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.