Three cusps are better than two: bicuspid aortic valve and implications for military service.

Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation. It is an aortopathy and is associated with other congenital heart disease. Although there is no mortality increase with BAV, the natural history increases the risk of aortic valve disease, aortic dilatation and infective endocarditis over the time frame of a full military career. Military service theoretically increases the risk of aortic dilatation and endocarditis in BAV. Conversely, there are some who have BAV who would not suffer any complications during their military career. Currently, potential UK Army recruits undergo personal/family history and physical examination plus an ECG and, although this goes beyond American Heart Association guidelines, it does not screen specifically for BAV. This would necessitate a transthoracic echo for each potential recruit but would be a considerable increase in resources-both time and financial. In addition to the recruitment medical, military personnel undergo frequent medicals, which could identify those who develop significant valvular disease. Those with mild valve disease are at lowest risk of complication. Those with aortic dilatation only remain a concern.