Clinical significance of the bicuspid aortic valve

Bicuspid aortic valve disease is associated with abnormal wall shear stress, viscous energy loss, and pressure drop within the ascending thoracic aorta: A cross-sectional study

Bicuspid aortic valve (BAV) disease has significant gaps in its clinical management practices. To highlight the potential utility of advanced hemodynamic biomarkers in strengthening BAV assessment, we used 4-dimentional flow magnetic resonance imaging to investigate altered hemodynamics in the ascending aorta (AAo).A total of 32 healthy controls and 53 age-matched BAV patients underwent cardiac magnetic resonance imaging at 3T, with cine imaging and 4D-flow. Analysis planes were placed along 3D-segmented aortas at the left ventricular outflow tract (LVOT), sinuses of Valsalva, mid-ascending aorta (MAA), and proximal to the first aortic branch. Locations were analyzed for aortic diameter (normalized to body surface area), pressure drop (PD), viscous energy loss (EL), and wall shear stress (WSS) sub-vectors (axial wall shear stress, circumferential wall shear stress [WSSC], magnitude wall shear stress). Student's t tests, or non-parametric equivalents, compared parameters between cohorts. Univariable and multivariable analyses explored the associations of AAo diameter with hemodynamics within the BAV cohort.Compared to control cohort, BAV patients showed significantly greater PD (MAA: 9.5 ± 8.0 vs 2.8 ± 2.4 mm Hg; P < .01), EL (from LVOT-AA1: 7.39 ± 4.57 mW vs 2.90 ± 1.07 mW; P < .01), and WSSC (MAA: 0.3 ± 0.1 vs 0.2 ± 0.06 Pa; P ≤ .01) throughout the AAo. Correlational analyses revealed an inverse association between AAo diameter and both magnitude wall shear stress and axial wall shear stress.BAV patients exhibited increased PD, EL, and WSSC in the AAo, and an inverse association between AAo diameter and WSS sub-vectors. This demonstrated the impact of PD, EL, and WSS in BAV disease and the importance of altered hemodynamics in aortic remodelling.

Transcatheter Heart Valve Implantation in Bicuspid Patients with Self-Expanding Device

Bicuspid aortic valve (BAV) patients are conventionally not treated by transcathether aortic valve implantation (TAVI) because of anatomic constraint with unfavorable outcome. Patient-specific numerical simulation of TAVI in BAV may predict important clinical insights to assess the conformability of the transcathether heart valves (THV) implanted on the aortic root of members of this challenging patient population. We aimed to develop a computational approach and virtually simulate TAVI in a group of n.6 stenotic BAV patients using the self-expanding Evolut Pro THV. Specifically, the structural mechanics were evaluated by a finite-element model to estimate the deformed THV configuration in the oval bicuspid anatomy. Then, a fluid–solid interaction analysis based on the smoothed-particle hydrodynamics (SPH) technique was adopted to quantify the blood-flow patterns as well as the regions at high risk of paravalvular leakage (PVL). Simulations demonstrated a slight asymmetric and elliptical expansion of the THV stent frame in the BAV anatomy. The contact pressure between the luminal aortic root surface and the THV stent frame was determined to quantify the device anchoring force at the level of the aortic annulus and mid-ascending aorta. At late diastole, PVL was found in the gap between the aortic wall and THV stent frame. Though the modeling framework was not validated by clinical data, this study could be considered a further step towards the use of numerical simulations for the assessment of TAVI in BAV, aiming at understanding patients not suitable for device implantation on an anatomic basis.

Extent of Coronary Artery Disease in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valves

Background Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, which is often complicated by aortic valve stenosis (AoS). In tricuspid aortic valve (TAV), AoS strongly associates with coronary artery disease (CAD) with common pathophysiological factors. Yet, it remains unclear whether AoS in patients with BAV is also associated with CAD. This study investigated the association between the aortic valve morphological features and the extent of CAD. Methods and Results A single-center study was performed, including all patients who underwent an aortic valve replacement attributable to AoS between 2006 and 2019. Coronary sclerosis was graded on preoperative coronary angiographies using the coronary artery greater even than scoring method, which divides the coronaries in 28 segments and scores nonobstructive (20%-49% sclerosis) and obstructive coronary sclerosis (>49% sclerosis) in each segment. Multivariate analyses were performed, controlling for age, sex, and CAD risk factors. A total of 1296 patients (931 TAV and 365 BAV) were included, resulting in 548 matched patients. Patients with TAV exhibited more CAD risk factors (odds ratio [OR], 2.66; 95% CI, 1.79-3.96; P<0.001). Patients with BAV had lower coronary artery greater even than 20 (1.61±2.35 versus 3.60±2.79) and coronary artery greater even than 50 (1.24±2.43 versus 3.37±3.49) scores (P<0.001), even after correcting for CAD risk factors (P<0.001). Patients with TAV more often needed concomitant coronary revascularization (OR, 3.50; 95% CI, 2.42-5.06; P<0.001). Conclusions Patients with BAV who are undergoing surgery for AoS carry a lower cardiovascular risk profile, correlating with less coronary sclerosis and a lower incidence of concomitant coronary revascularization compared with patients with TAV.

Non-aneurysmal ascending aorta diameter changes after aortic valve replacement in patients with stenotic bicuspid and tricuspid aortic valve

OBJECTIVE

The appropriate timing of aortic repair in patients with bicuspid aortic valve-related aortopathy remains controversial. We describe the changes in diameter of the non-aneurysmal ascending aorta after aortic valve replacement for bicuspid or tricuspid aortic valve stenosis.

METHODS

This retrospective review included 189 patients who had undergone aortic valve replacement for severe stenotic aortic valve with a non-aneurysmal ascending aorta diameter of 45 mm or less between January 2008 and December 2018. A linear mixed-effect model was used to analyze and compare the enlargement rates of the non-aneurysmal ascending aorta at the tubular portion after aortic valve replacement in bicuspid and tricuspid aortic valve patients.

RESULTS

The enlargement rate of the non-aneurysmal ascending aorta after aortic valve replacement was significantly greater in the bicuspid aortic valve group than in the tricuspid aortic valve group (0.36 mm/year vs. 0.09 mm/year, p < 0.001). The specific form of bicuspid aortic valve also affected aorta diameter enlargement: the enlargement rate of 0.85 mm/year in the Type 0 (according to Sievers' classification) group was approximately five times that in the Non-Type 0 group (p < 0.001). No aortic events were observed, and no patients needed reoperations for the ascending aorta, in either the bicuspid or tricuspid aortic valve groups.

CONCLUSION

The persistent possibility of progressive ascending aortic dilatation after aortic valve replacement for bicuspid aortic valve stenosis, especially in Type 0 bicuspid aortic valve patients, demands careful post-procedural evaluation of the ascending aorta.

Prosthesis Position after TAVI with Balloon-Expandable SAPIEN 3 in Bicuspid Aortic Valves

Background: Prior data suggest a correlation between the position of transcatheter heart valves (THV) and the occurrence of complications after transcatheter aortic valve implantation (TAVI) in patients with tricuspid aortic valves (TAV). However, data including a detailed analysis of prosthesis positioning in bicuspid aortic valves (BAV) are limited. Therefore, the purpose of this study was to investigate THV position after TAVI in BAV. Methods: We evaluated the THV position in 50 BAV and 50 TAV patients (all received the balloon-expandable Sapien 3 prosthesis) using fusion imaging of pre- and post-procedural computed tomography angiography. According to the manufacturers’ recommendations, a low implantation position was defined as >30% of the prosthesis below the annulus. Results: THV position was appropriate in the majority of the patients within both groups (90.0% for BAV vs. 96.0% for TAV, p = 0.240). In BAV, we observed a more pronounced THV waist (7.4 ± 4.5% vs. 5.8 ± 3.0%, p = 0.043) and a lower average THV expansion (91.9 ± 12.2% vs. 95.5 ± 2.7% of nominal expansion, p = 0.044). Conclusions: Accurate positioning in relation to the aortic annulus of the TAVI Sapien 3 prosthesis is possible in patients with BAV with results comparable to TAV. However, there is a more pronounced prosthesis waist and a lower average THV expansion in BAV.

