Features and predictors of ascending aortic dilatation in association with a congenital bicuspid aortic valve

Point on the Aortic Bicuspid Valve

Background—Bicuspid aortic valve (BAV) disease is the most prevalent congenital heart disease in the world. Knowledge about its subtypes origin, development, and evolution is poor despite the frequency and the potential gravity of this condition. Its prognosis mostly depends on the risk of aortic aneurysm development with an increased risk of aortic dissection. Aims—This review aims to describe this complex pathology in way to improve the bicuspid patients’ management. Study design—We reviewed the literature with MEDLINE and EMBASE databases using MeSH terms such as “bicuspid aortic valve”, “ascending aorta”, and “bicuspid classification”. Results—There are various classifications. They depend on the criteria chosen by the authors to differentiate subtypes. Those criteria can be the number and position of the raphes, the cusps, the commissures, or their arrangements regarding coronary ostia. Sievers’ classification is the reference. The phenotypic description of embryology revealed that all subtypes of BAV are the results of different embryological pathogenesis, and therefore, should be considered as distinct conditions. Their common development towards aortic dilatation is explained by the aortic media’s pathological histology with cystic medial necrosis. At the opposite, BAV seems to display a profound genetic heterogeneity with both sporadic and familial forms. BAV can be even isolated or combined with other congenital malformations. Conclusions—All those characteristics make this pathology a highly complex condition that needs further genetic, embryological, and hemodynamic explorations to complete its well described anatomy.

Sex differences in aortopathy and valve diseases among patients undergoing cardiac surgery

BACKGROUND

We aimed to study sex differences in aortopathy and valve disease among patients undergoing aortic valve replacement and/or surgery for ascending aortic aneurysm, and assess whether differences are specific for patients with bicuspid (BAV) compared to patients with tricuspid aortic valve (TAV).

METHODS

We used a single-center and observational cohort including 1,045 patients undergoing elective open-heart surgery for aortic valve disease and/or ascending aortic aneurysm at the Karolinska Hospital (Sweden).

RESULTS

Women (33.0%) were older than men (mean [SD]; 67.9 [11] years vs 62.5 [13] years for men; P < 0.001). No significant sex difference in prevalence of ascending aortic aneurysm was found according to absolute measures (P = 0.19), however, women had a greater dilation of the ascending aorta when normalized for body surface area (mean [SD], 21.8 [6.3] mm/m² vs 19.3 [4.4] mm/m² for men; P < 0.001). Among the 560 patients with BAV, women had significantly more AS (adjusted OR, 2.23; 95% CI, 1.19-4.20; P = 0.013) and less AI (adjusted OR 0.42; 95% CI, 0.23-0.78; P < 0.01); whereas no sex difference was found among patients with TAV.

CONCLUSIONS

In this large study of patients undergoing cardiac surgery, we found greater degree of aortic dilation in women compared to men suggesting a need for earlier monitoring of women. Moreover, women with BAV had a significantly higher prevalence of AS compared to men. These results describe the aorta and valvular characteristics of patients by sex and provide guidance regarding which patients might benefit from closer surveillance.

Native Bicuspid Pulmonary Valve in D-Loop Transposition of the Great Arteries: Outcomes of the Neo-Aortic Valve Function and Root Dilation After Arterial Switch Operation

Background Neo-aortic root dilation and neo-aortic regurgitation (AR) are common after arterial switch operation for D-loop transposition of the great arteries. We sought to evaluate these outcomes in patients with bicuspid native pulmonary valve (BNPV). Methods and Results A retrospective analysis of patients with transposition of the great arteries undergoing arterial switch operation at Boston Children's Hospital from 1989 to 2018 matched BNPV patients 1:3 with patients with tricuspid native pulmonary valve by year of arterial switch operation. Kaplan-Meier analyses with log-rank test compared groups for time to first neo-aortic valve reoperation, occurrence of ≥moderate AR, and neo-aortic root dilation (root z score ≥4). A total of 83 patients with BNPV were matched with 217 patients with tricuspid native pulmonary valve. Patients with BNPV more often had ventricular septal defects (73% versus 43%; P<0.001). Hospital length of stay (11 versus 10 days) and 30-day surgical mortality (3.6% versus 2.8%) were similar. During median 11 years follow-up, neo-aortic valve reoperation occurred in 4 patients with BNPV (6.0%) versus 6 patients with tricuspid native pulmonary valve (2.8%), with no significant difference in time to reoperation. More BNPV had AR at discharge (4.9% versus 0%; P=0.014) and during follow-up (13.4% versus 4.3%; hazard ratio [HR], 3.9; P=0.004), with shorter time to first occurrence of AR; this remained significant after adjusting for ventricular septal defects. Similarly, neo-aortic root dilation was more common in BNPV (45% versus 38%; HR, 1.64; P=0.026) with shorter time to first occurrence. Conclusions While patients with BNPV have similar short-term arterial switch operation outcomes, AR and neo-aortic root dilation occur more frequently and earlier compared with patients with tricuspid native pulmonary valve. Further long-term studies are needed to determine whether this results in greater need for neo-aortic valve reoperation.

