Heart, Lung and Circulation

Inter-Ethnic Differences in Valvular Dysfunction, Aortopathy, and Progression of Disease of an Asian Bicuspid Aortic Valve Population

Published:November 26, 2021DOI:


      There are differences in bicuspid aortic valve (BAV) characteristics between Asian and European populations, but little is known about the inter-ethnic differences in bicuspid valve function and aortic root dimensions within the diverse Asian population.


      From 1992–2017, 562 patients with index echocardiographic diagnosis of BAV in a tertiary health care institution in Singapore were analysed according to their ethnic groups: Chinese, Malay, Indian, and Eurasian. Study outcomes included BAV complications (infective endocarditis, aortic dissection) and clinical outcomes (aortic valve surgery, aortic root surgery, all-cause mortality). Total events were defined as composite outcome of all BAV complications and outcomes. Aortic dimensions and aortic dilatation rates were also studied.


      There were 379 (67.5%) Chinese, 79 (14.0%) Malay, 73 (13.0%) Indian, and 31 (5.5%) Eurasian patients. Type 1 BAV (58.5%) was the most prevalent BAV morphology, with moderate-to-severe aortic stenosis (AS) (36.8%) being the most common complication in the overall population. There was a higher prevalence of type 0 BAV in Chinese and Indian groups, and type 1 BAV with fusion of left-right coronary cusp in Eurasian and Malay groups (p=0.082). There was no difference in significant AS among groups. The highest prevalence of moderate-to-severe aortic regurgitation was observed amongst the Eurasian group, followed by Chinese, Indian, and Malay groups (p=0.033). The Chinese group had the largest mean indexed diameters of the aortic root. Multivariable linear regression demonstrated that only the Chinese had significantly larger indexed diameters in the aortic annulus, sinotubular junction (STJ), and ascending aorta (AA), relative to the Eurasian group, after adjusting for age, sex, smoking, hypertension, hyperlipidaemia, diabetes, and aortic regurgitation. On follow-up echocardiography, there was a trend towards the highest dilatation rates of sinus of Valsalva and STJ amongst Indian, and AA amongst Malay groups. Kaplan-Meier curves showed the highest incidence of total events amongst Chinese, followed by Malay, Indian and Eurasian (log-rank=9.691; p=0.021) patients.


      There were differences in BAV morphology, valve dysfunction, aortopathy, and prognosis within the Asian population. Chinese patients had one of the highest prevalence of significant aortic regurgitation, with the largest aortic dimensions and worst outcomes compared with other Asian ethnicities. Closer surveillance is warranted in BAV patients within the Asian population.