Transcatheter aortic valve replacement in bicuspid valves: The synergistic effects of eccentric and incomplete stent deployment

Bicuspid aortic valve is a congenital cardiac anomaly and common etiology of aortic stenosis. Given the positive outcomes of transcatheter aortic valve replacement (TAVR) in low-risk patients, TAVR will become more prevalent in the future in the treatment of severe bicuspid valve stenosis. However, asymmetrical bicuspid valve anatomy and calcification can prevent the circular and complete expansion of transcatheter aortic valves (TAVs). In previous studies, examining the impact of elliptical TAV deployment on leaflet stress distribution, asymmetric expansion of balloon-expandable intra-annular devices was studied up to an ellipticity index (long/short TAV diameter) of 1.4. However, such a high degree of eccentricity has not been observed in clinical studies with balloon-expandable devices. High degrees of stent eccentricity have been observed in self-expanding TAVs, such as CoreValve. However, CoreValve is a supra-annular device, and it was not clear if eccentric and incomplete stent deployment at the annulus would alter leaflet stress and strain distributions. This study aimed to assess the effects of eccentric and incomplete stent deployment of CoreValves in bicuspid aortic valves and compare the results to that of SAPIEN 3. Leaflet stress distribution and leaflet kinematics of 26-mm CoreValve and 26-mm SAPIEN 3 devices in bicuspid valves were obtained in a range that was observed in previous clinical studies. The results indicated that elliptical and incomplete stent deployment of TAVs increase leaflet stress and impair leaflet kinematics. The changes were more pronounced in CoreValve than SAPIEN 3. Increased leaflet stress can reduce long-term valve durability, and impaired leaflet kinematics can potentially increase blood stasis on the TAV leaflets. The study provides complementary insights into the mechanics of TAVs in bicuspid aortic valves.

High prevalence of ascending aortic dilation in adults with repaired coarctation of the aorta

BACKGROUND

Ascending aortic dilation is a feared complication in adults with repaired coarctation of the aorta, as the condition is associated with life-threatening complications such as aortic dissection and rupture. However, the data are currently limited regarding factors associated with ascending aortic dilation in these patients.

METHODS AND RESULTS

From the national register of congenital heart disease, 165 adult patients (≥ 18 years old) with repaired coarctation of the aorta, and echocardiographic data on aortic dimensions, were identified (61.2% male, mean age 35.8 ± 14.5 years). Aortic dilation (aortic diameters > 2 SD above reference mean) was found in 55 (33.3%) of the 165 included patients, and was associated with manifest aortic valve disease in univariable logistic regression analysis (OR 2.44, 95% CI [1.23, 4.83]).

CONCLUSIONS

Aortic dilation is common post-repair of coarctation of the aorta, and is associated with manifest aortic valve disease and thus indirectly with the presence of a bicuspid aortic valve. However, no association was found between aortic dilation and age or blood pressure.

Bicuspid aortic valve disease - the influence of valve morphotype on age at and types of surgical treatment

BACKGROUND

Patients with bicuspid aortic valve (BAV) with zero or two raphes have been under-represented in previous studies. Whether these patients have unique clinical courses remains unclear. We describe the indications for and types of surgery in patients with BAV, and describe differences between valve morphotypes.

METHODS

Adults who had undergone aortic and/or aortic valve surgery for BAV disease at our centres were identified and classified according to the Sievers definitions.

RESULTS

317 patients were included (74.4% male, median age at surgery 62 years). Of these, 187 (59.0%) had aortic valve surgery, 7 (2.2%) aortic surgery, 120 (37.9%) combined valve and aortic surgery and 3 had a Ross procedure. Most patients had aortic stenosis (71.9%), followed by aortic regurgitation (16.7%). 30-day mortality was low (1.6%).The commonest valve morphology was type-1 (one raphe) in 89.6%; type-0 (no raphes) occurred in 7.9% and type-2 (two raphes) in 2.5%. Patients with type-2 valves were substantially younger at time of surgery than type-1 patients (median 36 vs 63 years, p = 0.008). A higher proportion of patients with type-0 valves required aortic surgery than those with type-1 (68.0% vs 37.3%, p = 0.007). There were no differences between groups for the indication for surgery, valvular abnormality or 30-day mortality.

CONCLUSIONS

The number of BAV raphes was independently and significantly associated with age at surgery and the need for aortic intervention. Patients with type 0 and type 2 valves are a small but important proportion of the BAV population, potentially requiring different clinical surveillance and management.

Relationship between indexed aortic area and aortic diameter in bicuspid aortic valve aortopathy: A retrospective cohort study

BACKGROUND

Aortic dissection is a life-threatening complication of bicuspid aortic valve (BAV)-associated aortopathy. In these populations, whilst prophylactic replacement of proximal thoracic aortic aneurysms (TAAs) is generally recommended at threshold diameters ≥5.5 cm, dissection may occur in smaller aortas. An alternative size-based parameter, the cross-sectional aortic area/patient height ratio (indexed aortic area, IAA), correlates with increased dissection risk at abnormal values > 10 cm2/m. We sought to assess the utility of the IAA in identifying at-risk BAV-associated TAAs with abnormal IAA, albeit with sub-threshold aortic diameter.

MATERIALS AND METHODS

We retrospectively identified 69 patients with BAV-associated TAAs who underwent surgical repair between 2010 and 2016. Aortic diameter was measured on pre-operative imaging, and IAA calculated, at the mid-sinus of Valsalva, sino-tubular junction and mid-ascending aorta for each patient. We determined proportions of aneurysms with IAA >10 cm2/m, median IAAs corresponding to aortic diameters <4.0 cm, 4.0-4.5 cm, 4.5-5.0 cm, 5.0-5.5 cm and >5.5 cm, and median aortic diameters corresponding to an abnormal IAA.

RESULTS

50.9%, 12.5% and 64.6% of aneurysms at the sinus of Valsalva, sino-tubular junction and mid-ascending aorta, respectively, had an abnormal IAA. 51.9% and 88.9% of patients with aortic diameter 4.5-5.0 cm and 5.0-5.5 cm, respectively, had an abnormal IAA. In aneurysms with abnormal IAA involving the sinus of Valsalva, sino-tubular junction, and mid-ascending aorta, median aortic diameters were 4.98 cm, 5.04 cm and 5.11 cm, respectively. Overall, 57/72 (79.2%) at-risk aneurysms with IAA >10 cm2/m had diameters smaller than the 5.5 cm guideline cut-off for surgical intervention.

CONCLUSION

Significant proportions of BAV-associated TAAs are at increased risk of aortic dissection attending an IAA >10 cm2/m, whilst not fulfilling the size criteria indicating aortic surgery in contemporary guidelines. Further analysis of IAA in larger BAV cohorts is necessary to clarify its role in patient selection and optimal timing for prophylactic aortic replacement.

