Ascending Aortic Dimensions in Hypertensive Subjects: Reference Values for Two-Dimensional Echocardiography

Aortic Remodeling in Patients with Arterial Hypertension: Pathophysiological Mechanisms, Therapeutic Interventions and Preventive Strategies-A Position Paper from the Heart and Hypertension Working Group of the Italian Society of Hypertension

In patient with arterial hypertension the whole aorta is exposed to increased wall stress due to pressure overload. Different blood pressure (BP) components have been reported as main determinant of aortic remodelling. In particular increased diastolic BP has been associated with aortic dilatation across all its segments with smaller increase in aortic root and ascending aorta related to increased systolic BP and pulse pressure. Optimal BP control is crucial to prevent development of aortic aneurysm and acute aortic disease. Many studies have evaluated the role of different antihypertensive drug classes for prevention of adverse aortic remodelling including beneficial effects of ACEIs, ARBs, dihydropyridinic calcium channel blockers and Beta-blockers. The present review discusses pathophysiological mechanisms, therapeutic interventions and preventive strategies for development of aortic remodeling in patients with arterial hypertension.

Association Between Lipoprotein(a) and Dilatation of Different Aortic Segments in Hypertensive Patients

PURPOSE

There are limited reports on the potential link between Lp(a) and ARDM. Thus, we examined the relationship between Lp(a) and ARDM among hypertensive patients.

METHODS

We used echocardiography to measure ARDM in 513 consecutively hospitalized patients. namely, the aortic valve annulus (Ava), sinuses of Valsalva (SV), sinotubular junction (STJ), and ascending aorta (AA) in 513 consecutive inpatients. We also examined the Lp(a), and other laboratory profiles of all participants.

RESULTS

Lp(a) exhibited a positive and independent relationship with the SV diameter (coefficient [β] = 0.330, p = 0.002) and STJ (coefficient [β] = 0.253, p = 0.023), regardless of age, sex, height, or other clinical factors among hypertensive, but not nonhypertensive patients. We also demonstrated that a marked rise in Lp(a) levels was independently associated with SV dilatation (SVD) (OR: 1.006, 95% CI: 1.002-1.009, p = 0.002) and AA dilatation (AAD) (OR: 1.006, 95% CI: 1.000-1.011, p = 0.035) in patients with hypertension. In the subgroup analysis, elevated Lp(a) levels were significantly associated with SV dilatation in all subgroups, and with AAD in males and patients aged 65 years or younger (p < 0.05). The restricted cubic spline analysis indicated a linear association between Lp(a) levels and the risk of both SV and AAD (p < 0.05).

CONCLUSIONS

Herein, we were the first to report that among hypertensive patients, elevated Lp(a) concentrations were intricately linked to the ARDMs at SV and STJ. Moreover, we revealed that the Lp(a) level was a stand-alone indicator of SVD and AAD.

Development of idealized human aortic models for in vitro and in silico hemodynamic studies

Background

The aorta, a central component of the cardiovascular system, plays a pivotal role in ensuring blood circulation. Despite its importance, there is a notable lack of idealized models for experimental and computational studies.

Objective

This study aims to develop computer-aided design (CAD) models for the idealized human aorta, intended for studying hemodynamics or solid mechanics in both in vitro and in silico settings.

Methods

Various parameters were extracted from comprehensive literature sources to evaluate major anatomical characteristics of the aorta in healthy adults, including variations in aortic arch branches and corresponding dimensions. The idealized models were generated based on averages weighted by the cohort size of each study for several morphological parameters collected and compiled from image-based or cadaveric studies, as well as data from four recruited subjects. The models were used for hemodynamics assessment using particle image velocimetry (PIV) measurements and computational fluid dynamics (CFD) simulations.

Results

Two CAD models for the idealized human aorta were developed, focusing on the healthy population. The CFD simulations, which align closely with the PIV measurements, capture the main global flow features and wall shear stress patterns observed in patient-specific cases, demonstrating the capabilities of the designed models.

