Clinical Investigations
Infective Endocarditis and Bicuspid Aortic Valve
Clinical and Echocardiographic Features of Patients With Infective Endocarditis and Bicuspid Aortic Valve According to Echocardiographic Definition of Valve Morphology

https://doi.org/10.1016/j.echo.2023.01.010Get rights and content

Highlights

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    BAVIE patients appear to be referred late even when BAV disease is previously known.

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    Complications related to IE at in-hospital admission could reflect BAV type.

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    Valvular and paravalvular complications could be different according to BAV phenotype.

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    Different BAV phenotypes may have different clinical risk profiles in IE.

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    In-hospital and follow-up mortality are the same in different BAV types.

Background

The influence of different bicuspid aortic valve (BAV) morphology in the clinical course of infective endocarditis (IE) has not yet been investigated. This study aimed to describe the clinical and echocardiographic features of IE in patients with BAV (BAVIE) according to valve morphology.

Methods

Patients with definite BAVIE prospectively enrolled in 4 high-volume referral centers from 2000 to 2019 were evaluated and divided into 2 groups according to the echocardiographic definition of fused BAV morphology: right-left coronary (RL type) and right noncoronary or left noncoronary (non-RL type) cusp fusion. All patients were followed up for 1 year.

Results

One hundred thirty-eight patients with BAVIE were included (77.7% male; median age, 52 [36.83-61.00] years): 112 patients with RL type (81%) and 26 patients with non-RL type BAV (19%), with no significant differences in age, sex, and comorbidities between groups. Although 43% of the cohort had known BAV, the referral was late after symptom onset, particularly for the RL phenotype; time from symptom onset to hospitalization >30 days (31.3% vs 11.5%; P = .032) and New York Heart Association class ≥ II (64.3% vs 42.3%; P = .039) were more frequent in patients with RL type BAV than in patients with non-RL type BAV. Conversely, patients with non-RL type BAV had a higher incidence of hemorrhagic stroke (19.2% vs 5.4%; P = .034) and high-grade atrioventricular block (11.5% vs 0.9%; P = .021). Streptococcus viridans was more frequently isolated in patients with non-RL type BAV than in patients with RL type BAV (44% vs 24.1%; P = .045). No difference in short- and intermediate-term mortality was observed between groups.

Conclusions

Clinical profile and echocardiographic features in BAVIE patients may differ according to valve morphology, and patients with BAVIE appear to be referred late, even when BAV disease is previously known.

Introduction

Bicuspid aortic valve (BAV) is a congenital heart disease involving the aortic valve and aorta, with an estimated prevalence of about 0.5%-2% in the general population.1 Complications related to BAV involve a large spectrum of diseases ranging from severe aortic valve dysfunction to aortic dissection, occurring in a relatively young population.2 Currently, the incidence of infective endocarditis (IE) in BAV (BAVIE) is about 2%-4%, and patients with BAV are at increased risk of developing IE compared with patients with tricuspid aortic valve.3,4 The different valve anatomy of BAV influences the direction of blood flow throughout the aortic root, ascending aorta, and aortic arch and is associated with different aortic diseases. Bicuspid aortic valve IE is frequently associated with valvular and perivalvular complications, including abscess, pseudoaneurysm, severe regurgitation, and stenosis.5,6 Several studies have investigated the prognosis of BAVIE, but none has investigated whether clinical and echocardiographic complications associated with IE may differ between BAV types. The aim of our study was to describe in a population of BAVIE patients epidemiological characteristics, clinical course, microbiological features, and complications according to BAV morphology and to evaluate whether there is a correlation among BAV type and different complications related to IE.

Section snippets

Methods

Patients with BAVIE were retrospectively selected among those prospectively diagnosed with definite IE, referred to 4 high-volume referral centers (Marseille and Amiens, France; Mayo Clinic, Rochester, Minnesota; and Salerno, Italy), and registered in a dedicated database between July 2000 and January 2019. The diagnosis of IE was made according to the modified Duke criteria and the European Society of Cardiology and American Heart Association guidelines.7,8

All patients underwent transthoracic

Characteristics of the Study Population

The study population included 138 patients with BAVIE (median age, 52 [range, 36.8-61.0] years; 108 [78.3%] male), of whom 112 (80.6%) had RL type BAV and 26 (18.8%) had non-RL type BAV. The non-RL type BAV group was composed of 20 patients with right and noncoronary cusp fusion and 6 patients with left and noncoronary cusp fusion. Before IE, BAV anatomy was known in 60 (43.2%) patients. Medical history, source of infection, and clinical data are listed in Table 1. Streptococcus viridans was

Discussion

This study represents the largest published series of BAVIE with known valve morphology that evaluated for the first time the clinical course, echocardiographic features, and microbiological data according to cusp valve fusion. The main observations of our study are as follows: (1) NYHA class ≥ II at admission, higher incidence of abscesses, and early surgery in RL type BAV; and (2) higher rate of hemorrhagic stroke and high-grade atrioventricular block in non-RL type BAV. Nonetheless,

Conclusions

Infective endocarditis is a not a rare complication in patients with BAV. Although 43% of the cohort had known BAV before the infection, referral was late after symptom onset, particularly for the RL phenotype. Attention should be paid to the classification of aortic valve phenotype in BAVIE using echocardiography. In this setting, it may be useful to identify anatomic phenotypes that could correspond not only to different valve morphology but also to different clinical and risk profiles.

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    • Cited by (0)

    Michael H. Picard, MD, FASE, served as Editor-in-Chief for this report.

    Drs. Citro and Habib contributed equally to this work.

    Conflicts of Interest: None.

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