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\begin{document}

\title{Use of transillumination echocardiography in the assessment and
diagnosis of bicuspid aortic valve}



\author[1]{Nilda Espinola-Zavaleta}%
\author[1]{Pavel Martinez-Dominguez}%
\author[1]{Santiago Luna-Alcala}%
\author[1]{Enrique C. Guerra}%
\affil[1]{Instituto Nacional de Cardiologia Ignacio Chavez}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Bicuspid aortic valve is the most common congenital heart defect.
Transthoracic echocardiogram is the initial tool to assess and diagnose
this condition, however, transesophageal echocardiogram with 3D
modalities, including transillumination have a better anatomical and
functional evaluation of the valve, allowing to classify the bicuspid
aortic valve according to the position of the raphe and assess the main
vessels for complications or exclude other cardiovascular diseases.%
\end{abstract}%



\sloppy


\textbf{Use of transillumination echocardiography in the assessment and
diagnosis of bicuspid aortic valve}

Pavel Martinez-Dominguez M.D.\textsuperscript{1}, Santiago Luna-Alcala,
M.D.\textsuperscript{1}, Enrique C. Guerra M.D.\textsuperscript{1},
Nilda Espinola-Zavaleta M.D., Ph.D.\textsuperscript{1,2+}

1.- Department of Nuclear Cardiology, National Institute of Cardiology
Ignacio Chavez, Mexico City, Mexico.

2.- Department of Echocardiography, ABC Medical Center, Mexico City,
Mexico.

\textbf{Corresponding Author:}

\textsuperscript{+}Nilda Espinola-Zavaleta M.D., Ph.D.

National Institute of Cardiology Ignacio Chavez.

Juan Badiano N\selectlanguage{ngerman}º 1, Colonia Sección XVI, Tlalpan, C. P. 14030, Mexico
City, Mexico

Telephone: +525555732911; Fax number: +525556063931

Email: niesza2001@hotmail.com

\textbf{Disclosures:} There is nothing relevant to disclose for any
author.

\textbf{Acknowledgments:} None.

\textbf{Funding sources:} None.

\textbf{Conflict of interest:} Nothing to disclose.

\textbf{Keywords:} bicuspid aortic valve, echocardiography,
transillumination

\textbf{Abstract.}

Bicuspid aortic valve is the most common congenital heart defect.
Transthoracic echocardiogram is the initial tool to assess and diagnose
this condition, however, transesophageal echocardiogram with 3D
modalities, including transillumination have a better anatomical and
functional evaluation of the valve, allowing to classify the bicuspid
aortic valve according to the position of the raphe and assess the main
vessels for complications or exclude other cardiovascular diseases.

A 56-year-old male with a 10-year history of hypertension presented to a
routine primary care consult. Physical examination revealed a grade
II/VI diastolic murmur in the aortic focus. As such, the patient was
referred to a cardiologist where a transthoracic echocardiogram (TTE)
was performed. (Panel A; Video S1) Despite a suboptimal valve acoustic
window, it revealed mild aortic insufficiency and suspicion of bicuspid
aortic valve (BAV). The left ventricular ejection fraction was 63\% with
a pulmonary artery systolic pressure of 35 mmHg and grade I diastolic
dysfunction.

Transesophageal echocardiogram (TEE) was performed for optimal valve
visualization. (Panel B; Video S2) This study revealed moderate aortic
insufficiency with eccentric flow. Transillumination echocardiography
confirmed the presence of BAV with a raphe between the right and left
coronary cusps. (Panel C; Video S3) The patient is currently
asymptomatic.