Conclusions

The collected statistical data on the aorta and the two idealized aorta models, covering prevalent arch variants known as Normal and Bovine types, are shown to be useful for examining the hemodynamics of the aorta. They also hold promise for applications in designing medical devices where anatomical statistics are needed.

Development of hypertension models for lung cancer screening cohorts using clinical and thoracic aorta imaging factors

This study aims to develop and validate nomogram models utilizing clinical and thoracic aorta imaging factors to assess the risk of hypertension for lung cancer screening cohorts. We included 804 patients and collected baseline clinical data, biochemical indicators, coexisting conditions, and thoracic aorta factors. Patients were randomly divided into a training set (70%) and a validation set (30%). In the training set, variance, t-test/Mann-Whitney U-test and standard least absolute shrinkage and selection operator were used to select thoracic aorta imaging features for constructing the AIScore. Multivariate logistic backward stepwise regression was utilized to analyze the influencing factors of hypertension. Five prediction models (named AIMeasure model, BasicClinical model, TotalClinical model, AIBasicClinical model, AITotalClinical model) were constructed for practical clinical use, tailored to different data scenarios. Additionally, the performance of the models was evaluated using receiver operating characteristic (ROC) curves, calibration curves and decision curve analyses (DCA). The areas under the ROC curve for the five models were 0.73, 0.77, 0.83, 0.78, 0.84 in the training set, and 0.77, 0.78, 0.81, 0.78, 0.82 in the validation set, respectively. Furthermore, the calibration curves and DCAs of both sets performed well on accuracy and clinical practicality. The nomogram models for hypertension risk prediction demonstrate good predictive capability and clinical utility. These models can serve as effective tools for assessing hypertension risk, enabling timely non-pharmacological interventions to preempt or delay the future onset of hypertension.

Effect of physiological and pharmacological stress on heart rate, blood pressure, and echocardiographic measurements in healthy Warmblood horses

BACKGROUND

Echocardiographic measurements are important prognostic indicators but might be influenced by heart rate and blood pressure. This is particularly important when comparing repeated examinations.

HYPOTHESIS

To determine the effect of physiological stress at mildly increased heart rates and pharmacological challenge using IV administration of N-butylscopolammonium bromide and metamizol sodium on heart rate, blood pressure, and echocardiographic measurements.

ANIMALS

Twenty healthy Warmblood horses.

METHODS

Randomized crossover study. Horses were examined echocardiographically by 2-dimensional, M-mode, pulsed wave (PW) Doppler, and PW tissue Doppler imaging with simultaneous ECG recording and noninvasive blood pressure measurements during rest, physiological stress, and pharmacological challenge. Cardiac dimensions and functions were measured by a blinded observer. Data were analyzed using repeated-measures analysis of variance.

RESULTS

Mean heart rate and arterial blood pressure were significantly higher during physiological stress (46 ± 2 bpm, 93 ± 16 mm Hg) and pharmacological challenge (62 ± 13 bpm, 107 ± 17 mm Hg) compared with rest (34 ± 3 bpm, 86 ± 12 mm Hg; P < .05). Compared with rest, physiological stress resulted in increased left atrial fractional area change (34.3 ± 7.5 vs 27.3 ± 5.1%; P = .01) and left ventricular late diastolic radial wall motion velocity (13 ± 3 vs 10 ± 2 cm/s; P = .01) but had no significant effect on most other echocardiographic variables. Compared with rest, pharmacological challenge led to significantly decreased left atrial and diastolic ventricular dimensions (left ventricular internal diameter: 10.3 ± 0.9 vs 10.7 ± 0.8 cm; P = .01), increased aortic and pulmonary diameters, and ventricular wall thickness.

CONCLUSIONS AND CLINICAL IMPORTANCE

Physiological stress at mildly increased heart rates significantly enhanced atrial pump function. Larger heart rate and blood pressure increases during pharmacological challenge resulted in altered cardiac dimensions. This should be taken into account when evaluating echocardiographic measurements at increased heart rates.

