Goal 2: Reduce Human Disease

Controversies exist regarding thoracic aortic disease imaging

Controversies exist regarding aortic disease imaging (the aorta as well as the aortic valve, including characterization in the presence of a bicuspid aortic valve (BAV)). Many imaging approaches are optimized for evaluation of coronary artery disease rather than aortic disease. Without accurate characterization, the degree of disease progression may be under estimated, patient symptoms may be discounted, and those who qualify for timely intervention may not receive it.

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Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

Imaging specifically tailored to BAV and the thoracic aortic aneurysm population is needed. This includes efforts to identify subtle forms of aortic valve malformation such as the “forme fruste” BAV as described by Sperling and Lubet.

1. Echocardiogram is a useful noninvasive imaging tool, however, it is believed to miss detection of as many as 50% of BAVs.

2. The exercise echocardiogram is useful for evaluation of wall motion abnormality, which may be present in those with coronary artery disease or other underlying sources of myocardial injury. However, this is not a common issue in those with BAV. Rather, accurate assessment of BAV function is necessary. Pressure testing for eccentric AI and the short axis view of the AV area, including clear visualization of both the open and closed valve, may not be employed, and consequently clarity of BAV functioning is not achieved.

3. Although there are open questions about aortic size relative to timing of elective surgery, size of the aorta is a diagnostic parameter, and is frequently done via CT imaging. CT images are typically captured in diastole, which is appropriate for coronary artery disease. However, the aorta will be undersized if measured in diastole. Measurement of the aorta in systole captures the aorta when most distended.

4. Other considerations, such as the presence of bovine arch anatomy, may not be noted, since their relevance may not be appreciated.

Feasibility and challenges of addressing this CQ or CC :

Current imaging technology is widely available in most medical communities. It is very feasible, by focusing on valvular and aortic conditions separately from coronary artery disease, to optimize imaging for these conditions and make these imaging approaches broadly available to patients.

Name of idea submitter and other team members who worked on this idea : Arlys Velebir, Bicuspid Aortic Foundation

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Idea No. 623