Sutureless aortic valve with supracoronary ascending aortic replacement as an alternative strategy for composite graft replacement in elderly patients

Aortic valve disease is frequently associated with ascending aorta dilatation and can be treated either by separate replacement of the aortic valve and ascending aorta or by a composite valve graft. The type of surgery is depending on the exact location of the aortic dilatation and the concomitant valvular procedures required. The evidence for elective aortic surgery in elderly high-risk patients remains challenging and therefore alternative strategies could be warranted. We propose an alternative strategy for the treatment of ascending aortic aneurysm and aortic valve pathology with the use of a sutureless, collapsible, stent-mounted aortic valve prosthesis.

Therapeutic approach comparison in bicuspid aortic valve aortopathy and clinical practice implications

Bicuspid aortic valve (BAV) is the most common heart valve malformation, and it may be associated with the development of long-term complications, such as aortic stenosis (AS) secondary to valvular calcification and aortic insufficiency (AI), with or without ascending aortic aneurysm (AAA). This study was performed at the Institute of Cardiovascular Diseases, Timişoara, Romania, from 2015 through 2018 and included a total of 105 patients with BAV. Out of the 105 BAV patients, 14 displayed AAA, alongside either AS or AI, and were selected undergo aortic valve replacement (AVR) alongside surgical replacement or aortoplasty of the ascending aorta, and the elastic fiber loss in the ascending aortic wall was evaluated for each patient. Two surgical interventions used alongside AVR in BAV patients with AAA and AS or AI were compared in this study: reduction ascending aortoplasty (RAA) and ascending aorta replacement (AAR). Postoperative follow-ups have shown RAA is useful short-term but that, in contrast to AAR, it leads to aortic redilatation over time. These results can contribute to a major future meta-analysis with the goal of improving the current clinical practice guidelines for BAV aortopathy.

Does the Leaflet Fusion Subtype Affect Pattern and Rate of Growth in BAV Aortopathy?: A Study of 102 BAV Aortopathy Cases With A Literature Review

BACKGROUND

Bicuspid aortic valves (BAV) and related aortopathy remain an intriguing topic. Not all BAVs get diseased and around 40% would develop aortic dilatation in their lifetime. If haemodynamic theory is to be believed, then leaflet fusion pattern should have an impact. This study sought to compare the association of aortic morphologies and rate of growth in a set of 102 BAV acropathies operated at a single centre, based on the fusion patterns.

METHODS

Data on aortic valve replacements over a 10-year period was analysed from a prospectively maintained database. Of the 198 BAV undergoing surgery, 102 had aortic dilatation above 40 mm on echocardiogram. These underwent computed tomography (CT) aortograms and were followed up as a part of a database. The impact of leaflet fusion patterns on aortic dilatation pattern and rate was analysed.

RESULTS

Of the 102, two patients had type 0 pathology and one had left-noncoronary (LN) leaflet fusion. Seventy-four (74) had type 1A or left-right (RL) fusion and 25 had type 1B right-noncoronary (RN) fusion. RL fusion had more males, were taller, bigger and had more proportion of aortic stenosis (AS). Aortic diameters, angles and growth rates at root, ascending/descending aorta and arch were not different. Regression analyses for size or growth did not show any significant impact of fusion pattern.

CONCLUSIONS

Left-right fusion pattern comprised three-quarters of BAV in this cohort and these patients were bigger, taller and had a greater proportion of males with increased rate of aortic stenosis. Despite these differences, there was no significant impact of fusion pattern on aortic size or rate of growth.

Long-Term Risk Factors for Dilatation of the Proximal Aorta in a Large Cohort of Children With Bicuspid Aortic Valve

Background:

Patients with bicuspid aortic valve (BAV) have a higher risk of developing aortic valve dysfunction and progressive proximal aorta dilatation, which can lead to aortic dissection. To this day, identification of children at risk of developing severe aortic dilatation during their pediatric follow-up is still challenging because most studies were restricted to adult subjects. The overarching goal of this study was to identify risk factors of aortic dilatation in children with BAV.

Methods:

We extracted clinical and echocardiographic data of all BAV subjects aged 0 to 20 years followed at Centre Hospitalier Universitaire Sainte-Justine between 1999 and 2016. We excluded subjects with concomitant heart defects and conditions affecting proximal aorta dimensions. Proximal aorta diameters (expressed as Z scores) were modeled in relation to age and potential predictive variables in a linear mixed model. The primary outcome was the rate of dilatation.

Results:

We included 761 subjects (3134 echocardiograms) in final analyses. The mean ascending aorta Z score progression rate for BAV patient with a normally functioning aortic valve was estimated at 0.05 Z score unit per year. The strongest predictors of an increased dilatation rate were severe aortic stenosis, moderate and severe aortic regurgitation, and uncorrected coarctation of the aorta. Aortic valve leaflet fusion pattern and sex were not associated with progression rate.

Conclusions:

Children with a normally functioning BAV exhibited a very slow proximal aorta dilatation rate. Ascending aorta dilatation rate was significantly increased in patients with more than mild aortic valve dysfunction but was independent from BAV leaflet fusion type.

