MDCT differentiation between bicuspid and tricuspid aortic valves in patients with aortic valvular disease: correlation with surgical findings

Abstract

To identify multi-detector computed tomographic (MDCT) features discriminating bicuspid aortic valves (BAVs) from tricuspid aortic valves (TAVs) in patients with aortic valvular disease using surgical findings as reference. Forty-five patients underwent ECG-gated cardiac MDCT scans prior to aortic valve replacement. Morphologic patterns of aortic valves on MDCT were classified into: bicuspid without raphe (A), fused valve with a fish-mouth opening (B), fused valve without a fish-mouth opening (C), and tricuspid without fusion (D). To differentiate congenital raphe of BAV from commissural fusion of TAV, MDCT features of patterns B and C were evaluated. Diameters of the aortic root and ascending aorta between patients with BAVs and TAVs were also compared. Patterns A (n = 6) and B (n = 6) were all bicuspid, in pattern C: 8 of 26 (30.8%) were bicuspid, and pattern D (n = 7) were all tricuspid. In patterns B and C, uneven cusp size, round-shaped opening and midline calcification at leaflet fusion were strongly associated with BAVs (all, P < 0.05). The mean length of leaflet fusion in BAVs was significantly larger than in TAVs (13.5 vs. 8.7 mm, P < 0.0001), with a cutoff value of 10.3 mm providing a sensitivity of 85.7%, a specificity of 83.3%, and an area under the ROC curve of 0.90. In all patients, the mean diameter of the ascending aorta was larger in patients with BAVs than with TAVs (43.3 vs. 39.7 mm, P < 0.05). MDCT features of uneven cusp size, round-shaped opening, midline calcification, longer leaflet fusion and larger diameter of the ascending aorta can be helpful in distinguishing BAVs from TAVs.

Aortic valve type and calcification as assessed by transthoracic and transoesophageal echocardiography

“…It would also be difficult to perform unbiased individual interpretations during surgery. However, intra‐operative scoring has been successfully used as the reference in other studies aimed at evaluating accuracy in diagnosing AVC and BAV (Roberts et al ., ; Alkadhi et al ., ; Joo et al ., ). One may argue that surgeons do not focus on the details of the structure of valves explanted during surgery and that the valve details are usually not included in the routine report, or the report is not written in direct relation to surgery.…”

Vascular Calcifying Progenitor Cells Possess Bidirectional Differentiation Potentials

“…Cells were mixed with triosite (Zimmer) and were incubated for 1 h. Transplanted cells then were mixed with fibrinogen and thrombin before being implanted into a subcutaneous pocket of an 8-wk-old C57 mouse. Eight weeks later, ectopic mineralization was assessed by X-ray (TU-3000DR, Hitachi) and CT (Somatom Definition; Siemens Medical Solutions, Forchheim, Germany) and was quantified using the Agatston score [32],[55],[56]. Ectopically mineralized tissues were harvested and embedded in paraffin.…”

Morphological assessment of the aortic valve using coronary computed tomography angiography, cardiovascular magnetic resonance, and transthoracic echocardiography: comparison with intraoperative findings

“…The presence of a calcified bicuspid aortic valve with a raphe was confirmed at the time of surgery and asymmetric, leading to an asymmetrically limited motion and reduced opening of the valves. In some cases, valvular calcification extends from one cusp to the next and results in cusp fusion without a fish mouth opening (a similar appearance to that seen in patients with BAV) [1,27,28]. In patients with rheumatic AS, two or more of the three commissures are often fused, and the cusps may be either diffusely or focally fibrotic with or without commissural fusion or calcification [1,28].…”

“…In the present study, differentiation between BAV and TAV with CCTA and CMR was difficult due to fused cusps without a fish mouth opening, which resulted in misclassification of 9 AV and 7 AV, respectively. Joo et al [27] recently reported that the CCTA features of uneven cusp sizes, round-shaped openings, midline calcifications at the cusp fusion, and longer cusp fusions were strongly associated with BAV in patients with a fused valve with a fish mouth opening and a fused valve without a fish mouth opening.…”

“…The presence of severe calcification, a prominent raphe, and adhesive commissure on the AV can lead to difficulty in distinguishing between BAV and TAV, particularly in patients with AS [1,11,12,27]. In atherosclerotic TAV stenosis, calcific deposits at the valve annulus and along the commissural edges of the cusps are often very dense .…”