Different calcification patterns of tricuspid and bicuspid aortic valves and their clinical impact

Figures

• 

• 

  Figure 1:. Flow patterns and mechanical strain on tricuspid aortic valves and bicuspid aortic valves. During systole, laminar shear stress occurs on the ventricular side of the aortic valve. During diastole, significant axial pressure occurs on the aortic side of the aortic valve leaflets. The pressure is highest on the valvular commissures in tricuspid aortic valves. At the same time, oscillatory shear stress occurs over the non-coronary cusp because there is no runoff for the blood column (modified from [8]).

• 

  Figure 2:. Quantification of calcification using 3mensio Medical Imaging and distinct calcification patterns in tricuspid and bicuspid aortic valves. (A) In a first step, a measuring cylinder within the aortic root was defined in transverse sections. (B) Subsequently, the cranial (15 mm above the annulus) and caudal (5 mm below the basal plate) areas of interest were defined (red lines). The 2 grey lines indicate the height of the annulus. (C) The volume of valvular calcification was measured on each cusp using a specific Mercedes-star-like tool. (D) Finally, valvular calcifications were analysed in in 3 dimensions for every cusp.

• 

  Figure 3:. Calcification patterns in tricuspid and bicuspid aortic valves. (A) The non-coronary cusp showed the highest calcium load compared to the other leaflets irrespective of the biscuspid aortic valve . The bicuspid and tricuspid aortic valves showed significant differences in calcification patterns. (B) Bicuspid aortic valves were similar, with a greater total amount of aortic valvular calcification. (C) There was no difference in annular calcification between patients with tricuspid and bicuspid aortic valves. (D) Bicuspid aortic valves showed significantly higher calcification of the free leaflet edge. AN: annular; BAV: bicuspid aortic valve; FLE: free leaflet edges; LCC: left coronary cusp; NCC: non-coronary cusp; RCC: richt coronary cusp; TAV: tricuspid aortic valve.

• 

  Figure 4:. Bicuspid aortic valves calcify at the free leaflet edge. Quantification of valvular calcifications reveals distinct calcification patterns in transverse (A) and coronary sections (B) as well as in 3-dimensional reconstruction images (C). (D) In analogy to the valvular flow patterns, bicuspid aortic valves show calcifications on the free leaflet edge, whereas tricuspid aortic valves are mainly calcified on the commissures and the valvular annulus. BAV: bicuspid aortic valve; LCC: left coronary cusp; NCC: non-coronary cusp; RCC: richt coronary cusp; TAV: tricuspid aortic valve.

• 

  Figure 5:. Survival of patients with high and low calcific loads. (A) The survival between TAV and BAV patients was not affected. (B) Patients with valvular calcification above the median did not show impaired long-term survival. (C) However, annular calcification above the median was associated with impaired outcome. (D) Calcification of the free leaflet edge did not have an impact on long-term survival. BAV: bicuspid aortic valve; FLE: free leaflet edges; TAV: tricuspid aortic valve.