NUMERICAL SIMULATION OF DILATION PATTERNS OF THE ASCENDING AORTA IN AORTOPATHIES

Aortic dilation is associated with congenital bicuspid aortic valve (BAV) disease, and its etiology is still not completely understood. The aim of this study is to provide further insight into aortic hemodynamics in a BAV population with different degrees of aortic dilation and regurgitation in comparison with a patient without pathology. A fluid–structure interaction (FSI) numerical approach is implemented regarding patient-specific geometries, where the aortic valves are defined by analytical orifices. Results show that, while the patient without pathology displays a typical hemodynamic behavior of flows in bends, BAV-related aortas present an accelerated flow along the outer aortic wall. Wall shear stress (WSS) overload in the outer curvature is observed, more marked in more dilated aortas. Moreover, helices in the ascending aorta are present in these patients, enhanced with greater dilation. These findings support the fact that hemodynamic factors play an important role in aortic dilation onset and development in BAV patients, caused by a prolonged exposure of the outer ascending aortic curvature to altered WSS. Besides, our results suggest that greater aortic regurgitation may be associated with abnormal WSS distributions in the ascending aorta during diastole, which can facilitate aortic root dilation.

High prevalence of ascending aortic dilatation in a consecutive coronary CT angiography patient population

Objectives

To clarify the prevalence and risk factors of ascending aortic (AA) dilatation according to ESC 2014 guidelines.

Methods

This study included 1000 consecutive patients scheduled for diagnostic coronary artery computed tomographic angiography. AA diameter was retrospectively measured in 3 planes: sinus valsalva, sinotubular junction, and tubular part. The threshold for AA dilatation was set to > 40 mm which has been suggested as an upper normal limit for AA diameter in ESC 2014 guidelines on aortic diseases. Aortic size index (ASI) using the ratio between aortic diameter and body surface area (BSA) was applied as a comparative measurement. The threshold for AA dilatation was set to the upper limit of normal distribution exceeding two standard deviations (95%). Risk factors for AA dilatation were collected from medical records.

Results

The patients’ mean age was 52.9 ± 9.8 years (66.5% women). The prevalence of AA dilatation was 23.0% in the overall study population (52.5% males) and 15.1% in the subgroup of patients with no coronary artery disease or bicuspid (BAV)/mechanical aortic valve (n = 365). According to the normal-distributed ASI values, the threshold for sinus valsalva was defined as 23.2 mm/m² and for tubular part 22.2 mm/m² in the subgroup. Higher BSA was associated with larger AA dimensions (r = 0.407, p < 0.001). Male gender (p < 0.001), BAV (p < 0.001), hypertension (p = 0.009) in males, and smoking (p < 0.001) appeared as risk factors for AA dilatation.

Conclusions

The prevalence of AA dilatation is high with current ESC guidelines for normal AA dimension, especially in males. Body size is strongly associated with AA dimensions; it would be more reliable to use BSA-adjusted AA diameters for the definition of AA dilatation.

Key Points

• The prevalence of AA dilatation is high in patients who are candidates for coronary CT angiography.

• Body size is strongly associated with AA dimensions.

The bicuspid aortic valve: Is it an immunological disease process?

Bicuspid aortic valves (BAVs) are the most common congenital cardiac condition and are characterized by a structural abnormality whereby the aortic valve is composed of two leaflets instead of being trileaflet. It is linked to an increased risk for a variety of complications of the aorta, many with an immunological pathogenesis. The aim of this study is to review and analyze the literature regarding immunological processes involving BAVs, associated common pathologies, and their incidence in the population. This study will also examine current trends in surgical and therapeutic approaches to treatment and discuss the future direction of BAV treatment.

Clinical and pathophysiological aspects of bicuspid aortic valve disease

A bicuspid aortic valve is not only a common congenital heart defect but also an enigmatic condition that can cause a large spectrum of diseases, such as aortic valve stenosis and severe heart failure in newborns whereas aortic dissection in adults. On the contrary, a bicuspid aortic valve can also occur with normal function throughout life and never need treatment. Numerous genetic mechanisms are involved in the abnormal cellular functions that may cause abnormal development of the aortic valve during early foetal life. As several chromosomal disorders are also associated with a bicuspid valve, there does not appear to be an apparent common trigger to the abnormal development of the aortic valve. The clinical care of the bicuspid aortic valve patient has been changed by a significant body of evidence that has improved the understanding of the natural history of the disease, including when to best intervene with valve replacement and when to provide prophylactic aortic root surgery. Moreover, as bicuspid valve disease is also part of various syndromes, we can identify high-risk patients in whom a bicuspid valve is much more unfavourable than in the normal population. This review provides an overview of all aspects of the bicuspid aortic valve condition and gives an updated perspective on issues from pathophysiology to clinical care of bicuspid aortic valve disease and associated aortic disease in asymptomatic, symptomatic, and pregnant patients, as well as our viewpoint on population screening.

Aortic stiffness in aortic stenosis assessed by cardiovascular MRI: a comparison between bicuspid and tricuspid valves

Objectives

To compare aortic size and stiffness parameters on MRI between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with aortic stenosis (AS).

Methods

MRI was performed in 174 patients with asymptomatic moderate-severe AS (mean AVAI 0.57 ± 0.14 cm²/m²) and 23 controls on 3T scanners. Valve morphology was available/analysable in 169 patients: 63 BAV (41 type-I, 22 type-II) and 106 TAV. Aortic cross-sectional areas were measured at the level of the pulmonary artery bifurcation. The ascending and descending aorta (AA, DA) distensibility, and pulse wave velocity (PWV) around the aortic arch were calculated.

