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Structure and function of the tricuspid and
bicuspid regurgitant aortic valve: an
echocardiographic study
Mattias Rönnerfalk and Eva Tamas
Linköping University Post Print
N.B.: When citing this work, cite the original article.
Original Publication:
Mattias Rönnerfalk and Eva Tamas, Structure and function of the tricuspid and bicuspid
regurgitant aortic valve: an echocardiographic study, 2015, Interactive Cardiovascular and
Thoracic Surgery, (21), 1, 71-76.
http://dx.doi.org/10.1093/icvts/ivv072
Copyright: Oxford University Press (OUP): Policy N / European Association for Cardio-
thoracic Surgery
http://www.oxfordjournals.org/
Postprint available at: Linköping University Electronic Press
http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-120278
Funding: The work was supported by the Swedish Heart Lung Foundation [HLF 20120570]
and ALF Grants from the County Council of Östergötland, Sweden [LIO-204141].
.
Structure and Function of the Tricuspid and Bicuspid Regurgitant Aortic Valve - an
echocardiographic study
Mattias Rönnerfalk †*‡, Éva Tamás*‡
†Department of Clinical Physiology and *Department of Cardiothoracic Surgery, Heart and
Medicine Centre, Linköping, ‡ Division of Cardiovascular Medicine, Department of Medical and
Health Sciences, University of Linköping, Sweden
Abstract word count: 326 (excl. Keywords)
Text word count: 2886 (excl. Fig.,table,ref.)
Corresponding author:
Mattias Rönnerfalk
Dept. of Cardiothoracic Surgery
Heart and Medicine Centre
581 85 Linköping
Sweden
Telephone: +46 10 103 48 15
Fax: +46 +46 13 10 02 46
e-mail: [email protected]
2
Abstract
Objectives:
The emerging new treatment options for aortic valve disease call for more sophisticated diagnostics.
We aimed to describe the echocardiographic pathophysiology and characteristics of the purely
regurgitant aortic valve in detail.
Methods:
Twenty-nine men, with chronic aortic regurgitation without concomitant heart disease referred for
aortic valve intervention, underwent 2D transesophageal echocardiographic (TEE) examination
prior to surgery according to a previously published matrix. Measurements of the aortic valve
apparatus in long and short axis view were made in systole and diastole and analysed off-line. The
valves were grouped as tricuspid (TAV) or bicuspid (BAV) and classified by regurgitation
mechanism.
Results:
Twenty-four examinations were eligible for analysis of which 13 presented TAV and 11 BAV. The
regurgitation mechanism was classified as dilatation of the aorta in 6 cases, as prolapse in 11 cases
and as poor cusp tissue quality or quantity in 7 cases. The ventriculoaortic junction (VAJ) and valve
opening were closely related (TAV r = 0.5, BAV r = 0.73) but no correlation was found between the
VAJ and the maximal sinus diameter (maxSiD) or the sinotubular junction (STJ). However, the STJ
and maxSiD were significantly related (TAV vs. BAV: systole r = 0.9, r = 0.8; diastole r = 0.9, r =
0.7) forming an entity. The conjoined BAV cusps were shorter than the anterior cusps when closed
(p = 0.002); the inter-commissural distance of the cusps in the BAV group were significantly
different (p = 0.001 resp. 0.03) in both systole and diastole.
Conclusions:
3
The VAJ was independent of other aortic dimensions and should thereby be considered as a
separate entity with influence on valve opening. The detailed 2D TEE measurements of this study
add further important information to our knowledge about the function and echocardiographic
anatomy of the pathologic aortic valve and root either as a stand-alone examination or as a
benchmark and complement to 3D echocardiography. This may have an impact on decisions
regarding repairability of the native aortic valve.
Key words:
aortic valve insufficiency, transesophageal echocardiography, tricuspid valve, bicuspid valve,
cardiac surgery
4
Introduction
The prevalence of aortic regurgitation (AR) is 13% in men and 8.5% in women reported by the
Framingham Heart Study [1]. The aortic valve can be incompetent due to inflammatory process,
tissue degeneration as in tricuspid aortic valve (TAV) or affected congenitally as in bicuspid aortic
valve (BAV). The incidence of BAV is 0.9-1.36% [2] and the malformation usually does not affect
hemodynamics in children. The turbulent flow characteristics and the tissue changes may result in
both aortic stenosis (AS) and AR. Symptoms of chronic AR may occur first in the young adult or in
the middle-aged individual [3]. In surgical series of patients with BAV 69% of the patients were
men; 75% suffered from AS (mean age 65 years) and 13% had AR (mean age 46 years) and only
1% of the BAVs functioned normally [4]. In a study of patients with pure AR from the Mayo Clinic
[2], 20% of the valves proved to be bicuspid.
