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PurposeCorrect identification of aortic valve (AV) morphology is important in the management of patients with aortic stenosis (AS). The finding of a bicuspid valve (BAV) influences both the attention paid to the proximal aorta and recommendations regarding family screening. We sought to establish what factors contribute to accurate AV classification in clinical practice with transthoracic echocardiography (TTE).Methods:96 patients with moderate - severe AS were prospectively recruited for a clinical trial and underwent TTE by an accredited echocardiographer and cardiac magnetic resonance (CMR) imaging at 1.5 T. The TTE scans were reviewed independently by 3 blinded accredited echocardiographers who were asked to classify the valve morphology and grade calcification. The CMR scans were reviewed independently for valve classification by 2 experienced CMR operators blinded to the TTE results.Results:By CMR 41/96 (43%) BAVs were identified. There was complete agreement between CMR observers (kappa 1). TTE identified 23/96 bicuspid valves (24%). Of the 41 bicuspid valves on CMR, 23 (56%) were correctly identified by TTE (kappa for agreement with CMR 0.48). Inter-rater agreement among accredited echocardiographers was only moderate for valve morphology (Kappa 0.42, range 0.34 - 0.51). Bicuspid valves were much more likely to be mis-classified by TTE (p <0.001). Factors influencing correct identification of valve morphology (compared to CMR) were increased valve calcification (reduced accuracy in identifying tricuspid valves; p=0.04) and increased BMI, which showed a strong trend toward reduced accuracy (p=0.061).Conclusion:Routine TTE can underestimate the prevalence of BAV. Factors making the identification of valve morphology more difficult are increased BMI and an increased calcification score. Routine use of three dimensional echocardiography in clinical practice may improve valve classification in the future.