Aortic Bicuspid Valve in Flight Crew:

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Aortic Bicuspid Valve in Flight Crew 
Case-Reports andAeromedical Fitness

• Med Maj DELRUE
• Centre for Aviation Medicine
• Brussels
• Belgium

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Bicuspid Aortic Valve

• Most common cardiac defect
• Not only the valve but the whole aortic root
• 1 to 2 of the population
• Sex ratio 4 men/1 woman

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Normal Aortic Valvesystole
diastole
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Normal Aortic Valvesystole
diastole
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Bicuspid Aortic Valve
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Tricuspid

• Bicuspid

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Pathogenesis

• Defect fibrillin-1
• Hereditary? autosomal dominant with reduce
  penetrance
• screening of first degree relatives

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Type of Bicuspid Aortic Valve

• Prof Sievers (Luebeck Germany)

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Type of Bicuspid Aortic Valve

• Prof Sievers (Luebeck Germany)

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Type 1 L/R
A B
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RISKS of Bicuspid Ao Valve

• Serious complications 33
• Responsible for more complications and death than
  all others cardiac malformations
• Valvular stenosis
• Regurgitation
• Endocarditis
• Dilation and dissection Aortic Root (X9)

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Associations

• 50 of young people with normal bicuspid
  functioning valve have aortic dilation.
• coarctation of the aorta (50-80)
• septum anomalies
• Coronary anomalies
• More cerebral aneurysms ?

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Aortic Dilation and Bicuspid Aortic Valve

• Ascending Aorta
• D(mm) 310.16 age (years)
• Aneurysm
• 40 mm 20-year-old
• 45 mm 40 year-old
• 50 mm 60 year-old

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Follow-up

• Annual transthoracic of transesophageal
  echocardiography (valve function)
• Annual MRI (or CT angiography/aortic protocol) if
  gt40 mm or above age-related normal range
• (6 months if rapid progression)

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Ct scan
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Surgery Repair

• No valvular indication
• a. max diam gt 50 mm
• b. rapid growth progession of gt 0.5 cm/year
• b. maximum aortic cross-sectional area/body
  height gt 10 cm2/m

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Surgery Repair

• If valvular indication
• Max diameter gt45 mm
• Max aortic cross-sectional area/body gt 8-9 cm2/m
• More Attention if pregnancy, sudden death or
  aortic dissection in 1st degree relative

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Screening

• Auscultation - 60 Aortic regurgitation
• 16 of severe not diagnostiqued

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Screening?

• 2278 asymptomatic competitive Italian athletes
  (Age 31- 11 years) echocardiography
• 58 (2,5) BAV
• Only 9 normal function
• 45 Aortic regurgitation (14 mild, 25 moderate, 8
  severe)
• Stenosis 2
• Aortic root gt nl
• 15 disqualified for sport

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Case Report 1

• Jan 2013 Military Pilot applicant Male 18 year
• Sclerosis Aortic Valve
• Aortic Bicuspid valve
• Aortic Root dilatation 37 mm (nl 33.8 mm)
• Military Pilot Applicants systematic echography
• UNFIT

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• Classe 1 civilian ? EASA rules
• (European Aviation Safety Agency)
• May be assessed as fit if no other cardiac or
  aortic abnomaly
• Here proposal FIT with annual cardiologic
  review
• (outcome?) licensing autority

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Case Report 2

• Military ATC male 53 years
• 2002 aortic murmur detected
• echography Bicuspid Valve calcifications no
  dilation aorta Aortic regurgitation ¼
• Follow up every year echography
• 2011 dyspnea (stairs) progression of sclerosis
  valve (0.9 cm2) Aortic replacement Ross procedure
  (pulmonary autograft)
• 6 months unfit
• FIT with Annual cardiologic review

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Case report 3

• 41 year old helicopter pilot Federal Police
• 1990 military heli applicants no echography
• 2001 Aortic murmur echography Aortic Bicuspid
  Valve dilation Ao Root 41 mm
• Aorta Regurgitation 2/4
• Fit with 6 months cardiologic review
• 2005 Aortic Root 46 mm CT scan
• 2010 48.5 mm Classe 1 OML(multicrew) SIC
  Cardiologic evaluation 6 months
• 2011 51 mm unfit Classe 1

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Bentall

• video

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Read More

• Etz, Misfefd and al. Indication for Surgical
  Repair in Patients with Bicuspid Aortic Valve and
  Ascending Aortic Ectasia. Cardiol Res Pract 2012
  313879.
• Fedak, Verma and Al. Clinical and
  Pathophysiological Implications of a Bicuspid
  Aortic Valve. Circulation 2002 106 900-904.