Normalization of ascending aorta dimension for body size influences pathophysiologic correlation in hypertensive patients: the Campania Salute Network

AIMS

In the present study, we assessed correlates and their consistency of ascending aorta (AscAo) measurement in treated hypertensive patients.

METHODS AND RESULTS

A total of 1634 patients ≥ 18 years old with available AscAo ultrasound were included. Ascending aorta was measured at end-diastole with leading edge to leading edge method, perpendicular to the long axis of the aorta in parasternal long-axis view at its maximal identifiable dimension. Correlations of AscAo and AscAo normalized for height (AscAo/HT) or body surface area (AscAo/BSA) with demographics and metabolic profile were explored. Multi-variable regression was also used to identify potential confounders influencing univariate correlations. Sensitivity analysis was performed using cardiovascular (CV) outcome. Correlations with age, estimated glomerular filtration rate, systolic blood pressure (BP), and heart rate (HR) were similar among the three aortic measures. Women exhibited smaller AscAo but larger AscAo/BSA than men with AscAo/HT offsetting the sex difference. Obesity and diabetes were associated with greater AscAo and AscAo/HT but with smaller AscAo/BSA (all P < 0.001). In multi-variable regression model, all aortic measure confirmed the sign of their relations with sex and metabolic profile independently of age, BP, and HR. In Kaplan-Mayer analysis, only dilated AscAo and AscAo/HT were significantly associated with increased risk of CV events (both P < 0.008).

CONCLUSIONS

Among patients with long-standing controlled systemic hypertension, magnitude of aortic remodelling is influenced by the type of the measure adopted, with physiological consistency only for AscAo and AscAo/HT, but not for AscAo/BSA.

Proximal aorta dilatation in hypertension

Dilation of the proximal aorta is a common clinical manifestation in hypertensive patients. Although it is straightforward to link hypertension with proximal aortic dilation, previous studies on their interrelation have yielded controversial results. Cross-sectional design, methodology of blood pressure assessment, confounding factors like medications, and inconsistent reference values may lead to the paradoxical conclusions. Recently, advances have been made in the exploration of determinants and clinical value of proximal aortic dilatation. Thus, we reviewed these findings and summarized that aortic dilatation may be the consequence of hemodynamic and nonhemodynamic co-factors' combined action. Moreover, proximal aortic dilatation tends to be a predictor for aortic aneurysm dissection or rupture, hypertensive target organ damage as well as cardiovascular events. The present review contributes to a comprehensive understanding of the pathological process of proximal aortic dilatation in hypertension.

Prevalence and determinants of dilated ascending aorta in a Swedish population: a case-control study

Aims

Dilation of the ascending aorta (AA) is often asymptomatic until a life-threatening dissection or rupture occurs. An overall increase in the use of thoracic imaging has enabled early and sometimes incidental identification of AA dilation. Still, the prevalence and determinants of AA dilation remain to be clarified. The aim was to identify and characterize persons with AA dilation in a middle-aged Swedish population.

Methods and results

We used the Swedish CardioPulmonary BioImage Study Linköping (n = 5058, age 50-65 years) to identify cases with AA diameter ≥ 40 mm on coronary computed tomography angiography (CCTA) or chest computed tomography. Age- and gender-matched individuals with AA diameter < 40 mm served as controls. Echocardiography, blood pressure (BP) measurements (office and home), pulse wave velocity (PWV), coronary artery calcification (CAC), CCTA-detected coronary atherosclerosis, and carotid ultrasound were used to characterize these subjects. We identified 70 cases (mean AA diameter 44 mm, 77% men) and matched these to 146 controls (mean AA diameter 34 mm). Bicuspid aortic valve and aortic valve dysfunction were more common in cases than in controls (8% vs. 0% and 39% vs. 11%, respectively). Both office and home BP levels were significantly higher among cases. Also, high PWV (>10 m/s) levels were more common in cases (33% vs. 17%). Neither CAC scores nor prevalence or burden of atherosclerosis in coronary and carotid arteries differed between groups.

Conclusion

The prevalence of dilated AA was 1.4% and showed positive associations with male gender, aortic valve pathology, and diastolic BP, though not with subclinical atherosclerosis.