Bicuspid aortic valve annulus: assessment of geometry and size changes during the cardiac cycle as measured with a standardized method to define the annular plane

Purpose

Bicuspid aortic valve (BAV) is a complex malformation affecting not merely the aortic valve. However, little is known regarding the dynamic physiology of the aortic annulus in these patients and whether it is similar to tricuspid aortic valves (TAV). Determining the BAV annular plane is more challenging than for TAV. Our aim was to present a standardized methodology to determine BAV annulus and investigate its changes in shape and dimensions during the cardiac cycle.

Methods

BAV patients were prospectively included and underwent an ECG-gated cardiac CTA. The annulus plane was manually identified on reconstructions at 5% intervals of the cardiac cycle with a new standardized method for different BAV types. Based on semi-automatically defined contours, maximum and minimum diameter, area, area-derived diameter, perimeter, asymmetry ratio (AR), and relative area were calculated. Differences of dynamic annular parameters were assessed also per BAV type.

Results

Of the 55 patients included (38.4 ± 13.3 years; 58% males), 38 had BAV Sievers type 1, 10 type 0, and 7 type 2. The minimum diameter, perimeter, area, and area-derived diameter were significantly higher in systole than in diastole with a relative change of 13.7%, 4.8%, 13.7%, and 7.2% respectively (all p < 0.001). The AR was ≥ 1.1 in all phases, indicating an elliptic shape, with more pronounced flattening in diastole (p < 0.001). Different BAV types showed comparable dynamic changes.

Conclusions

BAV annulus undergo significant changes in shape during the cardiac cycle with a wider area in systole and a more elliptic conformation in diastole regardless of valve type.

Key Points

• A refined method for the identification of the annulus plane on CT scans of patients with bicuspid aortic valves, tailored for the specific anatomy of each valve type, is proposed.

• The annulus of patients with bicuspid aortic valves undergoes significant changes during the cardiac cycle with a wider area and more circular shape in systole regardless of valve type.

• As compared to previously published data, the bicuspid aortic valve annulus has physiological dynamics similar to that encountered in tricuspid valves but with overall larger dimensions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07916-8.

Aortic strain in bicuspid aortic valve: an analysis

Bicuspid aortic valve (BAV) is monitored by transthoracic echocardiography and computed tomography (CT) angiography. However, it does not have any early marker of disease progression. This study evaluated speckle-tracking echocardiography (STE) aortic and left ventricular (LV) strain prognostic values, their discriminative power, and their correlation with the degree of valvular regurgitation. We conducted a retrospective analysis of a prospectively enrolled cohort of 45 diagnosed with BAV and 20 gender and age matched controls. We performed 2D-STE aortic and LV strain analysis of the selected population. The cohort was followed-up during a median period of 19.9 months (IQR 12.9-25.2), and outcomes (hospital admission for heart failure (HF), aortic valve replacement (AVR), and death) were determined. The mean patient age was 46.6 ± 15.5 years and 80 % were male. LV indexed volumes and aortic diameter were higher in BAV patients. LV global longitudinal strain (GLS) was impaired (p < 0.001) and aortic GLS was significantly augmented (p = 0.027) in BAV patients. Aortic global circumferential strain (GCS) did not vary between groups. Aortic diameter was the best parameter related to BAV (AUC 0.92) and aortic GLS was best correlated with significant AR (AUC 0.76). AVR was the only outcome observed and its only predictor was indexed LV end-diastolic volume. BAV had impaired LV-GLS values. Aortic GLS was abnormally augmented in BAV patients, which might reflect higher aortic diameters that distorted strain calculations. STE aortic strain is related to AR but does not appear to be a reliable predictor of surgery in BAV patients, at 19 months.

Cardiac Neural Crest Cells: Their Rhombomeric Specification, Migration, and Association with Heart and Great Vessel Anomalies

Outflow tract abnormalities are the most frequent congenital heart defects. These are due to the absence or dysfunction of the two main cell types, i.e., neural crest cells and secondary heart field cells that migrate in opposite directions at the same stage of development. These cells directly govern aortic arch patterning and development, ascending aorta dilatation, semi-valvular and coronary artery development, aortopulmonary septation abnormalities, persistence of the ductus arteriosus, trunk and proximal pulmonary arteries, sub-valvular conal ventricular septal/rotational defects, and non-compaction of the left ventricle. In some cases, depending on the functional defects of these cells, additional malformations are found in the expected spatial migratory area of the cells, namely in the pharyngeal arch derivatives and cervico-facial structures. Associated non-cardiovascular anomalies are often underestimated, since the multipotency and functional alteration of these cells can result in the modification of multiple neural, epidermal, and cervical structures at different levels. In most cases, patients do not display the full phenotype of abnormalities, but congenital cardiac defects involving the ventricular outflow tract, ascending aorta, aortic arch and supra-aortic trunks should be considered as markers for possible impaired function of these cells. Neural crest cells should not be considered as a unique cell population but on the basis of their cervical rhombomere origins R3-R5 or R6-R7-R8 and specific migration patterns: R3-R4 towards arch II, R5-R6 arch III and R7-R8 arch IV and VI. A better understanding of their development may lead to the discovery of unknown associated abnormalities, thereby enabling potential improvements to be made to the therapeutic approach.

A patient with single coronary artery, bicuspid aortic valve and sinus of Valsalva aneurysm

BACKGROUND

We report a rare case of a patient who presented with chest pain and was found to have a constellation of rare cardiac anomalies.

CASE PRESENTATION

A 67-year-old patient with no past medical history presented with chest pain. He had mild troponin elevation, but no ischemic changes on ECG. He underwent a CT coronary angiogram for further evaluation. He was found to have a type 0 bicuspid aortic valve, large left sinus of Valsalva aneurysm and type R-III single coronary artery. These findings were confirmed with transesophageal echocardiogram and coronary angiogram. He underwent a successful repair of his aortic root aneurysm with a synthetic patch.

CONCLUSIONS

The combination of type R-III single coronary artery, bicuspid aortic valve, and left sinus of Valsalva aneurysm congenital anomalies in one individual is extremely rare and marks our case unique. Given the size of his Sinus of Valsalva aneurysm, the patient underwent surgical repair of his aneurysm and was asymptomatic when seen in follow-up.

Multimodal Assessment of Vascular and Ventricular Function in Children and Adults With Bicuspid Aortic Valve Disease

Background: Bicuspid aortic valve (BAV), the most common congenital cardiac anomaly, has been associated with an aortopathy, increased aortic stiffness and diastolic dysfunction. The involved mechanisms and impact of age remain unclear. It was the aim of this study to characterize arterial and cardiac function, their correlation, and the effect of age in children and adults with a history of BAV.

Methods: Multimodal cardiovascular assessment included echocardiography, ascending aortic distensibility, common carotid intima media thickness [cIMT], parameters of wave reflection [central (cAIx75) and peripheral (pAIx75) augmentation index corrected to a heart rate of 75/min, aging index (AI)], carotid-femoral pulse wave velocity [cfPWV], and endothelial function (EndoPAT). Multivariable linear regression and correlation analyses were performed.

Results: We included 47 BAV patients and 84 controls (age 8–65 years). Ascending aortic stiffness, pulse wave reflection (cAIx75, pAIx75, and AI) and central blood pressure were significantly increased in patients with BAV. However, PWV, cIMT, and endothelial function were not significantly different from controls. BAV patients had marginally reduced diastolic (E': β = −1.5, p < 0.001) but not systolic function compared to controls. Overall, all parameters of arterial stiffness had moderate-strong correlations with diastolic dysfunction and age. In the BAV group, ascending aortic distensibility had the strongest correlation with diastolic dysfunction.

Conclusions: BAV is associated with increased proximal arterial stiffness and wave reflection. However, PWV and cIMT are not increased, and endothelial function is preserved. This suggests that the mechanism of arterial and cardiac stiffening is different from patients with acquired heart diseases.

