A 55-year-old man with a known bicuspid aortic valve undergoes a contrast-enhanced cardiac CT for pre-procedural planning before valve replacement. Which of the following findings on a short-axis view through the aortic root is MOST characteristic of a bicuspid aortic valve?

• A Three separate leaflets with a triradiate commissural pattern and no raphe
• B A dome-shaped systolic bowing of the leaflets into the left ventricular outflow tract
• C Severe leaflet calcification restricted to the free edges with restricted diastolic closure
• D Two leaflets with a single raphe and a fish-mouth (elliptical) orifice in systole ✓

Explanation

On CT short-axis imaging of the aortic root, a bicuspid aortic valve is characterized by two leaflets, often with a fibrous raphe at the site of the fused commissure, producing a fish-mouth or elliptical orifice in systole. This is the hallmark morphological finding. Option A describes a normal tricuspid valve. Option B describes systolic anterior motion or a parachute mitral valve appearance, not BAV. Option C describes senile calcific degeneration of a tricuspid aortic valve, not the congenital bicuspid morphology.

Reference: Braunwald's Heart Disease, 12th ed.

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