Regurgitant aortic valves can be classified by echocardiography based on the mechanism causing
regurgitation. Both LePolains de Waroux et al. and Lansac et al. have presented valid
classifications. LePolain de Waroux et al. focused mainly on cusp morphology classifying
enlargement of the aortic root with normal cusps as type 1, cusp prolapse or fenestration as type 2,
and poor cusp tissue quality or quantity as type 3. Regurgitation mechanisms type 1 and 2 are
generally considered to be candidates for aortic valve repair [5]. Lansac et al. had aortic root
dilatation with (type I) or without (type II) cusp lesion as the starting point for their classification
and defined subgroups Ia as dilatation of the sinotubular junction (STJ) and Ib as simultaneous
dilatation of the ventriculoartic junction (VAJ) and the STJ. Subgroup IIa includes cusp prolapse,
IIb cusp retraction and IIc tear or perforation of the cusp tissue [6]. Type I lesions are generally
characterized by a central jet on echocardiography while type II lesions cause an eccentric jet.
According to current guidelines [7] aortic valve replacement (AVR) is the choice of treatment for
patients suffering from AS. However, for patients with AR (especially in physically active young
individuals) preservation of the native valve eliminates possible complication due to patient
prosthesis mismatch and warfarin treatment [8, 9], thereby leading to improved morbidity measures
5
and better quality of life for these patients. Regurgitant tricuspid aortic valves are reconstructed and
preserved with good short and medium term results measured by grading residual and/or recurrent
AR postoperatively [10, 11]. A few studies have been published on preserving BAV with promising
initial results [12]. The pre- and intraoperative evaluation and the postoperative follow-up of the
aortic valve were performed by echocardiography, preferably transesophageal echocardiography
(TEE). Even though a complete echocardiographic TEE examination is performed pre-operatively
the decision, whether or not the valve is possible to reconstruct, is made in the operating theatre by
surgical visual examination. Therefore a more standardised approach to the preoperative
examination could aid surgeons’ assessment and planning of the surgical intervention.
The clinical application of 3D TEE has been expanding. During only a decade the development
went from early reports of simple examinations of the aortic valve apparatus [13] to high quality
real-time examinations. Nevertheless, 2D TEE still forms the basis of clinical decisions and
description concerning aortic valve morphology in most of the tertiary centres.
The aim of the present study is to describe the detailed echocardiographic pathophysiology and
characteristics of the purely regurgitant aortic valve by 2D TEE.
6
Materials and Methods
A series of 29 patients referred to our centre for surgical interventions due to severe chronic aortic
regurgitation were included in this study. Patients with concomitant coronary artery disease, other
heart valve disease than chronic aortic regurgitation (aortic stenosis defined as aortic orifice area ≤
1.6 cm²; any history of active endocarditis) and with ascending aortic aneurysm were excluded. All
the patients underwent transesophageal ultrasound scan at rest (Vivid 5 or Vivid 7 ultrasound
system, GE Healthcare, Wauwatosa, WI) one day prior to the planned surgery. Images were
recorded, stored digitally and analysed off-line. Measurements on the aortic root and the cusps were
taken according to a previously published matrix [14], which was proved reliable and highly
reproducible. The analyses of AR mechanisms were performed according to the classification
presented by LePolain de Waroux et al. chosen for its versatility in clinical practice.
In absence of a comprehensive definition, including numerical cut-off for raphe, for
echocardiographic classification of BAV a merger of different, although not comprehensive
classifications eligible for echocardiographic use was constructed [15-17] to enable classification of
valves with challenging echocardiographic image. The aortic valve was classified as TAV when
having three visible cusps, three identifiable commissures as absolute criteria and a Y-shaped valve
opening in systole with a raphe/fusion less than 10 mm as relative criteria. To be classified as BAV
two visible cusps and two identifiable commissures were required as absolute criteria and a fish
mouth shaped valve opening and a raphe/fusion longer than 10 mm as relative criteria.
