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Original research
Prognostic implications of left atrial dilation in aortic regurgitation due to bicuspid aortic valve
  1. Steele C Butcher1,2,
  2. Federico Fortuni1,3,
  3. William Kong1,4,
  4. E Mara Vollema1,
  5. Francesca Prevedello1,5,
  6. Rebecca Perry6,7,
  7. Arnold Chin Tse Ng8,
  8. Kian Keong Poh9,
  9. Ana G Almeida10,
  10. Ariana González-Gómez11,
  11. Mylène Shen12,
  12. Tiong-Cheng Yeo4,
  13. Miriam Shanks13,
  14. Bogdan A Popescu14,
  15. Laura Galian-Gay15,
  16. Marcin Fijalkowski16,
  17. Michael Liang4,17,
  18. Edgar Tay4,
  19. Nina Ajmone Marsan1,
  20. Joseph B Selvanayagam6,
  21. Fausto J Pinto10,
  22. José Zamorano11,
  23. Philippe Pibarot12,
  24. Arturo Evangelista15,
  25. Jeroen J Bax1,18,
  26. Victoria Delgado1
  1. 1 Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
  2. 2 Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
  3. 3 Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  4. 4 Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
  5. 5 Division of Cardiology, West Vicenza General Hospitals, Arzignano (Vicenza), Italy
  6. 6 Department of Cardiovascular Medicine, Flinders University, Flinders Medical Centre, Bedford Park, Adelaide, Australia
  7. 7 University of South Australia, Allied Health and Human Performance, Adelaide, South Australia, Australia
  8. 8 Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
  9. 9 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  10. 10 Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte (CHULN), CCUL, Universidade de Lisboa, Lisboa, Portugal
  11. 11 Department of Cardiology, Hospital Universitario Ramo'n y Cajal, Madrid, Spain
  12. 12 Department of Cardiology, Québec Heart and Lung Institute, Laval University, Québec, Quebec, Canada
  13. 13 Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
  14. 14 University of Medicine and Pharmacy “Carol Davila” - Euroecolab, Institute of Cardiovascular Diseases “Prof. Dr. C. C. Iliescu”, Bucharest, Romania
  15. 15 Department of Cardiology, Hospital Universitari Vall d’Hebro'n, Barcelona, Spain
  16. 16 First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
  17. 17 Department of Cardiology, Khoo Teck Puat Hospital, Singapore
  18. 18 Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland, Turku, Finland
  1. Correspondence to Dr Victoria Delgado, Leiden University Medical Center, Leiden 2300 RC, The Netherlands; v.delgado{at}


Objective To investigate the prognostic value of left atrial volume index (LAVI) in patients with moderate to severe aortic regurgitation (AR) and bicuspid aortic valve (BAV).

Methods 554 individuals (45 (IQR 33–57) years, 80% male) with BAV and moderate or severe AR were selected from an international, multicentre registry. The association between LAVI and the combined endpoint of all-cause mortality or aortic valve surgery was investigated with Cox proportional hazard regression analyses.

Results Dilated LAVI was observed in 181 (32.7%) patients. The mean indexed aortic annulus, sinus of Valsalva, sinotubular junction and ascending aorta diameters were 13.0±2.0 mm/m2, 19.4±3.7 mm/m2, 16.5±3.8 mm/m2 and 20.4±4.5 mm/m2, respectively. After a median follow-up of 23 (4–82) months, 272 patients underwent aortic valve surgery (89%) or died (11%). When compared with patients with normal LAVI (<35 mL/m2), those with a dilated LAVI (≥35 mL/m2) had significantly higher rates of aortic valve surgery or mortality (43% and 60% vs 23% and 36%, at 1 and 5 years of follow-up, respectively, p<0.001). Dilated LAVI was independently associated with reduced event-free survival (HR=1.450, 95% CI 1.085 to 1.938, p=0.012) after adjustment for LV ejection fraction, aortic root diameter, LV end-diastolic diameter and LV end-systolic diameter.

Conclusions In this large, multicentre registry of patients with BAV and moderate to severe AR, left atrial dilation was independently associated with reduced event-free survival. The role of this parameter for the risk stratification of individuals with significant AR merits further investigation.

  • aortic regurgitation
  • bicuspid aortic valve
  • aortic valve insufficiency
  • echocardiography

Data availability statement

No data are available.

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  • Twitter @bogdan_popescu1, @PPibarot

  • Contributors All authors contributed to the conception and the design of the study. SCB, FF and VD analysed the data; all authors contributed to interpretation of the data. Drafting of the manuscript was done by SCB, FF and VD; the manuscript was critically revised by all authors. In addition, all authors gave final approval and agreed to be accountable for all aspects of the work ensuring integrity and accuracy.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests The Department of Cardiology of the Leiden University Medical Center received research grants from Abbott Vascular, Bayer, Bioventrix, Medtronic, Biotronik, Boston Scientific, GE Healthcare and Edwards Lifesciences. JJB and NAM received speaking fees from Abbott Vascular. VD received speaker fees from Abbott Vascular, Medtronic, Edwards Lifesciences, MSD and GE Healthcare. PP received funding from Edwards Lifesciences and Medtronic for echocardiography core lab analyses with no personal compensation. The remaining authors have nothing to disclose.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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