Results

The AA and DA areas were lower in the controls, with no difference in DA distensibility or PWV, but slightly lower AA distensibility than in the patient group. With increasing age, there was a decrease in distensibility and an increase in PWV. After correcting for age, the AA maximum cross-sectional area was higher in bicuspid vs. tricuspid patients (12.97 [11.10, 15.59] vs. 10.06 [8.57, 12.04] cm², p < 0.001), but there were no significant differences in AA distensibility (p = 0.099), DA distensibility (p = 0.498) or PWV (p = 0.235). Patients with BAV type-II valves demonstrated a significantly higher AA distensibility and lower PWV compared to type-I, despite a trend towards higher AA area.

Conclusions

In patients with significant AS, BAV patients do not have increased aortic stiffness compared to those with TAV despite increased ascending aortic dimensions. Those with type-II BAV have less aortic stiffness despite greater dimensions. These results demonstrate a dissociation between aortic dilatation and stiffness and suggest that altered flow patterns may play a role.

Key Points

• Both cellular abnormalities secondary to genetic differences and abnormal flow patterns have been implicated in the pathophysiology of aortic dilatation and increased vascular complications associated with bicuspid aortic valves (BAV).

• We demonstrate an increased ascending aortic size in patients with BAV and moderate to severe AS compared to TAV and controls, but no difference in aortic stiffness parameters, therefore suggesting a dissociation between dilatation and stiffness.

• Sub-group analysis showed greater aortic size but lower stiffness parameters in those with BAV type-II AS compared to BAV type-I.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5775-6) contains supplementary material, which is available to authorized users.

Aortic Dilatation Associated With Bicuspid Aortic Valve: Relation to Sex, Hemodynamics, and Valve Morphology (the National Heart Lung and Blood Institute-Sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions)

This study analyzed the impact of sex, hemodynamic profile, and valve fusion pattern on aortopathy associated with bicuspid aortic valve (BAV). The National Heart Lung and Blood Institute-sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) provided comprehensive information on a large population of well-characterized patients with BAV. Of 969 enrolled patients with BAV, 551 (57%, 77% male) had already undergone valvular and/or aortic surgery. Echocardiographic imaging data were available on 339 unoperated or preoperative participants who formed the basis of this study. BAV function was normal in 45 (14%), with a predominant aortic regurgitation (AR) in 127 (41%) and a predominant aortic stenosis (AS) in 76 (22%). Moderate-severe AR was associated with larger sinus of Valsalva (SOV) diameters compared with normal function and AS (all p <0.01). Moderate-severe AS was associated with a larger ascending aortic (AscAo) diameter compared with normal function (p = 0.003) but not with AR. The SOV diameter was larger in men than in women (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001), whereas AscAo diameters were comparable (3.9 ± 0.9 vs 3.7 ± 0.9 cm, p = 0.08). Right-left commissural fusion was associated with a larger SOV diameter (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001) compared with a right-noncoronary fusion pattern. Predominant AR was more common in men (45% vs 27%, p = 0.004), whereas AS was more common in women (29% vs 18%, p = 0.04). In conclusion, in the GenTAC Registry, AR was associated with diffuse (annular, SOV, and AscAo) enlargement, whereas moderate-severe AS was only associated with AscAo enlargement. Male sex and right-left cusp pattern of cusp fusion were associated with larger SOV diameters and a greater likelihood of AR, whereas women had a higher prevalence of AS.

Sex Differences in Phenotypes of Bicuspid Aortic Valve and Aortopathy: Insights From a Large Multicenter, International Registry

BACKGROUND

This large multicenter, international bicuspid aortic valve (BAV) registry aimed to define the sex differences in prevalence, valve morphology, dysfunction (aortic stenosis/regurgitation), aortopathy, and complications (endocarditis and aortic dissection).

METHODS AND RESULTS

Demographic, clinical, and echocardiographic data at first presentation of 1992 patients with BAV (71.5% men) were retrospectively analyzed. BAV morphology and valve function were assessed; aortopathy configuration was defined as isolated dilatation of the sinus of Valsalva or sinotubular junction, isolated dilatation of the ascending aorta distal to the sinotubular junction, or diffuse dilatation of the aortic root and ascending aorta. New cases of endocarditis and aortic dissection were recorded. There were no significant sex differences regarding BAV morphology and frequency of normal valve function. When presenting with moderate/severe aortic valve dysfunction, men had more frequent aortic regurgitation than women (33.8% versus 22.2%, P<0.001), whereas women were more likely to have aortic stenosis (34.5% versus 44.1%, P<0.001). Men had more frequently isolated dilatation of the sinus of Valsalva or sinotubular junction (14.2% versus 6.7%, P<0.001) and diffuse dilatation of the aortic root and ascending aorta (16.2% versus 7.3%, P<0.001) than women. Endocarditis (4.5% versus 2.5%, P=0.037) and aortic dissections (0.5% versus 0%, P<0.001) occurred more frequently in men.

CONCLUSIONS

Although there is a male predominance among patients with BAV, men with BAV had more frequently moderate/severe aortic regurgitation at first presentation compared with women, whereas women presented more often with moderate/severe aortic stenosis compared with men. Furthermore, men had more frequent aortopathy than women.