In summary, 2D ECG-synchronized cine loops of the aortic root in the long and short axis views
were recorded. Parameters (Fig.1.) were measured in end-diastole and end-systole using the inner
edge technique. Each parameter was measured three times and the mean was entered into the
statistical analysis. Systolic and diastolic parameters, as well as characteristics for tricuspid and
bicuspid valves were analysed by Mann-Whitney and Sign test, Wilcoxon’s matched paired test or
Friedman ANOVA, as appropriate, due to sample size and distribution pattern. Tree clustering
(Ward’s method based on variance) was used to detect relationships among parameters. For further
7
specification of relationships of significance within a cluster, Spearman’s rank order correlation (r)
was applied. Significance was set as p ≤ 0.05 throughout the statistical analysis. All statistical
analyses were performed by STATISTICA 10.0 Statsoft, Tulsa, Okla., USA. The Regional Ethical
Review Board in Linköping, Sweden approved the study.
8
Results
All of the included patients happened to be men. The echocardiographic images were technically
satisfactory and eligible for detailed analyses in 24 cases. Patients were grouped based on having
tricuspid or bicuspid valve according to the above definition. The demographic characteristics of the
two groups were comparable except that patients with BAV were significantly younger (Table 1).
The echocardiographic measurements and a comparison between TAV and BAV are presented in
Table 2. The opening of the valves was comparable for both BAV and TAV. Raphe was observed
between the left and the right coronary cusp in all but one case and the two cusps were unequal [4],
the conjoined cusp being bigger in all BAV cases. However, the inter-commissural distance of the
non-coronary cusp of TAVs and the anterior cusp of the BAVs were comparable.
Long axis view
A close relationship between the VAJ and valve-opening both in tricuspid (r = 0.5) and bicuspid (r
= 0.73) valves was verified. The VAJ, the STJ and the maximal sinus diameter (maxSiD) were
found to be significantly related only in the BAV group in systole (r = 0.6 each). The STJ and the
maxSiD were significantly related both in the TAV and the BAV groups in systole (r = 0.9, r = 0.8)
and in diastole (r = 0.9, r = 0.7).
The height of cusps (TAV: r = 0.9 resp. 0.9; BAV: r = 0.9 resp. 0.8) and sinuses (TAV: r = 0.9 resp.
0.9; BAV systole: r = 0.7) in LAX were significantly correlated throughout the heart cycle with the
exception of sinus height for BAV in diastole (r = 0.6), Fig.2. There was an indication of variation
in aortic measurements between diastole and systole in BAV (VAJ p = 0.09, maxSiD p = 0.02, STJ
p = 0.15).
Short axis view
The commissural distance of the TAV cusps were not significantly different (p = 0.55 resp. 0.23)
from each other. However, the inter-commissural (IC) distance of the anterior and the posterior
cusps in the BAV group were significantly different (p = 0.001 resp. 0.03) in both systole and
diastole. The commissure-to-raphe distance was not significantly different from the raphe-to-
9
commissure distance (Fig.1.) but both were significantly less than the IC- distance of the anterior
cusp when the valve was closed (p = 0.002 resp. 0.07).
Mechanisms of aortic regurgitation
All the patients had hemodynamically significant aortic regurgitation. The regurgitation
mechanisms in the TAV group were classified as five type 1, four type 2 and four type 3. The
distribution for the BAV group was one type 1, seven type 2 and three type 3.
10
Discussion
The main findings of the present study were that (A) the diameter of the ventriculoaortic junction
proved to be significantly related to the opening of the valve both in TAV and BAV but (B) it was
found to be a separate entity, not related to either the STJ or the maxSiD.
Both TAV and BAV have been studied previously in chronic aortic regurgitation but comparative
data are scarce, mainly focusing on functional aspects. Thus, the novelty of the present study
consists mainly of describing further complementing echocardiographic details and relations. The
anatomy, in particular the echocardiographic anatomy of the aortic root and mechanism of
regurgitation has an impact on planning aortic valve interventions, most specifically valve
preserving surgery which is well-established and performed with good results in some centres [10-
12] both on bicuspid and tricuspid valves but still not widely used in surgical practice. This is partly
due to the complexity of the anatomy of the normal aortic root [18], partly because of the fully
functional but anatomically basically different variations as in tricuspid and bicuspid valves.
Furthermore, the different anatomy has apparent implications for tissue quality [19, 20].