Ascending aorta curvature and flow displacement are associated with accelerated aortic growth at long-term follow-up: A MRI study in Marfan and thoracic aortic aneurysm patients

Background

Aortic aneurysm formation is associated with increased risk of aortic dissection. Current diagnostic strategies are focused on diameter growth, the predictive value of aortic morphology and function remains underinvestigated. We aimed to assess the long-term prognostic value of ascending aorta (AA) curvature radius, regional pulse wave velocity (PWV) and flow displacement (FD) on aortic dilatation/elongation and evaluated adverse outcomes (proximal aortic surgery, dissection/rupture, death) in Marfan and non-syndromic thoracic aortic aneurysm (NTAA) patients.

Methods

Long-term magnetic resonance imaging (MRI) and clinical follow-up of two previous studies consisting of 21 Marfan and 40 NTAA patients were collected. Baseline regional PWV, AA curvature radius and normalized FD were assessed as well as diameter and length growth rate at follow-up. Multivariate linear regression was performed to evaluate whether baseline predictors were associated with aortic growth.=.

Results

Of the 61 patients, 49 patients were included with MRI follow-up (n = 44) and/or adverse aortic events (n = 7). Six had undergone aortic surgery, no dissection/rupture occurred and one patient died during follow-up. During 8.0 [7.3-10.7] years of follow-up, AA growth rate was 0.40 ± 0.31 mm/year. After correction for confounders, AA curvature radius (p = 0.01), but not FD or PWV, was a predictor of AA dilatation. Only FD was associated with AA elongation (p = 0.01).

Conclusion

In Marfan and non-syndromic thoracic aortic aneurysm patients, ascending aorta curvature radius and flow displacement are associated with accelerated aortic growth at long-term follow-up. These markers may aid in the risk stratification of ascending aorta elongation and aneurysm formation.

Artificial intelligence measuring the aortic diameter assist in identifying adverse blood pressure status including masked hypertension

INTRODUCTION AND OBJECTIVES

Artificial intelligence (AI) made it achievable that aortic dilation could be measured in CT images indirectly, while aortic diameter (AD) has the certain relationship with blood pressure. It was potential that the blood pressure condition be determined by AD measurement using the data obtained from a CT scanning especially in identifying masked hypertension and predicting the risk of poor control of blood pressure (BP) which was easy to elude diagnosis in clinic. We aimed to evaluate the possibility of utilizing AD by AI for predicting the risk of adverse BP status (including masked hypertension or poor BP control) and the optimal thoracic aortic position in measurement as well as the cutoff value for predicting the risk.

METHODS

Eight hundred and one patients were enrolled in our study. AI-Rad Companion Cardiovascular (K183268 FDA approved) was used to perform automatic aorta measurement in thoracic CT images at nine key positions based on AHA guidelines. Data was post processed by software from AI-Rad Companion undergone rigorous clinical validation by both FDA and CE as verification of its efficacy and usability. The AD's risk and diagnostic value was assessed in identifying hypertension in the general population, in identifying the poor BP controlled in the hypertension population, and in screening masked hypertension in the general population respectively by multiple regression analysis and receiver operating curve analysis.

RESULTS

AD measured by AI was a risk factor for adverse BP status after clinical covariates adjustment (OR = 1.02 ~ 1.26). The AD at mid descending aorta was mostly affected by BP particularly, which is optimal indicator in identifying hypertension in the general population (AUC = 0.73) and for screening masked hypertension (AUC = 0.78).