Toward the Effective Bioengineering of a Pathological Tissue for Cardiovascular Disease Modeling: Old Strategies and New Frontiers for Prevention, Diagnosis, and Therapy

Cardiovascular diseases (CVDs) still represent the primary cause of mortality worldwide. Preclinical modeling by recapitulating human pathophysiology is fundamental to advance the comprehension of these diseases and propose effective strategies for their prevention, diagnosis, and treatment. In silico, in vivo, and in vitro models have been applied to dissect many cardiovascular pathologies. Computational and bioinformatic simulations allow developing algorithmic disease models considering all known variables and severity degrees of disease. In vivo studies based on small or large animals have a long tradition and largely contribute to the current treatment and management of CVDs. In vitro investigation with two-dimensional cell culture demonstrates its suitability to analyze the behavior of single, diseased cellular types. The introduction of induced pluripotent stem cell technology and the application of bioengineering principles raised the bar toward in vitro three-dimensional modeling by enabling the development of pathological tissue equivalents. This review article intends to describe the advantages and disadvantages of past and present modeling approaches applied to provide insights on some of the most relevant congenital and acquired CVDs, such as rhythm disturbances, bicuspid aortic valve, cardiac infections and autoimmunity, cardiovascular fibrosis, atherosclerosis, and calcific aortic valve stenosis.

Fate of mild-to-moderate bicuspid aortic valve disease untreated during ascending aorta replacement

BACKGROUND

Bicuspid aortic valve (BAV) is the most common congenital heart defect and it is responsible for an increased risk of developing aortic valve and ascending aorta complications. In case of mild to moderate BAV disease in patients undergoing supracoronary ascending aorta replacement, it is unclear whether a concomitant aortic valve replacement should be performed.

METHODS

From June 2002 to January 2020, 75 patients with mild-to-moderate BAV regurgitation (±mild-to-moderate stenosis) who underwent isolated supracoronary ascending aorta replacement were retrospectively analyzed. Clinical and echocardiographic follow-up was 100% complete (mean: 7.4 ± 3.9 years, max: 16.4). Kaplan-Meier estimates were employed to analyze long-term survival. Cumulative incidence function (CIF) for time to reoperation, recurrence of aortic regurgitation (AR) ≥3+ and aortic stenosis (AS) greater than moderate, with death as competing risk, were computed.

RESULTS

There was no hospital mortality and no cardiac death occurred. Overall survival at 12 years was 97.4 ± 2.5%, 95% confidence interval (CI: 83.16-99.63). At follow-up there were no cases of aortic root surgery whereas three patients underwent AV replacement. At 12 years the CIF of reoperation was 2.6 ± 2.5%, 95% CI [0.20-11.53]. At follow-up, AR 3+/4+ was present in 1 pt and AS greater than moderate in 3. At 12 years the CIF of AR more than 2+/4+ was 5.1 ± 4.98% and of AS more than moderate 6.9 ± 3.8%.

CONCLUSIONS

In our study mild to moderate regurgitation of a BAV did not do significantly worse at least up to 10 years after isolated supracoronary ascending aorta replacement.

Clinical Outcomes of Adults With Bicuspid Aortic Valve: A European Perspective

OBJECTIVE

To describe the clinical history of patients with a wide age range diagnosed with bicuspid aortic valve (BAV) and no surgical indication and to evaluate the long-term outcome of patients with BAV referred for elective surgery.

PATIENTS AND METHODS

Between 2005 and 2017, 350 consecutive patients with no surgical indication (surveillance group, mean age 53±16, 71% men) and 191 with a surgical indication (surgical group, mean age 59±13, 71% men) were prospectively included. Median follow-up was 80 (32 to 115) months.

RESULTS

In the surveillance group, the 5-year and 10-year survival rates were 93±1% and 89±2%, respectively, with a relative survival of patients with BAV compared with an age- and sex-matched control population of 98.7%. During follow-up, the cumulative 10-year incidence of aortic valve and aorta surgery was high; of 35±4%, the incidence of native valve infective endocarditis (IE) of 0.2% per patient-year, and no cases of aortic dissection were observed. In the surgical group, the 5-year and 10-year survival rates were 97±1% and 89±3%, respectively, with a relative survival of 99.4% compared with the general population. The incidence of IE was 0.4% per patient-year, and no cases of aortic dissection were observed.

CONCLUSION

This regional cohort shows that the 10-year survival rates of patients with BAV and a wide age range, but mostly middle-aged adults, were similar to those of the general population with a very low rate of complications. Adherence to prophylactic surgical indications and younger age might have contributed to this lack of difference.

Rapid ascending aorta stiffening in bicuspid aortic valve on serial cardiovascular magnetic resonance evaluation: comparison with connective tissue disorders

BACKGROUND

Aortic stiffness has been shown to be abnormal in patients with bicuspid aortic valve (BAV), and is considered a component of the aortopathy associated with this condition. Progressive aortic stiffening associated with aging has been previously described in normal adults. However, it is not known if aging related aortic stiffening occurs at the same rate in BAV patients. We determined the longitudinal rate of decline in segmental distensibility in BAV patients using serial cardiovascular magnetic resonance (CMR) studies, and compared to previously published results from a group of patients with connective tissue disorders (CTD).

METHODS

A retrospective review of CMR and clinical data on children and adults with BAV (n = 49, 73% male; 23 ± 11 years) with at least two CMRs (total 98 examinations) over a median follow-up of 4.1 years (range 1-9 years) was performed to measure aortic distensibility at the ascending (AAo) and descending aorta (DAo). Longitudinal changes in aortic stiffness were assessed using linear mixed-effects modeling. The comparison group of CTD patients had a similar age and gender profile (n = 50, 64% male; 20.6 ± 12 years).

RESULTS

Compared to CTD patients, BAV patients had a more distensible AAo early in life but showed a steeper decline in distensibility on serial examinations [mean 10-year decline in AAo distensibility (× 10-3 mmHg-1) 2.4 in BAV vs 1.3 in CTD, p = 0.005]. In contrast, the DAo was more distensible in BAV patients throughout the age spectrum, and DAo distensibility declined with aging at a rate similar to CTD patients [mean 10 year decline in DAo distensibility (× 10-3 mmHg-1) 0.3 in BAV vs 0.4 in CTD, p = 0.58].

CONCLUSIONS

On serial CMR measurements, AAo distensibility declined at significantly steeper rate in BAV patients compared to a comparison group with CTDs, while DAo distensibility declined at similar rates in both groups. These findings offer new mechanistic insights into the differing pathogenesis of the aortopathy seen in BAV and CTD patients.

Infective bicuspid aortic valve endocarditis causing acute severe regurgitation and heart failure: A case report

BACKGROUND

Infective endocarditis (IE) is an uncommon but potentially life-threatening infection, which occasionally develops into acute severe valve insufficiency leading to the onset of heart failure, and necessitates timely intervention. However, the variable and atypical clinical manifestations always make the early detection of IE difficult and challenging.

CASE SUMMARY

A 45-year-old female who was previously healthy presented with exertional shortness of breath and paroxysmal nocturnal dyspnea. She also suffered from a significant decrease in exercise capacity, whereas her body temperature was normal. She had severe hypoxemia and hypotension along with a marked aortic valve murmur. Diffuse pulmonary edema and bilateral pleural effusion were observed on both chest X-ray and computed tomography scan. Transthoracic echocardiography was performed immediately and revealed severe regurgitation of the bicuspid aortic valve. Transesophageal echocardiography was further performed and vegetations were detected. In addition to adequate medical therapy and ventilation support, the patient underwent urgent and successful aortic valve replacement. Her symptoms were significantly relieved and the postoperative chest X-ray showed that pulmonary edema was significantly reduced. Histopathology of the resected valve and positive microorganism culture of the surgical specimen provided evidence of definite IE.

