The prevalence and clinical significance of ecg abnormalities in individuals with a bicuspid aortic valve

Abstract Background Bicuspid aortic valve (BAV) is the most common congenital cardiac condition encountered in young people and athletes1. Clinical sequelae of BAV, including valvulopathy and aortopathy, increase cardiovascular risk and necessitate regular surveillance2. The electrocardiogram (ECG) remains the cornerstone of cardiovascular screening with echocardiography adopted for secondary evaluation3. However, ECG abnormalities associated with BAV are poorly characterized. Improved understanding of these changes may enhance identification and risk stratification during ECG-based screening. Aim To determine the prevalence, nature, and clinical significance of ECG abnormalities in individuals with BAV compared with those with tricuspid aortic valves (TAV). Methods Patients with confirmed BAV on echocardiogram were identified from electronic hospital records. Twelve-lead ECGs were indexed and systematically analyzed. ECG findings were compared with a cohort of patients with a TAV, identified as part of a separate study of individuals who had routine TTE’s performed and subject to the same exclusion and inclusion criteria as the BAV group. In patients with ≥5 years between ECGs, longitudinal changes were assessed. Outcomes were defined as progression to severe aortic stenosis, severe aortic regurgitation and significant aortic dilatation. Results The cohort consisted of 560 individuals with BAV (mean age 48 years, 71% male), of whom 263 (47%) had uncomplicated BAV. Among these, 56% demonstrated ECG abnormalities. The most frequent findings were left ventricular hypertrophy (22%), incomplete right bundle branch block (9.5%), and PR prolongation (7.6%), all significantly more prevalent than in TAV (p0.05) (Figure 1). Significant abnormalities commonly leading to further evaluation, including pathological T-wave inversion, left bundle branch block and prolonged QT interval-were associated with progression to valvulopathy and/or aortopathy (Figure 2). Conclusions Individuals with BAV are more likely than those with TAV to exhibit subtle ECG abnormalities, even in the absence of overt valve disease. Common features include left ventricular hypertrophy, incomplete right bundle branch block, and first-degree AV block. More advanced abnormalities predict progression to valvulopathy/aortopathy. While ECG alone lacks sensitivity for BAV detection, these findings suggest its potential role in disease stratification. Importantly, this opens the door for evaluation of ECGs with advanced computational technologies to predict the presence and possibly the severity of valvular disease, supporting integration of ECG analytics into preventive cardiology strategies.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.