Discussion
The current study assessed the association of valve morphology to
patient comorbidities, clinical profile and outcomes in a retrospective
cohort of patients with different degrees of AS. As expected, there were
relevant clinical differences between BAV and TAV patients with AS. On
one side, cardiovascular risk factors, coronary heart disease and
perypheral vascular disease were more frequent in the TAV group, On the
other side, aortic dilatation at the ascending aorta was more frequent
in patients with BAV. There were no significant differences in terms of
occurrence of the composite primary end-point between both groups, but
with significative differences in the composition of this end point.
While in the bicuspid group the majority of events were aortic valve
interventions, in TAV group the most frequent event was
non-cardiovascular death, indicating different clinical evolution.
Previous studies have reflected similar finding regarding comorbidities
in TAV patients. It shows that our cohort is consistent with previous
findings. We also found that associated aortopathy is more prevalent in
BAV group and it is related to treatment management, as reflected in
Figure 3. So, these two groups of patients differ not only in terms of
cardiac, valvular, and aortic parameters on imaging but also in terms of
therapeutic decision-making. Also, BAV group developed symtpoms and/or
left ventricle dysfunction in more advanced stages of AS, which could be
related to differences in coronary heart disease prevalence between both
groups.
There are some studies that have reported that AS severity progress
slowly over time, but they have included younger patients with BAV and
AS. 8 9 Yap et al found less
progression in younger BAV patients with mild disease than in older TAV
patients. 8 Indeed, our group has showed that the
majority of patients with BAV (mean age 43±14.9 years) without
significant baseline aortic valve dysfunction did not progress during
follow-up of 4 years. 16 Nevertheless, when we analyse
evolution of patients with AS over 50 years, aortic valve intervention
rate is high. In fact, Shen et al have recently reported that after
adjusting for age and comorbidities, BAV was independently associated
with faster AS progression and higher risk of AVR or death tan
TAV.3 The mean age of the patients with BAV included
in their study was similar to our study (49 ± 12 years). So, congenital
AS should not be conceived as a benign disease. As Namasivayam recenty
stated, latest findings support the need to pay careful attention to
these patients, no matter how young or otherwise healthy they may seem,
as they are not only at risk of accelerated disease progression but also
adverse outcomes, even over a relatively short follow-up
period.17
Lastly, in relation to aortic valve intervention requirement during
evolution, it should be emphasized that BAV patients required more
complex and combined procedures on aortic valve and ascending aorta,
such as Bentall and de Bono or Ross procedures more frequently tan TAV
patients. Conversely, TAVR was the procedure performed in 45% of
patients of the TAV group that had symptoms/left ventricle dysfunction,
reflecting contemporary management of patients with AS.