Nature Versus Nurture in Bicuspid Aortic Valve Aortopathy

There is no disease more conducive to clinical humility than aneurysm of the aorta. 1 -William Osler B icuspid aortic valve (BAV) is a common congenital car- diac malformation affecting 1 to 2% of the population with a predilection for males. 2 Although patients with BAV often develop aortic aneurysms requiring surgical intervention, 3,4 the formation of aortic aneurysms is variable and there are currently no good predictors of aneurysm formation.Although studies have shown that patients with BAV have genetically inherited aortic disorders that predispose them to aneurysm development, 5,6 there is ongoing controversy concerning the degree to which altered hemodynamics (nurture) and genetics (nature) interact.The study by Mahadevia et al 7 in this issue of Circulation provides important additional support for the argument that altered flow patterns attributable to abnormal valve architecture do indeed play a role in BAV aortopathy.