Association between bicuspid aortic valve morphotype and regional dilatation of the aortic root and trunk

Thoracic aortic disease, including thoracic aortic aneurysm (TAA), is frequently seen in patients with bicuspid aortic valve (BAV). We hypothesized that BAV morphotype would be associated with aortic aneurysm phenotypes but that other patient variables would significantly modify this relationship. 829 patients between 18 and 90 years with BAV and available raw imaging of the aortic valve and the ascending aorta to its mid-portion prior to aortic valve and aortic surgery were examined. The sinuses of Valsalva and proximal ascending aorta were measured from 2-dimensional co-planar echocardiographic images. We observed strong associations between patient habitus and raw and normalized dimensions of the aortic root and ascending aorta. Patients with R-L morphotype presented at an older age with larger aortic root but similar ascending aortic dimensions. After accounting for patient morphometric characteristics and severity of aortic valve disease, patients with R-L valve morphotype were marginally more likely to have an aortic root aneurysm (86% vs. 78%; P = 0.043), defined as aortic root dimension Z score ≥3. We observed only small differences in aortic dimensions between BAV morphotypes, that are eclipsed by variation in patient habitus. We interpret these findings to mean that BAV patients will not likely benefit from therapies based on aortic valve morphotype. Rather, we propose that all BAV patients should undergo longitudinal follow-up, independent of valve morphotype. Guidelines for aortic surgery based upon dimensions alone may be improved by considering patient characteristics such as age, body size and other characteristics.

The influence of the aortic valve angle on the hemodynamic features of the thoracic aorta

Since the first observation of a helical flow pattern in aortic blood flow, the existence of helical blood flow has been found to be associated with various pathological conditions such as bicuspid aortic valve, aortic stenosis, and aortic dilatation. However, an understanding of the development of helical blood flow and its clinical implications are still lacking. In our present study, we hypothesized that the direction and angle of aortic inflow can influence helical flow patterns and related hemodynamic features in the thoracic aorta. Therefore, we investigated the hemodynamic features in the thoracic aorta and various aortic inflow angles using patient-specific vascular phantoms that were generated using a 3D printer and time-resolved, 3D, phase-contrast magnetic resonance imaging (PC-MRI). The results show that the rotational direction and strength of helical blood flow in the thoracic aorta largely vary according to the inflow direction of the aorta, and a higher helical velocity results in higher wall shear stress distributions. In addition, right-handed rotational flow conditions with higher rotational velocities imply a larger total kinetic energy than left-handed rotational flow conditions with lower rotational velocities.

Higher neutrophil to lymphocyte ratio is related to a lower ejectionfraction in bicuspid aortic valve patients

BACKGROUND/AIM

Inflammation plays an important role in the pathophysiology of vascular disease. In this study, we aimed to evaluate the associations of neutrophil to lymphocyte ratio (NLR; an indicator of inflammation) with left ventricular ejection fraction and ascending aorta diameter in patients with a bicuspid aortic valve (BAV).

MATERIALS AND METHODS

One hundred and thirty-nine consecutive patients with the diagnosis of BAV were enrolled in the study. Complete blood counts were analyzed for neutrophil and lymphocyte levels and NLR. The subjects were separated into two groups based on their ascending aorta diameter. The patients with ascending aorta diameter equal to or above 3.9 cm were included in group 1 whereas those with ascending aorta diameter below 3.9 cm were included in group 2.

RESULTS

When the results were compared, it was demonstrated that there was a positive correlation between NLR and ascending aorta diameter (r: 0.485, P = 0.026), whereas there was a negative correlation between NLR and left ventricular end-diastolic diameter (r: 0.475, P = 0.030), left ventricular end-systolic diameter (r: 0.482, P = 0.027), and left ventricular ejection fraction (r: -0.467, P = 0.033) in BAV patients with ascending aorta dilatation (group 1).

CONCLUSION

NLR is associated with ascending aorta diameter and left ventricular ejection fraction in BAV patients with ascending aorta dilatation.

The extent of the raphe in bicuspid aortic valves is associated with aortic regurgitation and aortic root dilatation

Background

The clinical course of bicuspid aortic valves (BAVs) is variable. Data on predictors of aortopathy and valvular dysfunction mainly focus on valve morphology.

Aim

To determine whether the presence and extent of the raphe (fusion site of valve leaflets) is associated with the degree of aortopathy and valvular dysfunction in patients with isolated BAV and associated aortic coarctation (CoA).

Methods

Valve morphology and aortic dimensions of 255 BAV patients were evaluated retrospectively by echocardiography.

Results

BAVs with a complete raphe had a significantly higher prevalence of valve dysfunction (especially aortic regurgitation) than BAVs with incomplete raphes (82.9 vs. 66.7 %, p = 0.01). Type 1A BAVs (fusion of right and left coronary leaflets) and complete raphe had larger aortic sinus diameters compared with the rest of the population (37.74 vs. 36.01, p = 0.031). Patients with CoA and type 1A BAV had significantly less valve regurgitation (13.6 vs. 55.8 %, p < 0.001) and smaller diameters of the ascending aorta (33.7 vs. 37.8 mm, p < 0.001) and aortic arch (25.8 vs. 30.2 mm, p < 0.001) than patients with isolated BAV.

Conclusions

Type 1A BAV with complete raphe is associated with more aortic regurgitation and root dilatation. The majority of CoA patients have incomplete raphes, associated with smaller aortic root diameters and less valve regurgitation.

Statin Use and Aneurysm Risk in Patients With Bicuspid Aortic Valve Disease

BACKGROUND

No medical therapy has been proven to prevent the progression of aortic dilatation in bicuspid aortic valve (BAV) disease, and prophylactic aortic surgery remains the mainstay of treatment.

HYPOTHESIS

Among patients with BAV disease who are referred for surgery, preoperative statin use is associated with decreased odds of ascending aortic dilatation.