The significant difference in the age of the patients between TAV and BAV in this study can be
explained by the different aetiology of the chronic aortic regurgitation [19], which is concordant
with previous findings [4]. The comparison of the echocardiographic dimensions according to size
showed that the majority of parameters were larger in TAV. This is, however, contradictory to
previous knowledge which states that the aortic root containing a BAV is larger and more prone to
dilatation, even more so in reguritant BAV [21]. Aortic dimensions for both TAV and BAV in this
study were larger than diameters of the healthy aortic roots and most so in the TAV group. VAJ and
maxSiD changed less than one mm between systole and diastole in healthy TAV and the difference
was the same for STJ [14]. In this study of chronic aortic regurgitation there was a non-significant
change in TAV for VAJ, maxSiD and STJ but noticeably larger aortic dimensions. The difference
in diameters throughout the cardiac cycle was significant for maxSiD in BAV and a certain trend in
11
VAJ and STJ, indicating increased compliance in the aortic wall, was detected. Similar findings
were described in a sample of mildly regurgitant bicuspid valves [22] but as our design did not
include studies of elasticity or distensibility it does not allow any conclusions in this aspect. Since
we did not find any general dilatation of the aorta in the BAV group the hemodynamically
significant AR might be a forerunner and even the cause of imminent dilatation. The larger aortic
dimension in AR TAV and the increased aortic wall compliance of the BAV compared with
previously studied healthy valves are notable [14]. These two findings might indicate a selection
bias due to exclusion of patients with ascending aortic aneurysm.
The diameter of the VAJ was found to be significantly related to the opening of the valve both in
TAV and BAV but it was independent from both the STJ and the maxSiD. This is a finding which
followed the pattern of normal aortic root previously studied by our group [14] and it supports
previous findings made in healthy subjects stating that the VAJ is a separate entity not under the
influence of the aorta and should be considered and treated as such. It seems logical to assume it to
be under the influence of structures and physiological events in the left ventricle when it is not
under aortic influence [6, 14, 23], but that is beyond the scope of this study.
The position of the observed raphe between the left and right coronary cusp and the disparity of the
cusps in this study represented the most common pattern for BAV. This is in concordance with the
findings of Sabet et al. [4], who have published the single largest material on BAV so far, the
pattern of raphe location between the left and the right cusps with unequal cusp size could be seen
in 86% respectively 92% of the cases in their surgical material. Despite our modest number of
subjects this correlated well with the findings for the type of regurgitation. In our patients the most
common type of regurgitation in BAV was type 2 leading us to the conclusion that the conjoined
cusps in the posterior cusp in BAV usually have excessive leaflet tissue. The results of visual
observation of unequal cusps in BAV were confirmed by the statistical comparison of inter-
commissural distances.
12
LePolain de Waroux et al. showed that the echocardiographically classified type of regurgitation
mechanism has prognostic value for the result of valve-sparing surgery. Enlargement of the aortic
root with normal cusps (type 1) and excessive tissue, cusp prolapse or fenestration (type 2) are
candidates for valve-sparing surgery while type 3 regurgitation due to poor cusp tissue quality or
quantity is associated with adverse outcome and more often in need of re-operation resulting in
aortic valve replacement [5]. In the same study there were a number of valves classified as
repairable, type 1 or 2 regurgitations, which were operated on with valve-sparing techniques which
needed re-operation. These valves were suspected of being actually type 3 regurgitations
wrongfully classified visually as repairable by the surgeon. In our material too, there were a number
of TAV classified as type 3 regurgitation due to stretched cusps though with normal VAJ. These
valves may in the future be classified as probably unrepairable based on an extensive
echocardiographic examination incorporated in the process of decision complementing the
surgeons’ visual examination.
The regurgitation mechanisms in our study were evenly distributed in TAV, but with an
overrepresentation of prolapsing valves in BAV corresponding well with our findings of excessive
leaflet tissue in BAV. Our echocardiographic description has the potential to provide additional
knowledge prior to intervention thereby increasing the understanding of both the echocardiographic
anatomy of the regurgitant aortic valve and the possible mechanism of the regurgitation.
Although the clinical application of 3D TEE has been expanding during the last decade, making 3D
TEE an integrated part of transcatheter valve implantation procedures, there is a sparse number of
studies comparing 3D TEE to 2D TEE or validating 3D TEE for describing the morphology and
structures of the aortic valve. Studies comparing 2D TEE and 3D TEE focusing on a few specific
measurements are to be found [24]. Some measurements are not even possible to compare between
the two modalities because of their built-in limitations. Concerning the regurgitant aortic valve, 3D
TEE is validated as a superior method of measuring regurgitant volumes and effective regurgitant
13
orifice area [25]. 3D TEE has also brought new knowledge of the structures and physiology of the
aortic valve and of the aortic root as a complex structure. Real-time 3D TEE examination can today
be performed with an acceptable frame rate. However, although 3D visualization provides valuable
information on spatial relationships and may aid in determination of regurgitation mechanisms, due
to its even higher frame rate and spatial resolution, 2D TEE still has a place in the diagnostics of
aortic valve pathology based on its accuracy, which is needed to expose delicate structures such as
the aortic valve leaflets. Hence 2D TEE can form the basis of clinical decision making regarding
morphology of the regurgitant aortic valve for some time yet and constitute a possible benchmark
for future 3D studies.
