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\begin{document}

\title{Bicuspid aortic valve caused subaortic stenosis with bulging of valve
calcification through subaortic area in a young patient}



\author[1]{Burak Acar}%
\author[1]{Ozgur Cakir}%
\author[2]{Abdullah Dogan}%
\author[1]{Oguz Omay}%
\author[1]{Tayfun Sahin}%
\author[1]{Yavuz Şadan}%
\author[2]{Riza Türköz}%
\affil[1]{Kocaeli University Medical Faculty}%
\affil[2]{Acibadem Bakirkoy Hospital}%


\vspace{-1em}



  
  \date{June 04, 2024}


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\selectlanguage{english}
\begin{abstract}
Bicuspid aortic valve is the most common congenital cause for the
development of aortic valve calcification and stenosis. Calcification
cause valvular stenosis or valvular insufficiency due to coaptation
failure. We report a unique case of calcification of bicuspid valve was
extending to left ventricular outflow tract and attached to
interventricular septum which caused subvalvular stenosis.%
\end{abstract}%



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\subsection*{Title page-Case Image}

{\label{title-page-case-image}}

\textbf{Bicuspid aortic valve caused subaortic stenosis with bulging of
valve calcification through subaortic area in a young patient}

\textbf{Running title:} Bicuspid Aorta and Subaortic Stenosis

\textbf{Keywords:} bicuspid aorta, calcification, surgery, subaortic
stenosis

\textbf{Authors:}

Acar Burak, MD,(1) \#

Cakir Ozgur, MD (2) \#

Dogan Abdullah, (3) MD

Omay Oguz MD, (4)\#\#

Sahin Tayfun (1),MD)\#\#

Yavuz \selectlanguage{polish}Ş\selectlanguage{english}adan, (4) \#\#

T\selectlanguage{ngerman}ürköz R\selectlanguage{polish}ı\selectlanguage{english}za, (3) MD)\#\#

\# Assoc Prof

\#\#Prof Dr

\textsuperscript{1}Kocaeli University Medical Faculty, Department of
Cardiology, Kocaeli, Turkey.

\textsuperscript{2} Kocaeli University Medical Faculty, Department of
Radiology, Kocaeli, Turkey.

\textsuperscript{3} Department of Cardiovascular Surgery, Acibadem
Bakirkoy Hospital, \selectlanguage{polish}İ\selectlanguage{english}stanbul, Turkey.

\textsuperscript{4} Kocaeli University Medical Faculty, Department of
Cardiovascular Surgery, Kocaeli, Turkey.

\textbf{Corresponding Author:}

Burak Acar, Assoc Prof, MD

Kocaeli University Medical Faculty, Department of Cardiology, Umuttepe
Yerleskesi, 41380, Kocaeli, Turkey.

Communication number: +90 262 3038683

Fax: +90 262 3038003;

\textbf{E-mail} : burakacarmd@yahoo.com

\textbf{Bicuspid aortic valve caused subaortic stenosis with bulging of
valve calcification through subaortic area in a young patient}

\textbf{Abstract}

Bicuspid aortic valve is the most common congenital cause for the
development of aortic valve calcification and stenosis. Calcification
cause valvular stenosis or valvular insufficiency due to coaptation
failure. We report a unique case of calcification of bicuspid valve was
extending to left ventricular outflow tract and attached to
interventricular septum which caused subvalvular stenosis.

\textbf{Case Image}

A 28-year-old man admitted our outpatient cardiology clinic with
exertional dyspnea. He has been diagnosed with bicuspid aortic valve for
five years ago, however, he did not go routine follow-up. ~Cardiac
examination revealed regular pulse (90 beats/min) with normal blood
pressure and a 3/6 systolic crescendo-decrescendo murmur loudest at the
right upper sternal border. Electrocardiography revealed normal sinus
rhythm with left ventricular hypertrophy. Transthoracic echocardiography
showed bicuspid aorta with aortic aneurysm and severe aortic
regurgitation. Interestingly, severe calcification of the valve was
extending to subvalvular area and causing severe left ventricular
outflow tract obstruction (subaortic stenosis)(Figure 1, Video 1).
Transesophageal echocardiography and computed tomography revealed that
calcification was starting from coronary cusp and extending to the
interventricular septum and caused severe septal hypertrophy (Figure 2,
Video 2). The patient underwent aortic valve replacement with mechanical
prosthesis and thoracic aorta replacement with a Dacron graft after
heart team discussion. The patient was well after surgery and discharged
without any problem (Figure 3, Video 3).

BAV is the most common congenital cause for the development of aortic
valve calcification \textsuperscript{1} . Calcification of BAV has
different genetic tendency in contrast to tricuspid
valves\textsuperscript{2}. BAV mostly undergo strain, and wall shear
stress on their edges of the leaflets during opening
\textsuperscript{3}, however, in this case calcification started from
annularly and extending to LVOT and basal septum. Besides the valve
calcifications and stenosis, subaortic stenosis caused patient's
symptoms.

\textbf{Funding :} None

\textbf{Acknowledgement:} Informed consent was obtained from the patient
to use of images for academic purposes.

\textbf{Conflict of interest} : None

References

\textbf{Figure Legends}

Figure 1. (A)Parasternal long axis view of transthoracic
echocardiography (TTE) showing calcification of aortic valve extending
to the interventricular septum (arrows). (B) Continuous wave doppler of
TTE showing severe gradient in left ventricular outflow tract (C) Apical
view of TTE showing calcification. RA, right atrium; LA, left atrium;
RV, right ventricle; LV, left ventricle; Ao, aorta.

Figure 2. (A, B) Transesophageal echocardiography (TEE) revealing
calcification (arrows) attached to the interventricular septum and
causing subaortic stenosis (C,D) Computed tomography showing eccentric
calcification of aortic valve. RA, right atrium; LA, left atrium; LV,
left ventricle; Ao, aorta.

Figure 3. (A, B) Intraoperative view of aortic valve and partially
resected calcification of interventricular septum. (C, D) Postoperative
TTE showing mechanical aortic valve and diminished LVOT gradient. Video
2. TTE after operation. ; LA, left atrium; LV, left ventricle; Ao,
aorta.

\textbf{Video Legends}

Video 1. Transthoracic echocardiography before surgery showing bicuspid
aorta and huge calcification attached to septum

Video 2. Transesophageal echocardiography showing subvalvular stenosis
and calcification.

Video 3. Transthoracic echocardiography after aortic valve replacement
and correction of subvalvular stenosis with resection of calcification.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

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