CONCLUSION

IE should be considered in critical patients with refractory heart failure caused by severe bicuspid aortic valve regurgitation.

Sex and Race Differences in the Pathophysiology, Diagnosis, Treatment, and Outcomes of Valvular Heart Diseases

Valvular heart diseases have long been considered to be similar in men and women and across races/ethnicities. Recently, studies have demonstrated major differences between sexes. Unfortunately, studies on valvular heart diseases, as on other cardiovascular diseases, are mostly performed in Caucasian men or in cohorts with a vast majority of Caucasian men. Therefore, our knowledge on valvular diseases in women and non-Caucasians remains limited. Nevertheless, aortic stenosis has been shown to be almost as prevalent in women as in men, and less prevalent in African Americans. Men appear to have a more calcified aortic valve lesion, and women tend to have a more fibrosed one. Primary mitral regurgitation is more frequent in women who have more rheumatic and Barlow etiologies, whereas men have more fibroelastic deficiency and posterior leaflet prolapse/flail. Left ventricular remodelling due to valvular heart diseases is sex related in terms of geometry and probably also in composition of the tissue. Outcomes seem to be worse in women after surgical interventions and better than or equivalent to men after transcatheter ones. Regarding other valvular heart diseases, very few studies are available: Aortic regurgitation is more frequent in men, isolated tricuspid regurgitation more frequent in women. Rheumatic valve diseases are more frequent in women and are mostly represented by mitral and aortic stenoses. Many other sex/gender- and race/ethnic-specific studies are still needed in epidemiology, pathophysiology, presentation, management, and outcomes. This review aims to report the available data on sex differences and race specificities in valvular heart diseases, with a primary focus on aortic stenosis and mitral regurgitation.

Surgical Aortic Valve Replacement with Concomitant Aortic Surgery in Patients with Purely Bicuspid Aortic Valve and Associated Aortopathy

The bicuspid aortic valve (BAV) is the most common congenital cardiac malformation associated with aortopathy. The current study provides surgical clinical data on the patient characteristics and long-term survival of this less common adult purely BAV population undergoing surgical aortic valve replacement (SAVR) with concomitant aortic surgery. Adult patients with purely BAV who underwent SAVR and concomitant aortic surgery were included. Prevalence, predictors of survival, and outcomes for this patient population were analyzed. A total of 48 patients (mean age 58.7 ± 13.2 years, 33% female) with purely BAV underwent SAVR and concomitant aortic surgery between 1987 and 2016. The majority (62%) of the patients had pure aortic stenosis (AS). A total of 12 patients died. Survival was 92%, 73%, and 69% at 1, 5, and 20 years of follow-up. At 15 years of follow-up, the survival was close to that of the Dutch population, with a relative survival of 77%. Adult patients with a purely bicuspid aortic valve morphology undergoing SAVR and concomitant aortic root and/or ascending aorta present with excellent survival.

Progression and Outcomes of Non-dysfunctional Bicuspid Aortic Valve: Longitudinal Data From a Large Korean Bicuspid Aortic Valve Registry

Background: Using echocardiographic surveillance, many patients are diagnosed with bicuspid aortic valve (BAV) without significant valve dysfunction. Limited data are available regarding the progression and outcomes of non-dysfunctional BAV.

Methods and Results: We investigated 1,307 BAV patients (984 male, mean age 56 years) diagnosed from Jan 2003 through Dec 2018 in a single tertiary center. Seven hundred sixty-one patients underwent follow-up echocardiography at ≥1 year post-diagnosis. Non-dysfunctional BAV was defined as BAV without moderate aortic stenosis (AS) or aortic regurgitation (AR). The presence of aortopathy was defined as an ascending aorta diameter >37mm. Progression to significant BAV dysfunction, progression to severe aortopathy (ascending aorta diameter ≥45mm), and incidence of valve or aorta operation were analyzed. One hundred eighty-seven (25%) patients showed non-dysfunctional BAV. Among them, 104 (56%) had mild AS or AR, and 81 (43%) had aortopathy at indexed echocardiography. At 6.0 ± 3.8 years post-diagnosis, 56 (29%) progressed to dysfunctional BAV, 28 (15%) progressed to severe aortopathy, 22 (12%) underwent valve operation, and 19 (10%) experienced aorta operation. Eighty-nine percent of patients with normal BAV function and 61% of patients with mild AS or AR maintained non-dysfunctional BAV. More patients with aortopathy progressed to severe aortopathy (35 vs. 0% without aortopathy, p < 0.001), with a higher incidence of aorta operation (21 vs. 2%, p < 0.001).

Conclusions: In patients with non-dysfunctional BAV, initial BAV function and degree of aorta dilatation might be important for progression and outcomes. Patients without any dysfunction or aortopathy tend to maintain good structure and function for 6 years.

Evaluation of the Aortopathy in the Ascending Aorta: The Novelty of Using Matrix-Assisted Laser Desorption/Ionization Imaging

PURPOSE

Histopathological evaluation presents conflicting reports regarding aortic abnormalities. The authors aim to present proof-of-concept study to explore the feasibility of matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) in combination with histopathology for characterizing alterations in the aneurysmal ascending formalin-fixed paraffin-embedded (FFPE) aorta tissue.

EXPERIMENTAL DESIGN

The authors assess FFPE specimens from patients with a dilated aorta and bicuspid aortic valve (BAV), those with a standard tricuspid aortic valve (TAV), and those with Marfan syndrome (MFS) via histopathology and grade the conditions for elastic fiber fragmentation (EFF) and MALDI-IMS. The proteins using liquid chromatographic-mass spectrometry are identified and the results are confirmed by immunohistochemistry.

RESULTS

There is significant difference in terms of EFF between MFS and BAV, and TAV and BAV. Characteristic peptide signatures and m/z values in the EFF facilitate the characterization among the aortic specimens of BAV, MFS, and TAV. The m/z values from the aortic alpha smooth muscle actin and myosin heavy chains significantly increase in BAV compared with MFS and TAV. These findings are confirmed by immunohistochemistry.

CONCLUSION

The results represent a strategy that uses MALDI-IMS in combination with histopathology as promising approaches to characterize spatial alteration in the structure of the aneurysmal ascending aorta.

Aortic valve surgery: management and outcomes in the paediatric population

Congenital anomalies of the aortic valve frequently necessitate intervention in childhood. The most common aortic valve pathologies present in childhood are aortic stenosis and insufficiency. Presentation of aortic valve disease depends on severity and presence of concomitant syndromes and valvular disorders. Treatment options are largely categorised as medical, percutaneous repair or surgical repair and replacement. Surgical techniques have been refined over the last few years making this the mainstay of treatment in paediatric cases. Whilst repair is considered in most instances before replacement, there are substantial limitations which are reflected in the frequency of reintervention and restenosis rate. Replacements are typically undertaken with tissue or mechanical prosthesis. The current gold-standard aortic valve replacement surgery is called the Ross procedure-where replacement is undertaken with a competent pulmonic valve and a simultaneous pulmonary homograft.Conclusion: In this review, we aim to outline the various surgical options and discuss efficacy and complications of various interventions. What is Known: • Congenital aortic valve defects repair options medically and surgically What is New: • Comparisons between surgical options for aortic valve repair including efficacy, risks and long-term outcomes.