The fact that all but one of the BAV showed the same raphe position and inter-commissural
relations limits the generalizability of the findings in this study. However, the one presented here is
still the most common pattern and only less frequent dispositions are absent. Thus, the conclusions
still can be considered representative for the majority of the BAV population. All the patients in this
study happened to be men, which consequently does not allow conclusions to be drawn for women
though studying gender aspects of the morphology of the regurgitant aortic valve was not part of the
study design and, therefore, beyond the scope of this study. The gender distribution in purely
regurgitant BAV was described earlier as 17.3 : 1 [4]. Furthermore, the small number of patients in
this study is balanced by non-parametric analyses of the data to enhance generalizability.
In conclusion, the detailed 2D TEE measurements of this study can add further important
information to our knowledge about the function and echocardiographic anatomy of the pathologic
aortic valve and root as a stand-alone examination or as a benchmark and complement to 3D
echocardiography. This could have an impact on planning the type of aortic valve intervention.
Fundings
This work was supported by the Swedish Heart Lung Foundation [HLF 20120570] and ALF Grants
from the County Council of Östergötland, Sweden [LIO-204141].
14
Conflicts of interest
Conflicts of interest: none to be declared
15
Figure 1 Echocardiographic parameters of the aortic root with a bicuspid valve
16
Figure 2 Tree cluster analyses for variables seen in the long axis view
TAV LAX systole
0,00,2
0,40,6
0,81,0
1,21,4
1,6
Linkage Distance
RC Sinus HeightLC Sinus Height
STJMax Sinus Diameter
RC Cusp HeightLC Cusp HeightCusp separation
Ventriculoaortic Junction
TAV LAX diastole
0,00,2
0,40,6
0,81,0
1,21,4
1,6
Linkage Distance
RC Cusp Height
LC Cusp Height
RC Sinus Height
LC Sinus Height
STJ
Max Sinus Diameter
Ventriculoaortic Junction
BAV LAX systole
0,00,2
0,40,6
0,81,0
1,21,4
1,6
Linkage Distance
Posterior Cusp HeightAnterior Cusp Height
Posterior Sinus HeightAnterior Sinus Height
STJMax Sinus Diameter
Cusp SeparationVentriculoaortic Junction
BAV LAX diastole
0,00,2
0,40,6
0,81,0
1,21,4
1,6
Linkage Distance
Posterior Sinus Height
Anterior Sinus Height
Posterior Cusp Height
Anterior Cusp Height
STJ
Max Sinus Diameter
Ventriculoaortic Junction
17
Figure 3 Tree cluster analyses for variables seen in the short axis view
TAV SAX systole
0,0 0,3 0,6 0,9 1,2
Linkage Distance
RC Cusp Diameter
IC Distance NC Sinus
IC Distance RC Sinus
NC Cusp Diameter
LC Cusp Diameter
IC Distance LC Sinus
TAV SAX diastole
0,0 0,3 0,6 0,9 1,2
Linkage Distance
NC Cusp Diameter
IC Distance NC Sinus
RC Cusp Diameter
IC Distance RC Sinus
LC Cusp Diameter
IC Distance LC Sinus
BAV SAX systole
0,00,5
1,01,5
2,02,5
Linkage Distance
Posterior Cusp Diameter 2
Posterior Cusp Diameter 1
NC Cusp Diameter
IC Distance Posterior Cusp
Raphe-to-commissure Distance
IC Distance NC Sinus
Commissure-to-raphe Distance
BAV SAX diastole
0,00,2
0,40,6
0,81,0
1,2
Linkage Distance
Posterior Cusp Diameter 1
Posterior Cusp Diameter 2
IC Distance NC Sinus
