Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station. Today, I would like to talk about, I'm keen to talk about my cuspid aortic valve. Well, what does that mean? Well, first of all, the aortic valve is the valve that comes out of the heart into the aorta, which is the main blood vessel within the body. And normally that valve, the aortic valve, is a tricuspid valve, a three-leaflet, tri-three-leaflet valve, and opens in a balanced way. Imagine, if you like a Mercedes-Benz sign, each little cusp of the valve being pushed open as the heart squeezes blood out, and then it flops back in, like a little cusp, and all three of them come together. Well, in some individuals, You can have two of those cusps fuse and it becomes a functional bicuspid valve. So only two leaflets opening rather than three. Very, very rarely you can have four leaflets as well. I've never actually seen that clinically, but it does occur. Let's stick with bicuspid valves today because they're our area of interest. off balance a bit like if you had a car engine that was running slightly off balance instead of all four cylinders working properly three cylinders were working properly and one wasn't sort of throws things out a bit well bicuspid aortic valve is that sort of two leaflet opening And that means that it's not quite designed the same way and can be subject to more wear and tear than you might expect from a properly designed, the tri-leaflet aortic valve that we all have. Well, where does it come from? Well, in general terms, it's something you're born with. It's a genetic predisposition and bicuspid aortic valve is considered. the most common of the congenital cardiac abnormalities. It's really very hard to detect in someone who's just walking around and looks fit and well. And really the early part of having a bicuspid aortic valve for an individual, the young time in their life, is really generally unaffected at all and in fact this condition normally only becomes apparent in mid to late adulthood 40s 50s 60s and beyond and is generally characterized by the aortic valve because of its unbalanced function wearing out a little bit earlier than a normal valve so these people may well progress to a new aortic valve sooner than someone with a normal tricuspid valve. Now, it's worth remembering also that it can be picked up in a couple of situations. One of them is, because it's genetic, if there's a family history. So if there is a family history of bicuspid aortic valve in your family and you share that with your GP, he may well send you to a cardiologist to get that checked. And that's not a bad idea. And in fact, I saw someone... Just like that today, I was treating the father. We found the bicuspid aortic valve, which is under surveillance, and I put to him, look, it's really important to check the children because it is genetic. I've seen two of his children. One of them has bicuspid aortic valve, the one I saw today, and his other child was free of it. The other time it could be picked up is by the auscultation or the listening. murmur because that valve is slightly off angle there may be turbulence as the blood flows over the valve and that turbulence is the irregular bubbly sort of flow hemodynamically a bit like a babbling brook and that makes a murmur so that somewhat chaotic acceleration of blood over the valve could make a murmur so maybe A murmur being heard by the doctor could be a clue. A family history could be a clue. But sometimes we scan the heart for other purposes and find it incidentally. And lo and behold, there's the bicuspid aortic valve. Well, one of the things to ask is, in isolation, is this a problem? Well, we know that the valve can wear out a bit early. But we also know that in a reasonable number of people with bicuspid aortic valve, there is what we call an aortopathy. Now, that's a bit of a long word, but the aorta, which is the main blood vessel that comes out of the heart that the aortic valve is at the beginning of, that aorta can be weakened. connective tissue the structures that hold that aorta together when that's not working as well as it should we call that an aortopathy so one of the things that we see with bicuspid aortic valves can be the dilation or the enlargement of the aorta just above the heart so we look at that as well well how do we treat uh bicuspid aortic valve or for that matter um dilated aorta well if the valve's working well there's not really much we can do we simply need to track it and follow it with some regularity and see how it progresses because what we know is if that valve gets sticky and we have hemodynamic measurements which show us that it's severe or narrowed or leaky then we would change that valve so we track The heart, particularly with ultrasound, which gives us very good images of how the heart valve moves, but also how it leaks and some of the pressures over the valve. So number one with bicuspid aortic valve is surveillance and we'll follow that valve closely, making sure we know exactly the right time for timing of valve replacement. In regard to the aorta, we know that keeping the blood pressure down is really important. And it seems that not only keeping the blood pressure down is important, but the blood pressure agents we use for keeping the blood pressure down can make a difference. So it turns out our research is telling us that the ACE inhibitors, the drugs like perindipril or ramipril, tend to be really good for slowing down expansion of that aorta. We also know that the angiotensin receptor blockers, things like candesartan, mycardis, valsartan, similarly slow down progression of that expansion of the aorta over and above the blood pressure lowering effect. So we try and slow progression of the dilation of the root. We also track the valve and make sure we know exactly when it needs to be operated on. When the time comes, One of the things we do to measure the aorta most accurately is using a CT scanner. So we can use ultrasound to look at the heart, and in particular the aorta, but the aorta can be quite hard to visualise using ultrasound. And we have to get a measurement that's truly at 90 degrees to measure it most accurately. So generally, to get a double measurement, and a tradesman would understand this, measure twice and cut once, we measure with a CT scanner as well because we get beautiful ability to line up the anatomy and measure that aorta very accurately. We talk about replacement of the aorta if we're going to replace the valve or do something to the valve surgically. When the aorta is about 45 millimetres in diameter, normal somewhere around 35 to 38, generally under 40, but 45 millimetres dilated with a bicuspid aortic valve, we would fix the valve and the aorta at the same time. So that's a pretty big operation. Occasionally, though, we fix the aorta and spare the valve. So that's an interesting situation as well. also sometimes not need to replace the aorta because it's not dilated and all we need to do is replace the valve and occasionally that can be done either through a surgical procedure an open heart surgical procedure or it can also be done up through the leg using a transcutaneous aortic valve implantation which we call a TAVI. So A couple of ways we can deal with the aortic valve if it's the aortic valve alone. So, very interesting area, bicuspid aortic valve plus aortopathy. In summary, most common of the cardiac congenital conditions, it is the most common, it's two leaflets to the aortic valve rather than three. The aorta tends to not be as... robust as a normal person's aorta so it's more prone to dilate so we have to be aware of that we do want to keep the blood pressure down protects the valve a bit but it also looks after that aorta and then when it comes time to fix things up we have the important task of choosing whether it's the valve alone that needs to be fixed the aorta alone that needs to be fixed or both together If it is in your family, I strongly suggest that you speak with your GP and let the GP know because it is the sort of condition that we should be screening families and being very careful to delineate exactly what's going on. Why? Because if that aorta gets too big, it can rupture or dissect and those consequences can be lethal. Having said that, though, if we find it early, we manage it properly. It is a condition that average life expectancy really shouldn't be altered too much at all. So I hope you found that informative. I hope you found that interesting. If you have any queries or questions, please don't hesitate to be in touch. If you have any ideas for future podcasts, again, also let us know. Again, really appreciate you joining us. this information informative interesting and till next time i wish you good health and please don't die from a heart attack goodbye You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