CONCLUSION

Using AI to measure the AD of the aorta, particularly at the position of mid descending aorta, is greatly valuable for identifying people with poor BP status. It will be possible to reveal more clinical information reflected by ordinary CT images and enrich the screening methods for hypertension, especially masked hypertension.PLAIN LANGUAGE SUMMARYHTN has a significant adverse effect on arterial deformation. BP and arterial dilation promote each other in a vicious circle. Arterial dilation may not be restricted by apparent fluctuations in BP and is objective evidence of an undesirable BP state. The accuracy of AD measurements by AI on chest CT images has been verified. There has not been the application of AD measurement by AI in the scene of poor BP status in clinical practice.In this study, we applied AI to measure the diameter of the aorta in nine consecutive positions. We explored the association between AD at various positions and BP levels and the possibility that AD in identifying poor BP status in different populations. We found that the AD at the MD is of great value in screening MH and evaluating the control state of BP in HTN. It will be possible to significantly expand the clinical information reflected by ordinary CT images and enrich the screening methods for HTN, especially MH.

Personalising cardiovascular network models in pregnancy: A two-tiered parameter estimation approach

Uterine artery Doppler waveforms are often studied to determine whether a patient is at risk of developing pathologies such as pre-eclampsia. Many uterine waveform indices have been developed, which attempt to relate characteristics of the waveform with the physiological adaptation of the maternal cardiovascular system, and are often suggested to be an indicator of increased placenta resistance and arterial stiffness. Doppler waveforms of four patients, two of whom developed pre-eclampsia, are compared with a comprehensive closed-loop model of pregnancy. The closed-loop model has been previously validated but has been extended to include an improved parameter estimation technique that utilises systolic and diastolic blood pressure, cardiac output, heart rate, and pulse wave velocity measurements to adapt model resistances, compliances, blood volume, and the mean vessel areas in the main systemic arteries. The shape of the model-predicted uterine artery velocity waveforms showed good agreement with the characteristics observed in the patient Doppler waveforms. The personalised models obtained now allow a prediction of the uterine pressure waveforms in addition to the uterine velocity. This allows for a more detailed mechanistic analysis of the waveforms, eg, wave intensity analysis, to study existing clinical indices. The findings indicate that to accurately estimate arterial stiffness, both pulse pressure and pulse wave velocities are required. In addition, the results predict that patients who developed pre-eclampsia later in pregnancy have larger vessel areas in the main systemic arteries compared with the two patients who had normal pregnancy outcomes.

Aortic enlargement in chronic obstructive pulmonary disease (COPD) and emphysema: The Multi-Ethnic Study of Atherosclerosis (MESA) COPD study

BACKGROUND

The prevalence of abdominal aortic aneurysm is high in chronic obstructive pulmonary disease (COPD) population. Emphysema involves proteolytic destruction of elastic fibers. Therefore, emphysema may also contribute to thoracic aorta dilatation. This study assessed aorta dilation in smokers stratified by presence of COPD, emphysema and airway thickening.

METHODS

Aorta diameters were measured on 3D magnetic resonance angiography in smokers recruited from the Multi-Ethnic Study of Atherosclerosis (MESA), the Emphysema and Cancer Action Project (EMCAP), and the local community. COPD was defined by standard spirometric criteria; emphysema was measured quantitatively on computed tomography and bronchitis was determined from medical history.

RESULTS

Participants (n = 315, age 58-79) included 150 with COPD and 165 without COPD, of whom 56% and 19%, respectively, had emphysema. Subjects in the most severe quartile of emphysematous change showed the largest diameter at all four aorta locations compared to those in the least severe quartiles (all p < 0.001). Comparing subjects with and without COPD, aorta diameters were larger in participants with severe COPD in ascending and arch (both p < 0.001), and abdominal aorta (p = 0.001). Chronic bronchitis and bronchial wall thickness did not correlate with aorta diameter. In subjects with emphysema, subjects with coexistence of COPD showed larger aorta than those without COPD in ascending (p = 0.003), arch (p = 0.002), and abdominal aorta (p = 0.04).

CONCLUSIONS

This study showed larger aorta diameter in subjects with COPD and severe emphysema compared to COPD related to chronic bronchitis or bronchial wall thickening.

Aortic flow below and visceral circulation during aortic counterpulsation: Evaluation of an in vitro model

INTRODUCTION

This study aimed to test a computer-driven cardiovascular model for the evaluation of the visceral flow during intra-aortic balloon pump (IABP) assistance.