Commissure-to-raphe Distance
Raphe-to-Commissure Distance
IC Distance Posterior Cusp
18
Table 1 Patient characteristics
Tricuspid
N = 13
Bicuspid
N = 11
p
Age (yrs) 61 ± 12 42 ± 11 < 0.001
Height (cm) 177 ± 4 181 ± 8 0.22
Weight (kg) 87 ± 11 89 ± 17 0.76
BSA (m2) 2.0 ± 0.1 2.1 ± 0.2 0.26
BMI (kg/m2) 28 ± 3 27 ± 3 0.67
19
Table 2 Tricuspid and bicuspid aortic valve parameters
Tricuspid (mm) Bicuspid (mm)
Systole Diastole ps pd Systole Diastole
Ventriculoaortic
junction
25 ± 4 24 ± 3 0.05 0.08 28 ± 3 27 ± 3 Ventriculoaortic
junction
Maximal Sinus
Diameter
42 ± 6 41 ± 6 0.07 0.02 38 ± 5 36 ± 6 Maximal Sinus
Diameter
STJ 38 ± 8 39 ± 9 0.02 0.02 32 ± 6 31 ± 6 STJ
Opening (Cusp
Separation)
22 ± 7 - 0.95 22 ± 4 - Opening (Cusp
Separation)
Coaptation - 0 - 0 Coaptation
LC Cusp Height 11 ± 3 8 ± 3 0.49 0.11 12 ± 4 6 ± 4 Posterior Cusp
Height
RC Cusp Height 12 ± 3 8 ± 3 0.49 0.17 12 ± 3 6 ± 4 Anterior Cusp
Height
LC Sinus Height 22 ± 8 21 ± 7 0.69 0.46 20 ± 4 20 ± 5 Posterior Sinus
Height
RC Sinus Height 24 ± 9 24 ± 8 0.23 0.39 20 ± 4 20 ± 4 Anterior Sinus
Height
IC Distance LC
Sinus
30 ± 5 27 ± 4 0.07 0.15 27 ± 3 25 ± 3 Commissure-to-
raphe Distance
Posterior Sinus
IC Distance RC
Sinus
31 ± 4 29 ± 4 0.004 0.006 26 ± 4 24 ± 4 Raphe-to-
commissure
Distance
Posterior Sinus
- 52 ± 6 49 ± 7 IC Distance
Posterior Sinus *
IC Distance NC
Sinus
31 ± 4 28 ± 5 0.53 0.69 32 ± 4 28 ± 4 IC Distance
Anterior Sinus
LC Cusp Diameter 10 ± 3 16 ± 3 0.002 0.005 6 ± 2 13 ± 3 Posterior Cusp
Diameter 1
RC Cusp Diameter 10 ± 5 15 ± 6 0.61 0.86 8 ± 2 15 ± 4 Posterior Cusp
Diameter 2
NC Cusp Diameter 12 ± 3 18 ± 2 0.04 0.73 10 ± 4 18 ± 4 Anterior Cusp
Diameter
20
FIGURE LEGENDS
Figure 1
Aortic root and cusp parameters measured in diastole (A & C) and systole (B & D): 1, 2:
ventriculoaortic junction diameter (VAJ); 3, 4: maximal sinus diameter; 5, 6: sinotubular
junction (STJ); 7: valve opening; 9, 10: Posterior cusp height; 11, 12: Anterior cusp height;
13, 14: Posterior sinus height; 15, 16: Anterior sinus height;17, 18: Commissure-to-raphe
distance posterior cusp; 19, 20: Raphe-to-commissure distance posterior cusp; 21, 22: Inter-
commissural distance non-coronary (NC) sinus; 23, 24: Posterior cusp diameter 1; 25, 26:
Posterior cusp diameter 2; 27, 28: NC cusp diameter
Figure 2
BAV: Bicuspid aortic valve; TAV: Tricuspid aortic valve; LAX: long axis view; SAX: Short
axis view; LC: Left coronary; NC: Non-coronary; RC: Right coronary; STJ: Sinotubular
junction; IC: Inter-commissural.
Figure 3
BAV: Bicuspid aortic valve; TAV: Tricuspid aortic valve; LAX: long axis view; SAX: Short
axis view; LC: Left coronary; NC: Non-coronary; RC: Right coronary; STJ: Sinotubular
junction; IC: Inter-commissural.
Table 1
Patients with bicuspid and tricuspid aortic valve had comparable demographical parameters
except age. BSA: body surface area, BMI: body mass index.
21
Table 2
STJ: Sinotubular junction; LC: left coronary; RC: Right coronary; NC: Non-coronary; IC:
Inter-commissural. Measures in mm, mean ± SD. * calculated from commissure-to-raphe
distance posterior cusp and raphe-to-commissure distance posterior cusp.
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