A rare case of anaerobic streptococci endocarditis in a young female with bicuspid aortic valve: case report

BACKGROUND

Bicuspid aortic valve is the most common congenital cardiovascular malformation and occurs in 1-2% of the population. The haemodynamic changes appear early, leading to tissue damage and predisposing to germs attachment. The development of perivalvular extension is a constant in bicuspid aortic valve endocarditis. Infective endocarditis with anaerobic bacteria is a rare condition with a high rate of mortality.

CASE SUMMARY

We report a case of a young female with bicuspid aortic valve infective endocarditis. Involved bacteria were anaerobic streptococci, and the clinical course of the diseases was very aggressive. The echocardiographic evaluation revealed aortic and mitral regurgitation, perivalvular abscess, ventricular septum defect, and pericardial effusion. The surgery approach consisted of the aortic valve replacement with a mechanical prosthesis after radical resection of aortic root abscess and reconstruction of the annulus. The ventricular septum defect was also closed with a pericardial patch. Anticoagulation started the first day after surgery. The patient was received antibiotic therapy for 10 days before and 4 weeks after surgical intervention. Evolution was very good at 1 and 6 months follow-up.

DISCUSSION

This is a severe case of endocarditis, complicated with extensive valvular destruction, aortic root abscess, and fistula. Perivalvular complications are frequent in patients with bicuspid aortic valve endocarditis. The 'take away' message is that echocardiography is an essential tool for diagnosis, management, and follow-up of patients with infective endocarditis.

Left Main Stenosis Stenting Normalises Wall Shear Stress of Ascending Aorta in Bicuspid Aortic Valve

INTRODUCTION

Bicuspid aortic valve (BAV) is associated with dilation and dissection of the ascending aorta. The high shear forces within the ascending aorta lumen seem to have a pivotal role on the development of such complications. We describe the time-averaged wall shear stress (TAWSS) forces in a patient with normally functioning BAV and significant ostial/mid-shaft left main (LM) stenosis using computational fluid dynamic analysis (CFD).

CASE REPORT

A 47-year-old female patient with normally functioning BAV with fusion of right and non-coronary cusps was investigated for unstable angina. CFD and stress mapping of the ascending aorta before LM stenting showed a mean TAWSS of 9.4 Pa and was associated with higher TAWSS values at the site of LM stenosis. The LM lesion was treated by stent implantation of an Orsiro (Biotronik, Berlin, Germany) 4.0 × 12 mm at 18 atm, preceded with a pre-dilation with non-compliant Euphora (Medtronic Inc., Santa Rosa, CA, USA) balloon 3.0 × 12 mm at 16 atm, and followed by an over-dilation with 4.5 × 12 mm non-compliant Euphora balloon at 20 atm. The reconstructed post-procedural model revealed a decrease of the mean ascending aorta TAWSS to 5.6 Pa.

CONCLUSIONS

As suggested by our case, stenting of an LM lesion in a patient with BAV has the potential to improve the TAWSS in the ascending aorta, protecting the ascending aorta from the well-known complications of BAV.

Bicuspid aortic valve and sports: From the echocardiographic evaluation to the eligibility for sports competition

Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults. Although a BAV may remain without clinical consequences for a lifetime, it can deteriorate in aortic valve stenosis and regurgitation and aortic dilatation. Unfortunately, the impact of regular training on patients with BAV and its natural course is not fully understood, although preliminary evidence suggests that the progression of valvular disease occurs primarily in an independent manner from sports practice. The current review aims to report how to perform a comprehensive echocardiographic examination in athletes with BAV and analyze the current literature on the influence of sports practice and how it impacts the aortic valve in athletes with BAV. The article also summarizes the current recommendations on sports eligibility and disqualification for competitive athletes with BAV.

Long-term Results of Differentiated Anatomic Reconstruction of Bicuspid Aortic Valves

Importance

Bicuspid aortic valve (BAV) repair has been used in limited cohorts, but its long-term results in a large population are unknown.

Objectives

To analyze the long-term stability of BAV repair for survival and the factors associated with repair failure and to evaluate whether a differentiated anatomic repair approach may improve repair stability.

Design, Setting, and Participants

In this case series, 1024 patients underwent BAV repair for aortic regurgitation or aneurysm between October 1995 and June 2018, with a mean (SD) follow-up time of 56 (49) months and maximum follow-up of 271 months. Systematic modifications in technique based on anatomic principles were introduced in 2009 and applied for the last 727 patients. Data were acquired prospectively and analyzed retrospectively.

Exposures

Repair of BAV with or without concomitant aortic replacement, as well as postoperative clinical and echocardiographic follow-up.

Main Outcomes and Measures

Survival and incidence of reoperation or recurrent aortic regurgitation, as well as factors associated with valve repair failure.

Results

Among the 1024 patients in the study (920 male [89.8%]; mean [SD] age, 47 [13] years [range, 15-86 years]), the survival rate at 15 years was 82.1%. The cumulative incidence of reoperation was 30.7% (95% CI, 22.7%-38.7%) at 15 years. Cusp calcification (subdistribution hazard ratio, 1.78; 95% CI, 1.14-2.77; P = .01), asymmetric commissural orientation (subdistribution hazard ratio, 1.95; 95% CI, 1.02-3.72; P = .04), and use of a pericardial patch for cusp repair (subdistribution hazard ratio, 5.25; 95% CI, 3.52-7.82; P < .001) were associated with time to reoperation. At 10 years, the incidence of reoperation was significantly reduced among patients who received the anatomic repair concept compared with those who had undergone surgery in the earlier period (8.8% vs 24.6%; P < .001).

Conclusions and Relevance

This study suggests that survival after BAV repair is excellent and that a large proportion of BAV repairs will remain stable. Repair stability can be markedly improved by an anatomic repair concept. Cusp calcification and the need for cusp repair using a patch remain the factors most strongly associated with valve failure. In those instances, valve replacement should be preferred.

Regurgitant Bicuspid Aortopathy: Is Valve-Sparing Root Replacement Equivalent to Bentall Procedure?

BACKGROUND

Repair of aortic root aneurysms with nonstenotic bicuspid valves (NS-BAVs) is achieved either with valve-sparing root replacement (VSRR) or conventional Bentall procedure (ROOT). Procedural and long-term outcomes comparing these 2 techniques are sparse and need investigation.

METHODS

From March 2004 to January 2019, 158 patients with an aortic root aneurysm and NS-BAV underwent VSRR (n = 78, 49.3%) or ROOT (n = 80, 50.6%). VSRR involved optional aortic valve repair (n = 47, 60%), and ROOT was performed with bioprosthetic (81.3%) or mechanical valve replacement (18.7%). Procedural and postoperative outcomes were obtained, and univariate and Kaplan-Meier analyses were performed.

RESULTS

VSRR patients were younger (42.7 ± 12.0 years of age) than ROOT (54.8 ± 13.6 years of age) (P < .001). Cardiopulmonary bypass (CPB) and cross-clamp duration were longer in VSRR (CPB: 228.0 ± 39.1 minutes; cross-clamp: 200.1 ± 36.2 minutes) compared with ROOT (CPB: 199.5 ± 55 minutes; cross-clamp: 170.3 ± 39.5 minutes) (P < .001). Postoperative stroke, renal failure, pneumonia, and reoperation for bleeding were similar, but postoperative atrial and ventricular arrhythmias was lower in VSRR (15% vs 42%; P < .001). Length of stay and 30-day mortality were similar. At discharge, none had greater than trivial aortic insufficiency. Long-term 10-year survival and incidence of moderate-severe aortic insufficiency, aortic stenosis, and reoperation were equivalent between groups.