METHODS

The model includes a systemic and pulmonary circulation as well as a heart contraction model. The straight polyurethane tube aorta had a single visceral while four windkessel components mimicked resistance compliance of the brachiocephalic, renal and sub-mesenteric, pulmonary, and systemic circulation. Twelve flow probes were placed in the circuit to measure pressures and flows with the IABP on and off.

RESULTS

With the balloon off, the meantime to reach the steady state was 48 ± 16 s; with the balloon on, this figure was 178 ± 20 s. The stability of pressure and flow signals was obtained after 72 ± 11 min. The number of cycles of stability of the system was 93 [86-103]. Measurements were reliable either with samples of 10 or 20 beats. Bland Altman method demonstrated the reliability of measurements. Finally, all measurements were comparable to published in vivo data.

CONCLUSION

The presented mock circulation was reliable and gave values with high accuracy both at baseline and during mechanical assistance. This system allows evaluation of the mesenteric flow during IABP, under different clinical/hemodynamic conditions. Nonetheless, its translational potential needs to be further evaluated.

Identification of cardiac organ damage in arterial hypertension: insights by echocardiography for a comprehensive assessment

: Arterial hypertension, a widespread disease, whose prevalence increases with age, represents a major risk factor for cardiovascular events, causing damage in several organs, including the heart. In this context, echocardiography has a clear and pivotal role, being able to assess cardiac morphology and detect haemodynamic changes induced by this disease. 2018 European Society of Cardiology/European Society of Hypertension guidelines on AH identified main echo parameters such as left ventricular mass, relative wall thickness and left atrial volume, for detecting cardiac organ damage. The present review highlights the advantage of additional echocardiographic parameters such as diastolic measurement and both thoracic and abdominal aortic dimensions. An overlook on aortic valve should also be suggested to detect aortic regurgitation and stenosis, both frequent complications in hypertensive patients. In this kind of comprehensive assessment, the combination of standard and advanced echocardiography (speckle tracking echocardiography and, with a lesser extent, three-dimensional echocardiography) could be considered to improve the diagnostic accuracy, stratify prognosis and address management in arterial hypertension.

Prevalence of proximal ascending aorta and target organ damage in hypertensive patients: the multicentric ARGO-SIIA project (Aortic RemodellinG in hypertensiOn of the Italian Society of Hypertension)

AIM

The aim of this study was to assess the prevalence of ascending aortic dilatation and to evaluate the possible association between proximal aorta dilatation and structural or functional markers of cardiac organ damage in hypertensive patients.

BACKGROUND

Dilatation of the sinus of valsalva (SoV) is a common finding in clinical practice and it is associated with an increased cardiovascular risk in hypertensive patients: less is known about the dilatation prevalence of the subsequent portion, the proper ascending aorta and its relationship with cardiovascular organ damage.

METHODS

This multicentric study included 582 hypertensive and 104 normotensive control individuals. All individuals underwent clinical evaluation and two-dimensional transthoracic echocardiography focused on the evaluation of the aorta. Aortic diameters at three levels were measured: SoV, sinotubular junction and ascending aorta.

RESULTS

The prevalence of ascending aorta dilatation was 13%. Patients with ascending aorta dilatation were on average 10 years older than hypertensive patients without aortic dilatation and control individuals.Left ventricular mass was significantly increased (P < 0.0001) in patients with ascending aorta dilatation with (113.29 ± 3 g/m) or without (109.16 ± 3 g/m) SoV dilatation compared with patients with isolated SoV dilatation (98.80 ± 21.8 g/m) or normal aorta (96.04 ± 26.5 g/m), with left ventricular hypertrophy (LVH) being twice as common in this group compared with the latter (60 vs. 28%, P < 0.0001).

CONCLUSION

Prevalence of ascending aorta dilatation in hypertensive patients reaches 13%. Hypertensive individuals with enlarged ascending aorta showed significantly increased left ventricular mass, a well known sign of hypertension related cardiac damage and could thus represent a subset of hypertensive patients at an increased cardiovascular risk.

