18F-FDG PET/CT: bicuspid aortic valve patients’ underestimated ally. A systematic review

PurposeBicuspid aortic valve (BAV) is the most common congenital heart defect and, while often considered benign, is associated with significant complications including aortic stenosis (AS) and infective endocarditis (IE). The diagnosis of IE in BAV patients can be particularly challenging, especially in blood culture-negative cases and in the presence of prosthetic material or atypical presentations. 18F-FDG PET/CT has become an established diagnostic tool in prosthetic valve endocarditis but its utility in BAV patients remains underexplored. Scarce literature also reports the use of PET/CT to perform in-vivo evaluation of BAV stenosis progression by assessing valvular inflammation.MethodsThis systematic review was conducted following PRISMA 2020 guidelines, searching PubMed/MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov to identify studies reporting on the use of 18F-FDG PET/CT in BAV patients. Quality assessment was performed using the Joanna Briggs Institute checklist and the QUADAS-2 tool.ResultsOut of 96 initial records, 13 studies were included, 12 of which are case reports. The selected literature mostly highlighted the diagnostic value of 18F-FDG PET/CT in BAV patients with suspected IE, especially in blood culture-negative scenarios and chronic infections such as Q-fever, guiding patient management, detecting infection extension, influencing surgical decision-making, supporting prolonged antibiotic strategies and enabling accurate follow-up. However, considerable heterogeneity existed among cases, and technical details were underreported. In a single study, FDG PET/CT did not demonstrate a significant role in the prediction of AS progression.ConclusionsThis review emphasizes the growing role of 18F-FDG PET/CT in the diagnostic workup and follow-up of IE in BAV patients, particularly when conventional methods are inconclusive. Nonetheless, lack of detail on imaging protocols and the predominance of case-based evidence limits broader applicability. Further prospective studies are needed to establish consensus on PET/CT's optimal use in BAV-related infective and inflammatory conditions.