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Original research
Contemporary differences between bicuspid and tricuspid aortic valve in chronic aortic regurgitation
  1. Li-Tan Yang1,2,
  2. Giovanni Benfari1,
  3. Mackram Eleid1,
  4. Christopher G Scott3,
  5. Vuyisile T Nkomo1,
  6. Patricia A Pellikka1,
  7. Nandan S Anavekar1,
  8. Maurice Enriquez-Sarano1,
  9. Hector I Michelena1
  1. 1Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota, Rochester, New York, USA
  2. 2Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
  3. 3Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Hector I Michelena, Mayo Clinic, Rochester, MN 55905, USA; michelena.hector{at}


Objective To comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR).

Methods Consecutive patients with chronic ≥moderate-severe AR from a tertiary referral centre (2006–2017) were included. All-cause mortality, surgical indications and aortic valve surgery (AVS) were analysed.

Results Of 798 patients (296 BAV-AR, age 46±14 years; 502 TAV-AR, age 67±14 years, p<0.0001) followed for 5.5 (IQR: 2.9–9.2) years, 403 underwent AVS (repair in 96) and 154 died during follow-up. The 8-year AVS incidence was 60%±3% versus 53%±3% for BAV-AR and TAV-AR, respectively (p=0.014). The unadjusted (real-life) 8-year total survival was 93%±7% versus 71%±2% for BAV-AR and TAV-AR, respectively (p<0.0001), and became statistically insignificant after sole adjustment for age (p=0.14). The within-group relative risk of death in BAV-AR patients demonstrated a large age-dependent increase (two fold at 50–55 years, up to 10-fold at 70 years). The presence of baseline symptoms was significantly associated with death for both BAV-AR (p=0.039) and TAV-AR (p<0.0001), but the strength of the association decreased with age adjustment for BAV-AR (age-adjusted HR 2.43 (0.92–6.39), p=0.07) and not for TAV-AR (age-adjusted HR, 2.3 (1.6–3.3), p<0.0001). As compared with general population, TAV-AR exhibited baseline excess risk which further increased at left ventricular ejection fraction (LVEF) <60% and left ventricular end-systolic dimension index (LVESDi) >20 mm/m2; similar thresholds were observed for BAV-AR patients.

Conclusion BAV-AR patients were two decades younger than TAV-AR and underwent AVS more frequently, resulting in a considerable real-life survival advantage for BAV-AR that was determined primarily by age and not valve anatomy. Pragmatically, regardless of valve anatomy, patients with haemodynamically significant AR and age >50–55 years require a low-threshold for surgical referral to prevent symptom development where LVEF <60% and LVESDi >20 mm/m2 seem appropriate referral thresholds.

  • echocardiography
  • aortic regurgitation
  • bicuspid aortic valve

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  • Contributors All authors contributed to the design, data collection, analysis, drafting and revision of the manuscript. L-TY and HIM have had full access to all the data in the study, and we take full responsibility for the integrity of the data and the accuracy of the data analysis.

  • 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 None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement No data are available. All data relevant to the study are included in the article or uploaded as supplementary information. Because of confidentiality issues, the datasets and study materials safe guarded by the Health Science Department of Mayo Clinic cannot be made available to outside parties.

  • 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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