Technological Advancements in Echocardiographic Assessment of Thoracic Aortic Dilatation: Head to Head Comparison Among Multidetector Computed Tomography, 2-Dimensional, and 3-Dimensional Echocardiography Measurements

PURPOSE

The aim of this study was to evaluate the feasibility and accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (2DTTE, 3DTTE) versus multidetector computed tomography (MDCT) in patients with ascending aortic (AA) dilation.

MATERIALS AND METHODS

Fifty consecutive patients with AA dilation were evaluated by 2DTTE, X-plane (XP) 3DTTE, and MDCT. Aorta diameters were measured at aortic annulus, aortic root (SIN), sinotubular junction, AA, aortic arch before the prebrachiocephalic artery (PRE), and before left subclavian artery (INTRA). Leading edge-to-leading edge (L-L) and inner-to-inner (I-I) measurements were compared with MDCT data.

RESULTS

Feasibility, quality of imaging, and accuracy was high with all echocardiographic methods. Specifically for MDCT maximum SIN diameter, the best correlation and agreement was obtained using XP maximum diameter at 3DTTE (MDCT: 44.8±7.4 mm vs. XP: 44.4±7.4 mm; r=0.975; bias=-0.4 mm). The same was true for AA maximum diameter at MDCT (MDCT: 46.6±8.1 mm vs. XP: 47.5±8.1 mm; r=0.991; bias=0.1 mm). For aortic arch the best correlation and agreement with MDCT were as follows: 2DTTE L-L diameter for arch PRE (MDCT: 37.9±5.3 mm vs. TTE: 36.6±4.5 mm; r=0.927; bias=-0.9 mm) and MDCT minimum diameter with XP minimum diameter for arch INTRA (MDCT: 28.2±5.0 mm vs. TTE 28.8±4.7 mm; r=0.939; bias=-0.3 mm).

CONCLUSION

In patients with aortic dilatation or aneurysm, new techniques (mainly 2D-3D probes allowing XP views) facilitate accuracy of aortic measurements at different sites of the vessel and allow standardization of analysis to better compare with MDCT.

Reference Values for Mid-Ascending Aorta Diameters by Transthoracic Echocardiography in Adults

We sought to characterize mid-ascending aorta diameter reference values by age, sex, and body surface area (BSA) in a large echocardiography laboratory practice-based cohort. All subjects with transthoracic echocardiograms with mid-ascending aorta diameter measure from January 2004 to December 2009 were identified, and medical records were reviewed for medical history and anthropometric data. Those with aortic valve disease or replacement, congenital heart disease, any connective tissue or inflammatory disease that may affect the aorta, or known aortic aneurysm (>55 mm) were excluded. Mid-ascending aorta diameter was measured in a standardized manner using "leading edge to leading edge" technique at end-diastole. Of 27,839 eligible subjects, 16,620 did not have history of hypertension and were included in the analysis (56.3% female; mean age 52.0 ± 15.8 years), mean mid-ascending aorta diameter 31.7 ± 4.1 mm. Females had smaller diameter than males (30.5 ± 3.7 mm vs 33.3 ± 4.0 mm; p <0.001). Subjects with history of hypertension (n = 11,219; not included in the analysis) had larger mid-ascending aorta diameter compared with normotensive subjects (33.9 ± 3.8 mm vs 31.7 ± 4.1 mm; p < 0.001). Age had the greatest correlation with aortic size (r = 0.55), followed by sex (r = 0.35) and BSA (r = 0.35). Nomograms for predicted mid-ascending aorta diameter were generated at the 95th percentile using quantile regression for subjects without hypertension stratified by age, sex, and BSA. In conclusion, mid-ascending aorta diameter is predominantly associated with sex, age, and BSA. The nomograms established by this study may serve as useful reference values for echocardiographic screening and surveillance.

Aortic Diameters and Mild Functional Aortic Regurgitation in Hypertensive and Normotensive People: Do They Carry the Same Meaning?

