Bicuspid aortic valve (BAV) is the most common congenital heart disease in adults and is associated not only with valvular dysfunction but also with progressive involvement of the ascending aorta, constituting a true valvuloaortopathy. Its management requires a comprehensive assessment and a multidisciplinary approach aimed at optimizing long-term outcomes.
In the paper entitled "Diagnosis and Management of Bicuspid Aortic Valve Disease in Argentina", Carrero et al. (1) describe the current status of this condition in our setting, highlighting a significant gap between international guideline recommendations and daily practice. One of the most significant findings is that 50% of centers lack a Heart Team for complex decision-making, a figure that rises to 61.7% in inland centers, which is particularly worrying given the complexity of this condition.
From a surgical perspective, BAV disease should not be approached as an isolated condition. Surgery on the valve without an adequate assessment of the aorta and/or ascending, or vice versa, can lead to incomplete treatment strategies, with a negative impact on mid- and long-term outcomes. In this regard, it is essential to move towards the concept of an ‘Aortic Team’, integrating specialists with experience in aortic diseases into the multidisciplinary team. (2)
Another relevant aspect is the high proportion of indications for transcatheter aortic valve implantation (TAVI), which reaches 40.7%, despite the limited evidence available in patients with BAV. (1) Although recent trials have explored its use in low-risk populations, (3) durability and long-term outcomes in young patients remain uncertain. In this group, conventional surgery, valve repair and the Ross procedure offer advantages in terms of hemodynamics and reintervention-free survival.
Furthermore, the study highlights the low frequency of strategies such as valve repair or the Ross procedure in our setting, (1) which may reflect limitations in both surgical expertise and timely referral to specialized centers.
Furthermore, current evidence highlights the importance of family screening. Various studies demonstrate a significant prevalence of BAV and aortic dilatation in first-degree relatives, reinforcing the recommendation for systematic evaluation in this group. (4) However, adherence to this practice remains suboptimal in our context.
Finally, it is noteworthy that only 30.8% of specialists systematically assess the distal ascending aorta, (1) a region frequently involved in acute events such as dissection, which highlights a diagnostic gap with potential clinical impact.
Taken together, these findings underscore the need to improve the organization of the healthcare system, promote multidisciplinary work and adopt a comprehensive approach to managing BAV. Heart Teams represent a paradigm shift in decision-making, enabling more individualized and evidence-based medicine. (5) Bridging the gap between knowledge and practice is, in this context, a priority challenge.
Ethical considerations
Not applicable.
Conflicts of interest
None declared.
(See authors' conflict of interests forms on the web).
REFERENCES
1. Carrero MC, Constantin I, Streitenberger G, Reyes G, Makhoul S, Giunta G, et al.. Diagnosis and management of bicuspid aortic valve disease in Argentina. Rev Argent Cardiol 2026;94:12-19. https://doi.org/10.7775/rac.es.v94.i1.20974
2. Misfeld M, Etz CD, Leontyev S, Borger MA. The aortic team and bicuspid aortic valve patients. Ann Cardiothorac Surg 2022;11:459-61. https://doi.org/10.21037/acs-2021-bav-213
3. Jørgensen TH, Thyregod HGH, Savontaus M, Willemen Y, Bleie Ø, Tang M, et al.. Transcatheter aortic valve implantation in low-risk tricuspid or bicuspid aortic stenosis: the NOTION-2 trial. Eur Heart J 2024;45:3804-14. https://doi.org/10.1093/eurheartj/ehae331
4. Bray JJH, Freer R, Pitcher A, Kharbanda R. Family screening for bicuspid aortic valve and aortic dilatation: a meta-analysis. Eur Heart J 2023;44:3152-64. https://doi.org/10.1093/eurheartj/ehad320
5. Mesana T, Rodger N, Sherrard H. Heart Teams: A New Paradigm in Health Care. Can J Cardio. 2018;34:815-8. https://doi.org/10.1016/j.cjca.2018.02.028
AUTHORS’ REPLY
We thank Dr Vanesa del V. Audil for her interest in our work and her valuable comments regarding the reality of bicuspid aortic valve (BAV) disease management in our country. We fully agree with her perspective on the inherent complexity of this condition. As Dr Audil points out, BAV should be understood not as an isolated valvular heart disease, but as a true valvuloaortopathy. We share her concern regarding the low number of centers with Heart Team, which is useful for making complex decisions, as well as her suggestion to move towards the concept of Aortic Team. In such groups, multidisciplinary integration-including specialists in aortic diseases-is essential for designing long-term therapeutic strategies that go beyond a purely valvular approach.
Furthermore, the concern raised about the indication for TAVI in patients with BAV is highly pertinent. Our study reveals a trend towards the increasing use of this technique, likely driven by technological availability, but this must be analyzed with caution, as there is limited literature supporting this indication, and indeed, with adverse outcomes in patients with BAV.
Regarding the current scientific evidence on the therapeutic options, the results of the NOTION-2 study reinforce our stance of caution. (1) This randomized clinical trial, which is one of the few to have included a significant proportion of low-risk BAV patients who are excluded from most TAVI studies, demonstrated a higher incidence of moderate or severe paravalvular leaks (17.4% vs. 0% in the surgery group) and a higher incidence of the combined primary endpoint of death, stroke or rehospitalization in patients with BAV who underwent TAVI compared with those who underwent surgery, although the difference was not statistically significant (14.3% vs. 3.9%, p=0.08). These findings suggest that, even in experienced hands, the complex anatomy of the BAV remains a technical challenge that may compromise long-term clinical outcomes.
Furthermore, data from real-world registries and comparative follow-up studies indicate that, in young patients, TAVI in BAV is associated with a higher rate of immediate hemodynamic complications and a prosthetic durability that has yet to be established, compared with surgical aortic valve replacement. The presence of asymmetric calcification and frequent aortic root dilatation increases the risk of incomplete device expansion or annular damage. And prosthetic durability is a key factor in these very young patients, in contrast with those with degenerative aortic valve stenosis. Therefore, the lack of evidence about durability and long-term outcomes in younger patients with this valvular phenotype reinforces the need for rigorous Heart Team discussion before making decisions that compromise the clinical future of these patients.
Finally, Dr Audil’s call to encourage timely referral to high-complexity centers for surgical techniques such as valve repair or the Ross procedure highlights a priority challenge for our healthcare system. We hope that this exchange will help highlight these gaps and encourage improvements in the organization of the healthcare system while increasing adherence to evidence-based recommendations.
Yours sincerely,
María Celeste Carrero
On behalf of the research group of "Dr. Oscar Orías" Council
on Doppler Echocardiography and Vascular Ultrasound
REFERENCES
1. Jørgensen TH, Savontaus M, Willemen Y, et al.; NOTION-2 Investigators. Three-Year Follow-Up of the NOTION-2 Trial: TAVR Versus SAVR to Treat Younger Low-Risk Patients With Tricuspid or Bicuspid Aortic Stenosis. Circulation 2025;152:1326-37. https://doi.org/10.1161/CIRCULATIONAHA.125.076678
