Investigation of Patients With BAV Requiring Valve and/or Aortic Repair (GISSI Outliers VAR)
Investigation of Patients With BAV Requiring Valve and/or Aortic Repair (GISSI Outliers VAR)
Prospective longitudinal study on four small groups of surgical patients affected by: BAV
 with isolated regurgitation, BAV associated with aorta dilatation, or both and BAV with
 isolated stenosis in over 60 year-old patients.

 The aim of the study is to select homogeneous small groups of surgical patients with the same
 subtype of BAV and same aortic behaviour and identify markers/predictors of
 favorable-unfavorable aortic wall evolution to evaluate if there is a BAV phenotype more
 likely to be considered at high risk for aortic degeneration.
The aim of the study is to select homogeneous small groups of surgical patients with the same
 subtype of BAV and same aortic behaviour and identify markers/predictors of
 favorable-unfavorable aortic wall evolution to evaluate if there is a BAV phenotype more
 likely to be considered at high risk for aortic degeneration. The study will focus on
 multiple aspects of BAV disease. What follows will be considered and combined:

 Aortic valve, aorta root and ascending aorta morphology The use of two- (2DE) and
 three-dimensional (3DE) trans-thoracic (TTE) and/or transoesophageal (TOE) echocardiography
 can identify all kind of BAV morphology (leaflet position and coronary ostia displacement).
 It also gives quali- quantitative information about root and ascending aorta morphology and
 size.

 BAV genetics Recently, missense mutations in the NOTCH1 gene have been shown to be associated
 with calcific aortic valve disease plus BAV. However mutations in the NOTCH1 gene only
 partially explain the presence of BAV in the absence of other syndromic diseases (i.e. Marfan
 Syndrome, Loeys Dietz Syndrome type I and II and Ehlers Danlos type IV Syndrome).

 BAV Histology In all enrolled patients, during operation, tissue samples will be collected
 from valve cusps (in case of valve involvement), aortic wall (aortic root, concavity or
 convexity of ascending aorta) or from both of them. Samples will be analyzed in order to
 classify medial and intimal disruption and changes.

 Study Design and Setting of the Study The first step will consist in enrolling patients with
 echocardiographic diagnosis of BAV and indication for surgery. From the echo data, aortic
 valve, as well as aortic root and ascending aorta morphology will be assessed in order to
 classify patients in each phenotypic pattern. The echo images from participating centres will
 be sent to an echo core lab for quali- quantitative analysis (see below) and all data will be
 recorded in a specific database.

 The second step will consider first-degree relatives of each enrolled patient. The
 investigators will ask every first degree relative to perform a screening TTE in order to
 find out, according to familiar aetiology of BAV, the presence of BAV and/or associated
 disease (aortic root or ascending aorta enlargement or coronary ostia displacement).

 The third step will consist in collecting blood samples from each patient and from any of
 first-degree relatives with BAV diagnosis. BAV-specific genetic tests will be performed and
 all data will be recorder in a specific database.

 The fourth intraoperative step will consist in :

 1. performing a 3D TOE in order to study the geometry and the dynamic behaviour of the
 aortic valve and root and

 2. in collecting surgical tissue samples: during operation there will be described
 precisely the anatomy of the valve and the aorta in detail; then, from the usual site of
 surgery, there will be collected valve and aortic wall samples in order to perform
 histological, immunohistochemical and genetics tests.

 Blood and surgical samples will be stored in a bio-bank for future analysis related to this
 protocol.
Inclusion Criteria:

 -  Men and women over 18 years-old and under the age of 60 (age selection will prevent
 from enrolling patient with age-related valve and aortic wall degeneration). For the
 BAV stenosis group there will be considered patients over 60 years-old: including the
 most frequent form of BAV disease and the commonest age, this group could be used as a
 control group compared to the outlier ones.

 -  Echo diagnosis of BAV and indication to surgery:

 BAV with isolated regurgitation, BAV with normal valvular function but associated aorta
 dilatation, BAV with both valve regurgitation and aortic dilatation BAV with isolated
 stenosis

 - Signed informed consent

 Exclusion Criteria:

 -  Patient with a previous cardiac or great vessels surgery

 -  coexistent coarctation of the aorta

 -  non-associated cardiac diseases: valve disease (other than aortic), ischemic disease,
 congenital heart disease.

 -  Marfan syndrome or other connective tissue disorders involving aortic valve and aortic
 wall disease (history of disease or clinical signs).

 -  Other conditions/circumstances likely to lead to poor study adherence (e.g.
 psychological or organizational reasons).

 -  Serious disease other than aortic, severely limiting life expectancy.

 -  Patients who refuse to give informed consent