      Central Illustration


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hoffman J.I.
        • Kaplan S.
        The incidence of congenital heart disease.
        J Am Coll Cardiol. 2002; 39: 1890-1900
        • Hahn R.T.
        • Roman M.J.
        • Mogtader A.H.
        • Devereux R.B.
        Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves.
        J Am Coll Cardiol. 1992; 19: 283-288
        • Rahbab Z.
        • Faquir N.E.
        • Tchetche D.
        • Delgado V.
        • Kodali S.
        • Vollema E.M.
        • et al.
        Expanding the indications for transcatheter aortic valve implantation.
        Nat Rev Cardiol. 2020; 17: 75-84
        • Mylotte D.
        • Lefevre T.
        • Sondergaard L.
        • Watanabe Y.
        • Modine T.
        • Devir D.
        • et al.
        Transcatheter aortic valve replacement in bicuspid aortic valve disease.
        J Am Coll Cardiol. 2014; 64: 2330-2339
        • Giannini F.
        • Baldetti L.
        • Gallone G.
        • Tzanis G.
        • Latib A.
        • Colombo A.
        Transcatheter valve replacement in Asia Pacific.
        J Am Coll Cardiol. 2018; 72: 3189-3199
        • Kong W.K.F.
        • Regeer M.V.
        • Poh K.K.
        • Yip J.W.
        • van Rosendael P.J.
        • Yeo T.C.
        • et al.
        Inter-ethnic differences in valve morphology, valvular dysfunction, and aortopathy between Asian and European patients with bicuspid aortic valve.
        Eur Heart J. 2018; 39: 1308-1313
        • Sievers H.H.
        • Schmidtke C.
        A classification system for the bicuspid aortic valve from 304 surgical specimens.
        J Thorac Cardiovasc Surg. 2007; 133: 1226-1233
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • Afilalo J.
        • Armstrong A.
        • Ernande L.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270
        • Bonow R.O.
        • Carabello B.A.
        • Chatterjee K.
        • de Leon Jnr A.C.
        • Flaxon D.P.
        • Freed M.D.
        • et al.
        ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2006; 48: e1-e48
        • Vahanian A.
        • Baumgartner H.
        • Bax J.
        • Butchart E.
        • Dion R.
        • Filippatos G.
        • et al.
        Guidelines on themanagementof valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology.
        Eur Heart J. 2007; 28: 230-268
        • Fazel S.S.
        • Mallidi H.R.
        • Lee R.S.
        • Sheehan M.P.
        • Liang D.
        • Fleischman D.
        • et al.
        The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch.
        J Thorac Cardiovasc Surg. 2008; 135: 901-907
        • Roman M.J.
        • Devereux R.B.
        • Kramer-Fox R.
        • O’Loughlin J.
        Two-dimensional echocardiographic aortic root dimensions in normal children and adults.
        Am J Cardiol. 1989; 64: 507-512
        • Kinoshita T.
        • Naito S.
        • Suzuki T.
        • Asai T.
        Valve phenotype and risk factors of aortic dilatation after aortic valve replacement in Japanese patients with bicuspid aortic valve.
        Circ J. 2016; 80: 1356-1361
        • Sun B.J.
        • Oh J.K.
        • Lee S.H.
        • Jang J.Y.
        • Lee J.H.
        • Lee S.
        • et al.
        Mid-term clinical outcomes in a cohort of asymptomatic or mildly symptomatic Korean patients with bicuspid aortic valve in a tertiary referral hospital.
        J Cardiovasc Imaging. 2019; 27: 105-118
        • Kong W.K.F.
        • Delgado V.
        • Poh K.K.
        Prognostic implications of raphe in bicuspid aortic valve anatomy.
        JAMA Cardiol. 2017; 2: 285-292
        • Rodrigues I.
        • Agapito A.F.
        • de Sousa L.
        • Oliveira J.A.
        • Branco L.M.
        • Galrinho A.
        • et al.
        Bicuspid aortic valve outcomes.
        Cardiol Young. 2017; 27: 518-529
        • Thanassoulis G.
        • Yip J.W.L.
        • Filion K.
        • Jamorski M.
        • Webb G.
        • Siu S.C.
        • et al.
        Retrospective study to identify predictors of the presence and rapid progression of aortic dilatation in patients with bicuspid aortic valves.
        Nat Clin Pract Cardiovasc Med. 2008; 5: 821-828
        • Eleid M.F.
        • Forde I.
        • Edwards W.D.
        • Maleszewski J.J.
        • Suri R.M.
        • Schaff H.V.
        • et al.
        Type A aortic dissection in patients with bicuspid aortic valves: clinical and pathological comparison with tricuspid aortic valves.
        Heart. 2013; 99: 1668-1674
        • Russo C.F.
        • Cannata A.
        • Lanfranconi M.
        • Vitali E.
        • Garatti A.
        • Bonacina E.
        Is aortic wall degeneration related to bicuspid aortic valve anatomy in patients with valvular disease?.
        J Thorac Cardiovasc Surg. 2008; 136: 937-942
        • Bissell M.M.
        • Hess A.T.
        • Biasiolli L.
        • Glaze S.J.
        • Loudon M.
        • Pitcher A.
        • et al.
        Aortic dilation in bicuspid aortic valve disease: flow pattern is a major contributor and differs with valve fusion type.
        Circ Cardiovasc Imag. 2013; 6: 499-507
        • Fernandes S.M.
        • Sanders S.P.
        • Khairy P.
        • Jenkins K.J.
        • Gauvreau K.
        • Lang P.
        • et al.
        Morphology of bicuspid aortic valve in children and adolescents.
        J Am Coll Cardiol. 2004; 44: 1648-1651
        • Asch F.M.
        • Yuriditsky E.
        • Prakash S.K.
        • Roman M.J.
        • Weinsaft J.W.
        • Weissman G.
        • et al.
        The need for standardized methods for measuring the aorta: multimodality core lab experience from the GenTAC registry.
        JACC Cardiovasc Imaging. 2016; 9: 219-226