METHODS

We reviewed all BAV patients who underwent aortic valve and/or aortic surgery at our center between April 2004 and December 2013. Aortic diameter (AD), defined as the maximum ascending aortic dimension, was determined by magnetic resonance imaging, computed tomography, or echocardiography. Patients were divided into 2 groups: maximal AD <4.5 cm or ≥4.5 cm. The association between preoperative statin use and aortic dilatation was assessed using multivariable logistic regression modeling.

RESULTS

Of 680 consecutive patients, 405 (60%) had AD <4.5 cm (mean age, 60 ± 14 years; 45% on statins), whereas 275 (40%) had AD ≥4.5 cm (mean age, 54 ± 13 years; 35% on statins) at the time of surgery. After adjusting for age, body surface area, sex, hypertension, aortic stenosis, severity of aortic regurgitation, and use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and β-blockers, patients with AD ≥4.5 cm had 0.66× lower odds (95% confidence interval: 0.45-0.96) of being on preoperative statins compared with those with AD <4.5 cm (P = 0.029).

CONCLUSIONS

In a retrospective study of BAV patients referred for surgery, preoperative statin use was associated with lower odds of clinically significant ascending aortic dilatation.

Long-term results after treatment of the ascending aorta for bicuspid aortic valve patients

PURPOSE

We evaluated the long-term results of aortic valve replacement for bicuspid aortic valve patients with or without surgical treatment of the ascending aorta.

METHODS

A total of 145 bicuspid aortic valve patients had undergone aortic valve replacement since 1974 at our institution. No surgical treatment (Group-N; n = 115) was performed in the ascending aorta if the diameter was less than 40 mm. We wrapped an ascending aorta of 40-50 mm with an artificial graft (Group-W; n = 19), and performed replacement (Group-R; n = 11) if the ascending aorta measured more than 50 mm. Follow-up was completed for 144 patients (99.3 % of the cases).

RESULTS

The hospital mortality rate was 1.4 %. There were no significant differences among Groups N, W and R in the freedom from valve-related death and cardiac death at 10 years after surgery. The rates of freedom from aorta-related events in the three groups at 10 years after surgery were 98.3 % (Group-N), 100 % (Group-W) and 100 % (Group-R).

CONCLUSIONS

The long-term survival was equivalent among the three groups, and the rates of freedom from aorta-related death or events were low. Our surgical protocol for the treatment of the enlarged ascending aorta associated with BAV is appropriate.

Predictors of ascending aortic dilation in bicuspid aortic valve disease: a five-year prospective study

BACKGROUND

Bicuspid aortic valves are associated with aortic dilation and dissection. There is a paucity of prospective studies evaluating changes in aortic size over time in adult subjects with bicuspid aortic valves.

METHODS

A total of 115 subjects with asymptomatic bicuspid aortic valves were enrolled from 2003 to 2008 and followed prospectively over 5 years. Clinical and family histories, as well as transthoracic echocardiograms, were obtained at baseline, and echocardiograms were performed annually thereafter.

RESULTS

The mean age of subjects was 41.8 ± 12.8 years, and 61% were male. Ascending aortic size at baseline averaged 35.5 ± 5.6 mm and increased in 71.1% of subjects (mean, 0.66 ± 0.05 mm/y; range, 0.2-2.3 mm/y) over an average of 4.8 years. In 15.6% of subjects, the rate of change exceeded 1 mm/y. The average rate of ascending aortic dilation for all subjects was 0.47 ± 0.05 mm/y (P < .001). A family history of aortic valve disease was associated with progression in both unadjusted (P = .029) and logistic regression analyses adjusted for age, gender, and body surface area (odds ratio, 13.7; P = .021). Multivariate analysis did not find leaflet orientation or moderate to severe aortic valve dysfunction as independent predictors of aortic dilation.

CONCLUSIONS

We found that in subjects with bicuspid aortic valve, studied prospectively, there was an annual rate of ascending aortic dilation of 0.47 mm/y. In contrast to previous reports, leaflet orientation and aortic valve dysfunction were not independent predictors of aortic dilation. A family history of aortic valve disease was associated with a significantly increased risk of increasing ascending aortic size.

The Association Between Aortic Valve Leaflet Morphology and Patterns of Aortic Dilation in Patients With Bicuspid Aortic Valves

BACKGROUND

Dilation of the aorta is a frequent complication in patients with bicuspid aortic valves. The aim of this study was to determine the relationship between the subtype of leaflet fusion, right and noncoronary leaflet (R/N) fusion versus right and left leaflet (R/L) fusion, and the patterns of aortic dilation and valve dysfunction in young patients with bicuspid aortic valves.

METHODS

We performed a retrospective review of 642 patients who presented with bicuspid aortic valves between 1994 and 2014. Of these patients, 210 (33%) had aortic dilation (z score >3) by echocardiogram. For each patient, the most recent study or the last study before intervention was reviewed.

RESULTS

Median patient age was 15 years (range, 0 to 40 years) with patients with R/N fusion being younger. The most prevalent subtype was R/N fusion (R/N, n = 114, 54% versus R/L, n = 96, 46%). Dilation of the ascending aorta was seen more often in patients with R/N fusion (R/N, 88% versus R/L, 68%; p = 0.004), whereas the prevalence of dilation of the sinuses of Valsalva was significantly higher in patients with R/L fusion (R/L, 46% versus R/N, 20%; p = 0.01). The magnitude of dilation differed as well. The z value of the sinuses of Valsalva was significantly higher in patients with R/L fusion (R/L, 2.03 versus R/N, 1.2; p = 0.003), whereas the z values of the ascending aorta and sinotubular junction were similar between the groups. Patients with R/N fusion were more likely to have aortic stenosis, and within the R/N group, patients with aortic insufficiency had a greater degree of ascending aorta dilation (p = 0.04).

