Many patients with BAV will develop AS or AR over their lifetimes. In a recent meta-analysis of natural history studies of patients with BAV, 13% to 30% of patients developed moderate or greater AR and 12% to 37% developed moderate or greater AS during follow-up.1 TTE usually is adequate for evaluation of aortic valve anatomy and hemody- namics. TEE provides improved 2D and 3D images if needed. Aortic enlargement at the level of the sinuses or proximal ascending aorta has been reported in 20% to 40% of patients with BAV,1 and some develop severe aneurysmal dilation and are at increased risk of aortic dissection.2,3,7 10 Aortic measurements are reported at the aortic annulus, sinuses of Valsalva, sinotubular junction, and mid-ascending aorta. Doppler interrogation of the proximal descending aorta and abdominal aorta should also be performed to evaluate for the presence of aortic coarctation, which is asso- ciated with BAV in a subset of patients, although a coarctation also can be detected by comparing arm and leg blood pressures. 2. CT angiography or CMR provides better images of the aortic sinuses, sinotubular junction, or ascending aorta when TTE does not adequately visualize the sinus and proximal 5 to 6 cm of the ascending aorta. The choice of CMR versus CT angiography depends on patient preference, insurance coverage, institutional expertise, and consideration of radiation exposure. 3. In about 20% to 30% of patients with a BAV, other family members also have a BAV and/or an associated aortopathy. A specific genetic cause has not been identified, and the patterns of inheritance are variable. Imaging can identify the presence of a BAV and aortic dilation, but there is a paucity of data on the cost-effectiveness of this approach and whether earlier diagnosis would improve long-term clinical outcomes.6,11 5.1.1.2. 