BAV is considered the most common congenital heart defect, with a
prevalence of 1-2\% in general population, predominantly in men. {[}1{]}
It can present isolated or associated with other congenital defects.
{[}2{]} According to the Sievers classification, BAV is categorized
according to the orientation of the valve orifice and the presence or
absence of a raphe. The subtypes include type 0 (without a raphe), type
1 (one raphe) and type 2 (two raphes). The fusion of two cusps creates a
raphe, which can be located in different positions: between the
left-right coronary cusps (L-R), right-noncoronary cusps (R-N) and
noncoronary-left cusps (N-L). {[}3{]} After comparison with a
corresponding anatomopathological specimen, this BAV was classified as
Sievers 1 L-R. (Panel D)

TTE is the standard and initial imaging tool for diagnosing BAV.
Nevertheless, limitations, such as suboptimal acoustic windows or
restricted evaluation of the ascending aorta, have prompted the
consideration of other alternatives for appropriate valvular assessment.
{[}1{]} An alternative is 3D TEE, offering real higher spatial
resolution and diagnostic accuracy, also guiding management decisions
for valvular replacement with evaluation of the outflow tract size.
{[}4{]} Previous studies have shown that 2D TEE compared to 2D TTE has a
higher accuracy in identifying the valvular phenotype, (90.1\% vs
47.4\%) and those unable to be identified with this method, were
successfully identified by 3D TEE. {[}3{]}

Transillumination 3D TEE increases the depth perception and border
delineation, as such it can be an alternative to accurately detect
aortic valve disease as BAV and assess the main vessels for
complications as bicuspid aortopathy or exclude other cardiovascular
diseases. {[}5{]}

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Yakar Tülüce S, Tülüce K, \selectlanguage{polish}Ş\selectlanguage{english}im\selectlanguage{polish}ş\selectlanguage{english}ek E\selectlanguage{ngerman}Ç, et al. Assessment of bicuspid
  aortic valve phenotypes and associated pathologies: A transesophageal
  echocardiographic study. Turk Kardiyol Dern Ars. 2017;45(8):690-701.
  doi:10.5543/tkda.2017.03152
\item
  Saef JM, Ghobrial J. Valvular heart disease in congenital heart
  disease: a narrative review. Cardiovasc Diagn Ther.
  2021;11(3):818-839. doi:10.21037/cdt-19-693-b
\item
  Liu T, Xie M, Lv Q, et al. Bicuspid Aortic Valve: An Update in
  Morphology, Genetics, Biomarker, Complications, Imaging Diagnosis and
  Treatment. Front Physiol. 2019;9:1921. Published 2019 Jan 30.
  doi:10.3389/fphys.2018.01921
\item
  Italiano G, Fusini L, Mantegazza V, et al. Novelties in 3D
  Transthoracic Echocardiography. J Clin Med. 2021;10(3):408. Published
  2021 Jan 21. doi:10.3390/jcm10030408
\item
  Kendall MR, Chacon M, Janardhanan R. Incidental Quadricuspid Aortic
  Valve Demonstrated by Transillumination on Three-Dimensional
  Transesophageal Echocardiography. CASE (Phila). 2023;7(3):113-115.
  Published 2023 Jan 24. Doi:10.1016/j.case.2022.11.006
\end{enumerate}

\textbf{Figure legends}

\textbf{Figure 1. Bicuspid aortic valve. A)} 2D transthoracic
echocardiogram with suboptimal valve acoustic window, no raphe was
observed. \textbf{B)} 2D transesophageal echocardiogram showing a raphe
between the left and right coronary cusp. \textbf{C)} 3D
transillumination transesophageal echocardiography confirming the
presence of the raphe between the left and right coronary
cusp.\textbf{D)} Anatomopathological specimen corresponding with this
patient, Sievers type 1 L-R.

1: non-coronary cusp, 2: right coronary cusp, 3: left coronary cusp, LA:
left atrium, PA: pulmonary artery, RA: right atrium.

\textbf{Video legends}

\textbf{Video S1: 2D transthoracic echocardiogram with color
flow.}Demonstrates suspicion of bicuspid aortic valve, however no raphe
is observed.

\textbf{Video S2: 2D transesophageal echocardiogram at 53°.} Presence of
bicuspid aortic valve with a raphe between the right and left coronary
cusps.

\textbf{Video S3: 3D transillumination transesophageal
echocardiogram.}Cristal mode allowing a better visualization of the
bicuspid aortic valve with a raphe between the right and left coronary
cusps.\selectlanguage{english}
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