CONCLUSIONS

Our study suggests that in young patients with bicuspid aortic valves and aortic dilation, aortic valve morphology may be associated with the patterns of aortic dilation and valve dysfunction. Patients with R/N fusion were more likely to have ascending aorta dilation, whereas patients with R/L fusion were more likely to have dilation of the aortic root. In addition, patients with R/N fusion presented at a younger age and were more likely to have aortic stenosis. Recognition of these differences may eventually be helpful for patient counseling and the planning of follow-up.

Towards an individualized approach to bicuspid aortopathy: different valve types have unique determinants of aortic dilatation

OBJECTIVES

Bicuspid aortic valve (BAV)-related aortopathy is increasingly recognized to be a heterogeneous disease entity, although the surgical approach, from indications to techniques, is still standard rather than individualized. We aimed to define the determinants of aortic dilatation in BAV patients stratified according to the valve morphotype.

METHODS

A consecutive echocardiographic series of 622 BAV patients was analysed. Among demographic (age, sex), anthropometric (height, weight, body surface area, body mass index), clinical (associated diseases) and echocardiographic variables (valve function, ventricular parameters), the determinants of aortic root and ascending tract diameter were assessed by multivariate regression models, as well as the predictors of aortic dilatation (size index >2.1 cm/m(2)) both in the overall population and separately in groups of different valve morphotypes (RL, right-left fusion; RN, right-non-coronary fusion).

RESULTS

Independent determinants of aortic root diameter (at sinuses) were age (P < 0.001), significant aortic regurgitation (P < 0.001), sex (female protective, P < 0.001) and valve morphotype (RN protective, P < 0.001). Independent determinants of ascending aortic diameter (tubular tract) were age (P < 0.001), RN morphotype (P < 0.001), body mass index (P = 0.005) and chronic obstructive pulmonary disease (P < 0.001). In univariate analysis, the RL morphotype was associated with dilatation (ASI > 2.1 cm/m(2)) at sinuses in 41% cases vs 22% for RN (P < 0.001), and the RN morphotype was associated with dilatation at the tubular tract in 68 vs 56% for RL (P = 0.007). The presence of root dilatation was predicted by age and absence of significant stenosis in the RL morphotype subgroup, and by severe regurgitation in the RN subgroup. In the RL-type subgroup, non-regurgitant aortic valve and chronic lung disease predicted dilatation at the ascending level; and in the RN-type subgroup, age and obesity.

CONCLUSIONS

The two most common BAV morphotypes are associated with aortic dilatation at two different tracts (RL at the root; RN at the tubular ascending tract) independently of valve function. Moreover, the determinants of aortic dilatation were at least in part different between the two morphotypes: this may provide stratification criteria for individualized methods of follow-up and treatment.

Bicuspid aortic valve disease: recent insights in pathophysiology and treatment

Bicuspid aortic valve is a common congenital cardiac malformation with a broad spectrum of clinical outcomes. Bicuspid aortic valve may go undetected throughout an individual's lifetime or, alternatively, they may have devastating clinical consequences, resulting in death. Both clinicians and medical scientists have taken a renewed interest in the development, pathophysiology and treatment options for this subtle but often substantial clinical entity. Evidence is mounting to suggest that an underlying disease of the aorta is inherited with bicuspid aortic valve, although considerable controversy surrounds this theory. Novel molecular mechanisms underlying the valve and vascular pathologies, as well as new surgical therapies for these patients have been proposed in the past 10 years.

Factors affecting a dilated ascending aorta in patients with bicuspid aortic valve: the relevance of valve anatomy, body size and age

PURPOSE

Information regarding the appropriate management of patients with moderately dilated ascending aortas is limited. We investigated factors affecting ascending aortic dilatation in BAV patients, such as anatomy, body size and age.

METHODS

We evaluated 130 patients with BAV (age, 59.9 ± 16.1 years; body surface area (BSA), 1.58 ± 0.20 m(2)) who underwent aortic valve surgery. The cusp configuration was determined according to the presence and location of the raphe and the cusp direction. The ascending aortic diameter index (AADI) was calculated using computed tomography and the BSA.

RESULTS

Sixty-four patients had A-P-type BAV, while 66 had R-L-type BAV. The mean ascending aorta diameter was 42.6 ± 6.7 mm, and the mean AADI was 27.1 ± 5.6 mm/m(2). Based on the AADI, cusp configuration (R-L-BAV: 28.3 ± 6.0 mm/m(2) vs.

A-P-BAV

25.8 ± 4.9 mm/m(2), P < 0.05), a female gender, age and the presence of aortic stenosis were found to be related to ascending aortic dilatation, while the mean ascending aortic diameter did not differ between the groups. Among the elderly patients, an AADI greater than 28 mm/m(2) was more frequently observed in the R-L-BAV group than in the A-P-BAV group. Ascending aortic replacement was required after 10 years in two patients with R-L-BAV and no patients with A-P-BAV.

