Beyond the two cusps: disparities in echocardiographic assessment and guideline adherence in bicuspid aortic valve management in Argentina

Background Bicuspid Aortic Valve (BAV) is the most prevalent congenital cardiac anomaly, frequently leading to valvular dysfunction at young age. While recently was published an international consensus which provides clear diagnostic frameworks, the "real-world" echocardiographic characterization among imaging specialists remains largely unexplored. Purpose To evaluate the diagnostic practices, classification and measurement techniques used by certified cardiovascular imaging specialists in the assessment of BAV and associated aortopathy in Argentina. Methods A nationwide, voluntary, anonymous online survey was conducted (2024- 2025) among cardiologists. This sub-analysis focuses on the responses of 108 certified cardiovascular imaging specialists (54.6% male, 44.7 ± 10.1 years). Data regarding BAV classification, morphological description, and aortic measurement techniques were analyzed. Results Regarding BAV morphology, 70.3% of specialists claimed to follow the International BAV Consensus with a significant reporting gap for high-risk features: while raphe (93%) and aortic valve calcification (84%) were widely reported, critical prognostic markers such as cusp prolapse (59%) and root asymmetry (45%) were frequently omitted, and commissural angle was almost entirely neglected (1.8%). Assessment of BAV-associated aortopathy revealed a striking discrepancy in segmental evaluation: although 94.4% of specialists routinely measured the aortic root at the sinuses of Valsalva, only 31% performed habitual measurements of the distal tubular aorta, despite it being the most common site of aneurysmal dilation in this population. Measurement techniques also varied: 57% used aortic diameter indexed to body surface area (BSA), but only 6.4% incorporated Z-scores or height-indexed diameters in their reports, critical for younger and obese patients. For quantifying aortic regurgitation, the most valued parameters were diastolic reverse flow in the abdominal aorta (70.4%) and unexplained left ventricular dilatation (62%). Regarding institutional resources, 73.1% had access to multi-modality imaging (CT/MRI), and Heart Team availability was limited to 52.7%, with significantly lower access in non-tertiary centers. Conclusions This survey revealed a mismatch between clinical evidence and professional practice. Despite the distal tubular aorta being the most frequent site of dilation in BAV-associated aortopathy, only 31% of certified imaging specialists routinely measured this segment. Furthermore, the negligible use of Z-scores and height-indexed diameters in their reports and the underreporting of high-risk morphological features suggests a fragmented adherence to international standards. These findings underscore an urgent need for national standardized imaging protocols to ensure that high-risk aortic segments are not overlooked, alongside the expansion of multidisciplinary Heart Teams to manage these complex patients.Measurement techniques for aortic assessmentTable 1.