CONCLUSIONS

Surgery for aortopathy associated with NS-BAV is safe and effective with either VSRR or ROOT. Despite its complexity, VSRR should be considered in the surgical treatment of this population.

Aortic Dissection in an Undiagnosed Familial Form of Bicuspid Aortic Valve with a Short Raphe

•

BAV is associated with risk for dissection of the proximal aorta.

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Thorough BAV investigation is required for any aortic dissection.

•

Familial forms of BAV are probably associated with an increased risk for aortopathy.

•

Familial screening is desirable to organize follow-up of each patient with BAV.

An aortic root abscess in a patient with a bicuspid aortic valve: a case report

Background

Infective endocarditis is a serious infection associated with high mortality and severe complications, such as heart failure, uncontrolled infection, and embolic events. Certain populations, including individuals with a prosthetic valve and those with native valve disease, such as bicuspid aortic valve, are considered to be more at risk of developing infective endocarditis.

Case summary

A 51-year-old previously healthy male presented with a 2-week history of persistent fever, malaise, and night sweats despite taking a long course of oral antibiotics. Examination was unremarkable; however, blood tests showed elevated inflammatory markers. Three sets of blood cultures revealed coagulase-negative gram-positive cocci (later identified as Staphylococcus lugdunensis), and the patient was subsequently started on IV antibiotics. His echocardiography showed a bicuspid aortic valve with severe regurgitation, and an aortic root abscess surrounding a dilated aortic root. In view of the presence of locally uncontrolled infection, the patient was referred for urgent debridement of the abscess and replacement of the aortic valve with tissue prosthesis. Fortunately, after a total of 6 weeks of IV antibiotics and successful operative management, our patient made a complete recovery.

Discussion

The development of an aortic root abscess occurs in 10–40% of cases of aortic valve endocarditis. Clinically, this should be suspected in any patient with endocarditis who fails to improve despite appropriate antibiotic therapy. This case demonstrates that severe infective endocarditis can develop in apparently healthy individuals due to underlying cardiac abnormalities.

Genetic Polymorphisms of MMP1, MMP9, COL1A1, and COL1A2 in Polish Patients with Thoracic Aortopathy

BACKGROUND

The pathogenesis of thoracic aortopathy is complex, and much evidence suggests the influence of genetic factors. Some genes with polymorphisms are widely considered critical factors in the initiation and development of aortic aneurysm. The aim of our study was to analyze the association of genetic polymorphisms of MMP1 rs1799750 (c.-1607G>GG), MMP9 rs3918242 (c.-1562C>T), COL1A1 rs1800012 (c.1245G>T), and COL1A2 rs42524 (c.1645G>C) with predisposition to thoracic aortopathy in Polish patients and with clinical characteristics of these patients.

METHODS

The study was carried out with 96 patients with thoracic aortopathy (47 patients with ascending aortic aneurysm and 49 patients with thoracic aortic dissection) and 61 control subjects without thoracic aortopathy. The MMP1, MMP9, COL1A1, and COL1A2 polymorphisms were determined by PCR-RFLP.

RESULTS

No significant differences in the frequency distributions of MMP1, MMP9, COL1A1, and COL1A2 genotypes or alleles were found (1) between the control group and patients with ascending aortic aneurysm (AsAA), (2) between the control group and patients with thoracic aortic dissection (TAD), or (3) between AsAA and TAD patients. Multivariate logistic regression analysis revealed that MMP1 and MMP9 polymorphisms were associated with the degree of aortic valve regurgitation.

CONCLUSION

The results of our study did not support associations between MMP1, MMP9, COL1A1, and COL1A2 genetic variants with the risk of thoracic artery disease in Polish patients. However, rs1799750 MMP1 and rs3918242 MMP9 seem to be associated with the degree of aortic regurgitation.

Native Valve Endocarditis due to Staphylococcus warneri Developing in a Patient with Type 1 Diabetes

A 59-year-old man with type 1 diabetes presented with heart failure. Echocardiography showed large vegetations on the mitral and aortic valves. Blood bacterial culture was positive for Staphylococcus warneri, a coagulase-negative staphylococcus (CoNS) family member. He was diagnosed with native valve endocarditis (NVE) induced by the resident bacteria and ultimately underwent double valve replacement. Retrospectively, slight laboratory data abnormalities and weight loss beginning four months before may have been signs of NVE. He had no history of immunosuppressive therapies or medical device implantation. Thus, CoNS can cause NVE after a long asymptomatic course in patients with poorly controlled diabetes.

4D flow MRI applications in congenital heart disease

Advances in the diagnosis and management of congenital heart disease (CHD) have resulted in a growing population of patients surviving well into adulthood and requiring lifelong follow-up. Flow quantification is a central component in the assessment of patients with CHD. 4D flow magnetic resonance imaging (MRI) has emerged as a tool that enables comprehensive study of flow. It involves the acquisition of a three-dimensional time-resolved volume with velocity encoding in all three spatial directions along the cardiac cycle. This allows flow quantification and visualization of blood flow patterns as well as the study of advanced hemodynamic parameters as kinetic energy and wall shear stress. 4D flow MRI-based study of flow has given insight into the altered hemodynamics in CHD particularly in bicuspid aortic valve disease and Fontan circulation. The aim of this review is to discuss the expanding clinical and research applications of 4D flow MRI in CHD as well its limitations.Key Points• Three-dimensional velocity encoding allows not only flow quantification but also the visualization of multidirectional flow patterns and the study of advanced hemodynamic parameters.• 4D flow MRI has added insight into the abnormal hemodynamics involved in congenital heart disease in particular in bicuspid aortic valve and Fontan circulation.• The main limitation of 4D flow MRI in congenital heart disease is the relatively long scan duration required for the complete coverage of the heart and great vessels with adequate spatiotemporal resolution.

Causes, Diagnosis, Risk Stratification and Treatment of Bicuspid Aortic Valve Disease: An Updated Review

The most common congenital heart disease is the bicuspid aortic valve. Understanding the pathophysiology and the altered hemodynamics is a key component for the diagnosis, risk stratification and treatment. Among others, aortic valve stenosis is the most common complication. Treatment strategies vary depending on the severity of the disease, particularly the dilation of the aorta playing a major role. Together with valve replacement, transcatheter aortic valve implantation is now considered as an alternative option with good results. With this review we would like to discuss the causes, diagnostic methods, risk stratification and treatment strategies of the bicuspid aortic valve.

Outcomes of Florida Sleeve Procedure in Patients with Bicuspid Versus Tricuspid Aortic Valve

OBJECTIVE

Outcomes of the Florida Sleeve (FS) procedure in patients with bicuspid aortic valve (BAV) have not been reported before. We compared outcomes of the FS procedure between patients with BAV and those with tricuspid aortic valve (TAV).

METHODS

From May 1, 2002 to January 1, 2016, 177 patients including 18 BAV and 159 TAV underwent the FS procedure. Baseline characteristics, perioperative outcomes, and echocardiographic measurements were compared between the 2 groups. Kaplan-Meier and life-table analyses were used to evaluate survival and freedom from reintervention rates.

RESULTS

Mean ± standard deviation age and aortic root diameter were comparable in BAV and TAV groups, 47.83 ± 11.19 versus 49.59 ± 15.79 years (P = 0.55) and 56.57 ± 6.18 versus 55.17 ± 8.84 mm (P = 0.46), respectively. The 30-day mortality and stroke rates were zero in the BAV group and 1.88% (n = 3) in the TAV group (P = 1.00). One patient (5.55%) in the BAV group and 8 (5.03%) patients in the TAV group needed permanent pacemaker implantation (P = 0.62). Freedom from reoperation was 93% in the BAV group and 99% in the TAV group at 8 years (P = 0.041). Patient survival rate was 100% in the BAV group and 91% in the TAV group at 8 years (P = 0.42). Freedom from aortic insufficiency greater than mild was 93% in the BAV group and 96.5% in the TAV group at 5 years (P = 0.61).

