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It can occur alone, that is, without other heart problems, or in association with bicuspid aortic valve, coarctation of the aorta, ventricular septal defect, mitral valve
septal defect, and Shone's syndrome (supra-valvular mitral ring, parachute mitral valve, subaortic stenosis, and aortic coarctation). 22, 27 Rheumatic heart disease is rare