{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T01:19:54Z","timestamp":1792113594992,"version":"4.4.0"},"reference-count":34,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2025,12,28]],"date-time":"2025-12-28T00:00:00Z","timestamp":1766880000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Department of Experimental and Clinical Medicine, University of Florence institutional funding","award":["RICATEN2024"],"award-info":[{"award-number":["RICATEN2024"]}]},{"name":"Department of Experimental and Clinical Medicine, University of Florence institutional funding","award":["RICATEN2025"],"award-info":[{"award-number":["RICATEN2025"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Bicuspid aortic valve (BAV) is the most common congenital heart defect, and its complications (namely, dilatation of the thoracic ascending aorta) raise concerns regarding the proper timing of aortic surgery. The study aim is to unravel the genetic basis of BAV and its complications through a high-throughput sequencing (HTS) approach and segregation analysis if family members were available. Methods: Fifty-two Italian BAV patients were analyzed by HTS using the Illumina MiSeq platform. Targeted sequencing of 97 genes known to be or plausibly associated with connective tissue disorders or aorthopathy was performed. Thirty-five first-degree relatives of N = 10 probands underwent mutational screening for variants identified in the index cases. Results: HTS identified 194 rare (MAF &lt; 0.01) variants in 63 genes. Regarding previously reported genes, five NOTCH1 variants in four BAV patients, four FBN1 variants in two patients and one GATA5 variant in one patient were identified. Interestingly, among further loci, the possible contribution of PDIA2, LRP1 and CAPN2 was suggested by (a) the increased prevalence of rare genetic variants, independently from their ACMG classification in the whole BAV cohort, and (b) segregation analyses of variants identified in family members. Moreover, the present data also suggest the possible contribution of rare variants to BAV complications, specifically MYLK in aortic dilatation, CAPN2 in BAV calcification and VHL and AGGF1 in valve stenosis. Conclusions: Our results underline clinical and genetic diagnosis complexity in traits considered monogenic, such as BAV, but characterized by variability in disease phenotypic expression (incomplete penetrance), as well as the contribution of different major and modifier genes to the development of complications.<\/jats:p>","DOI":"10.3390\/diagnostics16010104","type":"journal-article","created":{"date-parts":[[2025,12,28]],"date-time":"2025-12-28T23:54:36Z","timestamp":1766966076000},"page":"104","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Bicuspid Aortic Valve: Old and Novel Gene Contribution to Disease Onset and Complications"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0990-4618","authenticated-orcid":false,"given":"Elena","family":"Sticchi","sequence":"first","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"},{"name":"Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi Hospital, 50139 Florence, Italy"},{"name":"Atherothrombotic Diseases Center, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosina","family":"De Cario","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-6517-8399","authenticated-orcid":false,"given":"Samuele","family":"Suraci","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ada","family":"Kura","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8281-4734","authenticated-orcid":false,"given":"Martina","family":"Berteotti","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"},{"name":"Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi Hospital, 50139 Florence, Italy"},{"name":"Atherothrombotic Diseases Center, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-9419-0812","authenticated-orcid":false,"given":"Lapo","family":"Squillantini","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giulia","family":"Barbieri","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca","family":"Orsi","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Pia","family":"Fugazzaro","sequence":"additional","affiliation":[{"name":"Cardiology Service, CMSR Veneto Medica, 36077 Altavilla Vicentina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefania","family":"Colonna","sequence":"additional","affiliation":[{"name":"Outpatient Cardiology Unit, Health District 1 ULSS 6, Vigonza and Carmignano di Brenta, 35128 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6669-420X","authenticated-orcid":false,"given":"Francesca","family":"Gensini","sequence":"additional","affiliation":[{"name":"Medical Genetics Unit, Department of Experimental and Clinical Biomedical Sciences \u2018Mario Serio\u2019, University of Florence, 50139 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2686-1592","authenticated-orcid":false,"given":"Erika","family":"Fiorentini","sequence":"additional","affiliation":[{"name":"Medical Genetics Unit, Department of Experimental and Clinical Biomedical Sciences \u2018Mario Serio\u2019, University of Florence, 50139 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6857-5861","authenticated-orcid":false,"given":"Anna Maria","family":"Gori","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"},{"name":"Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi Hospital, 50139 Florence, Italy"},{"name":"Atherothrombotic Diseases