CONCLUSIONS

This is the first study reporting outcomes of the FS procedure in patients with BAV. This technique is feasible, and the results appear to be durable when compared to patients with TAV.

Gemella morbillorum endocarditis in a patient with a bicuspid aortic valve

Gemella morbillorum is one of the rare causative microorganisms of endocarditis. We herein report a case of infective endocarditis in a patient with bicuspid aortic valve caused by G. morbillorum. Infective endocarditis diagnosis was established based on the Modified Duke’s criteria. The patient was successfully treated with medical-surgical management.

Implications of Renal Disease in Patients Undergoing Structural Interventions

Chronic kidney disease patients have a high prevalence of severe valvular heart disease, which reduces life expectancy. Transcatheter valve interventions has revamped the way we manage severe valvular heart disease and are an attractive alternative to invasive surgery in patients with chronic kidney disease and severe valvular heart disease. This review summarizes the impact of transcatheter valve interventions in patients with severe valvular heart disease and chronic kidney disease.

Bicuspid Aortic Valve Repair: Causes of Valve Failure and Long-Term Outcomes

BACKGROUND

Repair of bicuspid aortic valves (BAVs) for aortic regurgitation (AR) has favorable outcomes, but the impact of natural disease progression on durability of repair is uncertain. We evaluated causes of reoperation and compared outcomes of BAV repair to those of patients undergoing aortic valve replacement (AVR).

METHODS

Between January 1993 and December 2016, 113 patients had BAV repair at our institution for significant AR. Operative notes and pathology reports were studied to identify late causes of repair failure. For comparison with AVR, we utilized propensity score weighting with the score derived from preoperative and operative characteristics using gradient boosting machine model.

RESULTS

A total of 26 patients had late AVR after initial repair. Causes of late valve dysfunction included calcification or fibrosis of the cusps (68%), concomitant replacement addressing moderate degree of aortic valve disease to avoid future operation (20%), and cusp prolapse (12%). Pathological evaluation of these excised valves reported calcification and fibrosis in 88% of the valves. Ten-year survival of patients undergoing BAV repair was 91% compared with 90% for patients undergoing AVR with a mechanical valve and 79% for AVR with a bioprosthesis (P = .6). Incidence of reoperation after AVR with a bioprosthesis was similar to risk after repair whereas AVR with mechanical valve showed significant advantage.

CONCLUSIONS

Disease progression with calcification or fibrosis is the most common cause of valve failure after initial repair of BAV. Clinical outcomes of BAV repair for severe AR appear superior to AVR with bioprosthesis.

The role of stress concentration in calcified bicuspid aortic valve

Calcific aortic valve disease (CAVD) is the most common valvular heart disease in the aging population, and is now believed to be a slow, progressive, yet actively regulated process. The disease progression can be divided into two phases: initiation phase associated with lipid deposition and inflammation response, and the later propagation phase with active calcification growth. It has been hypothesized that elevated mechanical stress plays a major role in both phases of disease progression. In order to identify a direct link between leaflet stress and calcification development, we performed patient-specific finite-element (FE) analyses of six bicuspid aortic valves (BAV), where the leaflets, raphe and calcifications were all considered. The results showed that during the initiation phase, calcium buildup is likely to occur along the leaflet-root attachment curve (ATC), and the commissures, which are subject to the most drastic changes in stress during the cardiac cycle. During the propagation phase, the presence of calcification would lead to local stress concentration along its boundary, hence further calcification growth. Three patterns of calcification formation were identified on BAV leaflets: 'radial', which extended radially from ATC into the leaflet belly region; 'commissure to commissure', which extended circumferentially along the coaptation; and 'raphe', which located in the vicinity of the raphe. Furthermore, we found a strong correlation between regions with a high risk of calcium buildup and regions with elevated mechanical stress. The high-risk regions predicted at diastole on the non-calcified leaflet from FE models agreed reasonably well with the in vivo calcification locations, which indicates that patient-specific FE modelling could help us to evaluate the potential risk of calcification formation in the early stage of CAVD.

Biomechanical Assessment of Bicuspid Aortic Valve Phenotypes: A Fluid-Structure Interaction Modelling Approach

PURPOSE

Bicuspid aortic valve (BAV) is a congenital heart malformation with phenotypic heterogeneity. There is no prior computational study that assesses the haemodynamic and valve mechanics associated with BAV type 2 against a healthy tricuspid aortic valve (TAV) and other BAV categories.

METHODS

A proof-of-concept study incorporating three-dimensional fluid-structure interaction (FSI) models with idealised geometries (one TAV and six BAVs, namely type 0 with lateral and anterior-posterior orientations, type 1 with R-L, N-R and N-L leaflet fusion and type 2) has been developed. Transient physiological boundary conditions have been applied and simulations were run using an Arbitrary Lagrangian-Eulerian formulation.

RESULTS

Our results showed the presence of abnormal haemodynamics in the aorta and abnormal valve mechanics: type 0 BAVs yielded the best haemodynamical and mechanical outcomes, but cusp stress distribution varied with valve orifice orientation, which can be linked to different cusp calcification location onset; type 1 BAVs gave rise to similar haemodynamics and valve mechanics, regardless of raphe position, but this position altered the location of abnormal haemodynamic features; finally, type 2 BAV constricted the majority of blood flow, exhibiting the most damaging haemodynamic and mechanical repercussions when compared to other BAV phenotypes.

CONCLUSION

The findings of this proof-of-concept work suggest that there are specific differences across haemodynamics and valve mechanics associated with BAV phenotypes, which may be critical to subsequent processes associated with their pathophysiology processes.

Patients with bicuspid aortic valves may be associated with infra-hisian conduction disease requiring pacemakers

BACKGROUND

Bicuspid aortic valves (BAVs) are associated with accelerated valvular dysfunction. Increasing rates of conduction system disease are seen in patients with calcific tricuspid aortic valves (TAVs). However, little is known regarding the extent of conduction disorders in BAV patients. We sought to determine the extent of infra-hisian conduction pathology among patients with BAVs undergoing EP studies.

METHODS

We prospectively analyzed patients presenting to the EP laboratory from 2006 to 2017 at our institution. Thirty-three BAV patients had measured HV intervals. Each individual was matched by age and gender to two control patients. Clinical characteristics were collected and compared, and patients followed for outcomes.

RESULTS

The BAV cohort had a mean age of 47.8 ± 17.2 years (range 19-76 years). Indications for referral to the EP lab in the BAV cohort included SVT ablation (n = 16), VT ablation (n = 10), and EP study for syncope, pre-syncope, or palpitations (n = 29). Patients with BAVs had a mean HV interval of 58.7 ms ± 18.6 ms, compared to a mean of 47.2 ms ± 9.6 ms for controls (p value = 0.0001). Over a 10-year follow-up period, 9 BAV patients (27%) went on to require permanent pacing compared to 6 patients (9%) in the control group (p value = 0.03).

CONCLUSION

Compared to patients with TAVs presenting for EP evaluation, individuals with BAVs have longer HV intervals and a significantly increased requirement for pacemaker therapy over long-term follow-up. Closer monitoring of progressive conduction system disease in BAV patients may be warranted.

State-of-the art bicuspid aortic valve repair in 2020

Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.