OBJECTIVES

The association between the aortic root diameter and aortic regurgitation in hypertensive and normotensive people is still disputed, and the underlying mechanisms remain to be clearly elucidated. We aimed to investigate the relationship between the aortic root diameter and trivial to mild functional aortic regurgitation in never-treated hypertensive patients with a new diagnosis compared with healthy normotensive participants.

METHODS

A total of 182 hypertensives and 232 age-matched normotensives were included in the study. Anthropometric and office blood pressure (BP) measurements, echocardiography, and a carotid stiffness assessment were performed in all of the participants. Aortic measures for the annulus, sinuses of Valsalva, sinotubular junction, and ascending aorta were taken in late diastole according to the leading-edge method.

RESULTS

The mean age of all participants was 52 years. Hypertensive patients had a significantly higher body surface area, mean arterial pressure, and pulse pressure (P < .0001) than normotensive participants. Annulus and sinotubular junction diameters adjusted for confounders and indexed to the body surface area were significantly higher in normotensives than in hypertensives. The prevalence of functional aortic regurgitation was higher in hypertensives (34.8% versus 15.4%; P < .0001). Among the hypertensives, no difference in aortic diameters was found between patients with or without functional aortic regurgitation, whereas normotensives with functional aortic regurgitation had larger aortic root diameters. Aging and BP among the hypertensives were the main determinants of functional aortic regurgitation.

CONCLUSIONS

Hypertensive patients had a smaller indexed aortic root diameter than normotensive participants but had a higher prevalence of trivial to mild functional aortic regurgitation. The aging process is the main determinant of functional aortic regurgitation in both groups, but high BP also plays an important role in hypertensives.

A systematic approach to 3D echocardiographic assessment of the aortic root

[first paragraph of article]Severe aortic regurgitation (AR) and/or severe abnormalities of the aortic root and the tubular ascending aorta (TAA) are indications for surgical treatment. The correct diagnosis, the choice of optimal treatment, as well as optimal timing of surgery, mainly depend on findings obtained by echocardiography - which is usually the initial diagnostic modality applied in clinical practice. Therefore, an appropriate morphological and functional quantification of the aortic valve (AV) and the aortic root complex is required. Aside from the need of standardization to provide a precise objective evaluation, the use of modern echocardiographic technologies - especially 3D-echocardiography -are less often implemented in clinical routine. The present manuscript focuses on the advantages of transthoracic and transesophageal 3D-echocardiography (TTE, TEE) for an improved assessment of the AV and the aortic root complex to provide accurate and comprehensive measurements for making the correct diagnosis and defining further therapeutic strategies.

Out of proportion proximal aortic remodeling: A subclinical marker of early vascular ageing? A systematic review

INTRODUCTION

Proximal aorta stiffens and dilates with aging. Aortic stiffening is a well known process, carrying prognostic implications. On the contrary, few data are available about proximal aorta dilatation. It is not known if "out of proportion" aortic remodeling, i.e. in excess for age, sex and body size, could be a marker of early vascular ageing; there is controversy on how it would be accelerated by classical risk factors or would associate with validated markers of cardiovascular organ damage.

AIM

We conducted a systematic review in order to evaluate the determinants of proximal aortic dimensions, focusing on the association with arterial hypertension, cardiovascular risk factors and markers of organ damage.

DETERMINANTS OF PROXIMAL AORTA REMODELING

Age, gender and body size explain 40-50% of the variability of aortic dimensions; genetic predisposition accounts for nearly 20%. Among cardiovascular risk factors obesity and hypertension seem to be associated with faster outward aortic remodeling. Arterial hypertension would account for a 0.60-0.78 mm greater diameter at the ascending aorta. Moreover, in hypertension, left ventricular mass showed a strict association with aortic diameter in nearly all studies. Other classical risk factors for atherogenesis such as dyslipidemia and smoking showed a weak influence on proximal aortic dimensions. No study reported a greater aortic remodeling in diabetics.

CONCLUSIONS

"Out of proportion" proximal aortic remodeling, could represent a subclinical marker of early vascular ageing, describing the cumulative influence of genetic predisposition, arterial hypertension and obesity.