28 Moreover, proximal aortic measurements by TTE may be less reliable than by CT or cardiac magnetic resonance, especially in the presence of asymmetric aortic root aneurysm. 29 Furthermore, echocardiography has a limited value in visualization of the more distal aorta (i.e., beyond the aortic root) and may therefore miss an aneurysm of the mid-ascending aorta.…”

Clinical impact of pathology-proven etiology of severely stenotic aortic valves on mid-term outcomes in patients undergoing surgical aortic valve replacement

“…non-tertiary care center, the presence of aortic aneurysm, and the presence of severe aortic valve calcification [5]. Although preoperative cardiac computerized tomography can be more accurate in differentiating between tricuspid and bicuspid aortic valves than TTE examinations, sufficient studies have not been implemented in the distinction between calcific/degenerative and post-inflammatory valves within the tricuspid aortic valves [25].…”

“…Thus, the evaluation and use of multimodality imaging, including transesophageal echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography, are highly recommended. Nevertheless, in selected cases such as congenital AS, there are still challenges in the preoperative identification of accurate AS etiology [5,6]. When these stenotic aortic valves meet the standardized criteria for severe status in symptomatic patients irrespective of their etiology, most patients are referred to cardiovascular surgeons for surgical or transcatheter aortic valve replacement (AVR).…”

The Association between Morphological and Functional Characteristics of the Bicuspid Aortic Valve and Bicuspid Aortopathy

“…However, the diagnostic accuracy of TTE is limited by operator dependency and possible impairment due to poor acoustic window, a large body habitus, limited field of vision, or technical artifacts. Recently, Hillebrand et al [ 9 ] demonstrated that concomitant aortic aneurysms and the presence of severe aortic valve calcifications resulted in an inaccurate diagnosis of BAV with TTE. In contrast, cardiac computed tomography (CCT) allows for detailed and accurate assessment of aortic valve morphology and ascending aorta dimensions in patients with BAV [ 10 11 ].…”