Center, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rossella","family":"Marcucci","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"},{"name":"Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi Hospital, 50139 Florence, Italy"},{"name":"Atherothrombotic Diseases Center, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guglielmina","family":"Pepe","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4723-6646","authenticated-orcid":false,"given":"Stefano","family":"Nistri","sequence":"additional","affiliation":[{"name":"Cardiology Service, CMSR Veneto Medica, 36077 Altavilla Vicentina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8708-9444","authenticated-orcid":false,"given":"Betti","family":"Giusti","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy"},{"name":"Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi Hospital, 50139 Florence, Italy"},{"name":"Atherothrombotic Diseases Center, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"832","DOI":"10.1016\/j.jacc.2014.04.073","article-title":"A roadmap to investigate the genetic basis of bicuspid aortic valve and its complications: Insights from the International BAVCon (Bicuspid Aortic Valve Consortium)","volume":"64","author":"Prakash","year":"2014","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1016\/j.ijcard.2011.12.009","article-title":"Association of Marfan syndrome and bicuspid aortic valve: Frequency and outcome","volume":"155","author":"Nistri","year":"2012","journal-title":"Int. J. Cardiol."},{"key":"ref_3","first-page":"581","article-title":"Bicuspid aortic valves in hearts with other congenital heart disease","volume":"4","author":"Duran","year":"1995","journal-title":"J. Heart Valve Dis."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1016\/j.jtcvs.2016.10.088","article-title":"Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results","volume":"153","author":"Patel","year":"2017","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"180297","DOI":"10.1155\/2012\/180297","article-title":"Genetic insights into bicuspid aortic valve formation","volume":"2012","author":"Laforest","year":"2012","journal-title":"Cardiol. Res. Pract."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Giusti, B., Sticchi, E., De Cario, R., Magi, A., Nistri, S., and Pepe, G. (2017). Genetic Bases of Bicuspid Aortic Valve: The Contribution of Traditional and High-Throughput Sequencing Approaches on Research and Diagnosis. Front. Physiol., 8.","DOI":"10.3389\/fphys.2017.00612"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2219","DOI":"10.1016\/j.ajhg.2024.08.001","article-title":"Whole-exome sequencing uncovers the genetic complexity of bicuspid aortic valve in families with early-onset complications","volume":"111","author":"Mansoorshahi","year":"2024","journal-title":"Am. J. Hum. Genet."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1104","DOI":"10.1001\/jama.2011.1286","article-title":"Incidence of aortic complications in patients with bicuspid aortic valves","volume":"306","author":"Michelena","year":"2011","journal-title":"JAMA"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"178","DOI":"10.31083\/j.rcm2406178","article-title":"Implications of Bicuspid Aortic Valve Disease and Aortic Stenosis\/Insufficiency as Risk Factors for Thoracic Aortic Aneurysm","volume":"24","author":"Jabagi","year":"2023","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1016\/j.acra.2011.10.012","article-title":"Incidental aortic valve calcification on CT scans: Significance for bicuspid and tricuspid valve disease","volume":"19","author":"Hope","year":"2012","journal-title":"Acad. Radiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1007\/s11739-020-02458-1","article-title":"When should a rare inherited connective tissue disorder be suspected in bicuspid aortic valve by primary-care internists and cardiologists? Proposal of a score","volume":"16","author":"Pepe","year":"2021","journal-title":"Intern. Emerg. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1093\/eurheartj\/ehab395","article-title":"2021 ESC\/EACTS Guidelines for the management of valvular heart disease","volume":"43","author":"Vahanian","year":"2022","journal-title":"Eur. Heart J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"4635","DOI":"10.1093\/eurheartj\/ehaf194","article-title":"2025 ESC\/EACTS Guidelines for the management of valvular heart disease","volume":"46","author":"Praz","year":"2025","journal-title":"Eur. Heart J."},{"key":"ref_14","unstructured":"VASCERN (2025, December 13). HTAD-WG. Available online: https:\/\/vascern.eu\/group\/heritable-thoracic-aortic-diseases-2\/clinical-decision-support-tools\/clinical-practice-guidelines\/."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"718","DOI":"10.1016\/j.amjcard.2005.04.051","article-title":"Frequency of bicuspid aortic valve in young male conscripts by echocardiogram","volume":"96","author":"Nistri","year":"2005","journal-title":"Am. J. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1016\/0002-9149(89)90430-X","article-title":"Two-dimensional echocardiographic aortic root dimensions in normal children and adults","volume":"64","author":"Roman","year":"1989","journal-title":"Am. J. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"914","DOI":"10.1016\/j.amjcard.2014.06.024","article-title":"Reference values for echocardiographic assessment of the diameter of the aortic root and ascending aorta spanning all age categories","volume":"114","author":"Campens","year":"2014","journal-title":"Am. J. Cardiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1056\/NEJM200008313430903","article-title":"Predictors of outcome in severe, asymptomatic aortic stenosis","volume":"343","author":"Rosenhek","year":"2000","journal-title":"N. Engl. J. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1038\/gim.2015.30","article-title":"Standards and guidelines for the interpretation of sequence variants: A joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology","volume":"17","author":"Richards","year":"2015","journal-title":"Genet. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"8386123","DOI":"10.1155\/2018\/8386123","article-title":"Bicuspid Aortic Valve: Role of Multiple Gene Variants in Influencing the Clinical Phenotype","volume":"2018","author":"Sticchi","year":"2018","journal-title":"Biomed. Res. Int."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Wooten, E.C., Iyer, L.K., Montefusco, M.C., Hedgepeth, A.K., Payne, D.D., Kapur, N.K., Housman, D.E., Mendelsohn, M.E., and Huggins, G.S. (2010). Application of gene network analysis techniques identifies AXIN1\/PDIA2 and endoglin haplotypes associated with bicuspid aortic valve. PLoS ONE, 5.","DOI":"10.1371\/journal.pone.0008830"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"420","DOI":"10.1016\/j.amjcard.2015.10.058","article-title":"Identification of Gender-Specific Genetic Variants in Patients With Bicuspid Aortic Valve","volume":"117","author":"Dargis","year":"2016","journal-title":"Am. J. Cardiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.bcp.2010.09.018","article-title":"Signaling through LRP1: Protection from atherosclerosis and beyond","volume":"81","author":"Boucher","year":"2011","journal-title":"Biochem. Pharmacol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1365","DOI":"10.2119\/molmed.2011.00286","article-title":"Unraveling divergent gene expression profiles in bicuspid and tricuspid aortic valve patients with thoracic aortic dilatation: The ASAP study","volume":"17","author":"Folkersen","year":"2011","journal-title":"Mol. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1186\/s40246-022-00405-z","article-title":"Identification of recurrent variants implicated in disease in bicuspid aortic valve patients through whole-exome sequencing","volume":"16","author":"Chen","year":"2022","journal-title":"Hum. Genom."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1016\/j.ajhg.2011.10.002","article-title":"Abdominal aortic aneurysm is associated with a variant in low-density lipoprotein receptor-related protein 1","volume":"89","author":"Bown","year":"2011","journal-title":"Am. J. Hum. Genet."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1161\/CIRCRESAHA.107.160077","article-title":"Targeting the calpain\/calpastatin system as a new strategy to prevent cardiovascular remodeling in angiotensin II-induced hypertension","volume":"102","author":"Letavernier","year":"2008","journal-title":"Circ. Res."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"983","DOI":"10.1161\/CIRCULATIONAHA.108.843516","article-title":"Proteomic analysis in aortic media of patients with Marfan syndrome reveals increased activity of calpain 2 in aortic aneurysms","volume":"120","author":"Pilop","year":"2009","journal-title":"Circulation"},{"key":"ref_29","first-page":"523","article-title":"The role of extracellular and intracellular proteolytic systems in aneurysms of the ascending aorta","volume":"31","author":"Werner","year":"2016","journal-title":"Histol. Histopathol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.bbadis.2010.10.002","article-title":"NOTCH1 missense alleles associated with left ventricular outflow tract defects exhibit impaired receptor processing and defective EMT","volume":"1812","author":"Riley","year":"2011","journal-title":"Biochim. Biophys. Acta"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Bonachea, E.M., Zender, G., White, P., Corsmeier, D., Newsom, D., Fitzgerald-Butt, S., Garg, V., and McBride, K.L. (2014). Use of a targeted, combinatorial next-generation sequencing approach for the study of bicuspid aortic valve. BMC Med. Genom., 7.","DOI":"10.1186\/1755-8794-7-56"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Ma, M., Li, Z., Mohamed, M.A., Liu, L., and Wei, X. (2021). Aortic root aortopathy in bicuspid aortic valve associated with high genetic risk. BMC Cardiovasc. Disord., 21.","DOI":"10.1186\/s12872-021-02215-y"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e005889","DOI":"10.1161\/JAHA.117.005889","article-title":"Targeting AGGF1 (angiogenic factor with G patch and FHA domains 1) for Blocking Neointimal Formation After Vascular Injury","volume":"6","author":"Yao","year":"2017","journal-title":"J. Am. Heart Assoc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1002\/ajh.26920","article-title":"JAK2 unmutated erythrocytosis: 2023 Update on diagnosis and management","volume":"98","author":"Gangat","year":"2023","journal-title":"Am. J. Hematol."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/1\/104\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,29]],"date-time":"2025-12-29T00:07:06Z","timestamp":1766966826000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/1\/104"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,28]]},"references-count":34,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["diagnostics16010104"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16010104","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,28]]}}}