CONCLUSIONS

The relative ascending aortic diameter helped to identify patients with BAV with a risk of dilatation, indicating that the use of ascending aortic replacement should be considered more frequently in patients with R-L-type BAV, while the procedure is avoidable in elderly patients with A-P-type BAV.

Association between leaflet fusion pattern and thoracic aorta morphology in patients with bicuspid aortic valve

PURPOSE

To determine if patients with certain bicuspid aortic valve (BAV) phenotypes are predisposed to particular morphological abnormalities of the thoracic aorta.

MATERIALS AND METHODS

One hundred ninety-two patients with BAV who underwent magnetic resonance angiography between January 2007 and July 2010 were retrospectively identified. Aortic morphology was examined through measurements of aortic size index at nine levels along the thoracic aorta, three-dimensional volume of the ascending aorta, vessel asymmetry, and assessment of aortic root morphology.

RESULTS

We found 140 patients (73%) with right and left coronary cusps (R-L) fusion, 46 patients (24%) with R-N fusion, and 6 patients (3%) with left and noncoronary cusps (L-N) fusion. Mean aortic volume in the proximal ascending aorta was significantly greater in R-L patients (0.93 versus 0.60 cm(3)/m(2); P < 0.01). R-N patients possessed greater aortic size index at the distal ascending aorta and proximal aortic arch, and were also significantly more likely to have Type 2 patterns of aortic dilatation.

CONCLUSION

Our results suggest that BAV with R-L fusion is associated with increased dimensions of the aortic root, while BAV with R-N fusion is associated with increased dimensions of the distal ascending aorta and proximal arch. Our findings illustrate the morphological heterogeneity that exists among BAV phenotypes.

Association between bicuspid aortic valve phenotype and patterns of valvular dysfunction and bicuspid aortopathy: comprehensive evaluation using MDCT and echocardiography

OBJECTIVES

We sought to define the clinical importance of an integrated classification of bicuspid aortic valve (BAV) phenotypes and aortopathy using multidetector computed tomography (MDCT).

BACKGROUND

An association between BAV phenotypes and the pattern of valvular dysfunction or bicuspid aortopathy has yet to be definitely established.

METHODS

The study cohort included 167 subjects (116 men, age 54.6 ± 14.4 years) who underwent both MDCT and transthoracic echocardiography from 2003 to 2010. Two BAV phenotypes-fusion of the right and left coronary cusps (BAV-AP) and fusion of the right or left coronary cusp and noncoronary cusp (BAV-RL)-were identified. Forty-five patients showed normal aortic dimensions and were classified as type 0. In the remaining patients, hierarchic cluster analysis showed 3 different types of bicuspid aortopathy according to the pattern of aortic dilation: type 1 (aortic enlargement confined to the sinus of Valsalva [n = 34]), type 2 (aortic enlargement involving the tubular portion of the ascending aorta [n = 49]), and type 3 (aortic enlargement extending to the transverse aortic arch [n = 39]).

RESULTS

The prevalence of BAV-AP and BAV-RL was 55.7% and 44.3%, respectively. Comparing BAV-AP and BAV-RL, no differences in age or in the prevalence of male sex were determined. However, significant differences in the valvular dysfunction pattern were noted, with moderate-to-severe aortic stenosis predominating in patients with BAV-RL (66.2% vs. 46.2% in BAV-AP; p = 0.01), and moderate-to-severe aortic regurgitation in BAV-AP (32.3% vs. 6.8% in BAV-RL; p < 0.0001). A normal aorta was the most common phenotype in BAV-AP patients (33.3% vs. 18.9% in BAV-RL; p = 0.037), and type 3 aortopathy was the most common phenotype in BAV-RL patients (40.5% vs. 9.7% in BAV-AP; p < 0.0001).

CONCLUSIONS

The patterns of valvular dysfunction and bicuspid aortopathy differed significantly between the 2 BAV phenotypes, suggesting the possibility of etiologically different entities.

Patterns of aortic dilatation in bicuspid aortic valve-associated aortopathy

BACKGROUND

Bicuspid aortic valves (BAVs) are associated with aortopathy. Recent studies suggest that aortic dilatation is more likely to be seen with left-right coronary cusp fusion (type I) compared with right-noncoronary cusp fusion (type II). The aim of this study was to investigate the association between BAV morphology and patterns of aortopathy.

METHODS

Aortic dimensions and BAV morphology were obtained retrospectively from archived cine loops of 581 consecutive patients with BAVs and 277 matched normal controls from the Vancouver General Hospital echocardiography database. Patient demographics and other echocardiographic parameters were extracted from the database.

RESULTS

The study population was composed of 71% type I BAVs (415 patients) and 26% type II BAVs (149 patients). Aortic dilatation was present in 30% of the population. Type I BAV was associated with increased dimensions indexed to body surface area at the sinus of Valsalva compared with type II BAV. No difference in proximal ascending aortic dimension was seen between different BAV morphologies. The pattern of dilatation with type I BAV was more likely to be at the level of the annulus or sinus of Valsalva compared with type II BAV (62% vs 33%, P= .002). Type I BAV was an independent predictor of proximal aortic dilatation (odds ratio, 3.42; 95% confidence interval, 1.07-10.9).

CONCLUSIONS

Type I BAV is associated with a greater likelihood of dilatation at the annulus and sinus of Valsalva. There is relative sparing of this region of the aorta in patients with type II BAVs. Individuals with different BAV morphologies may require different strategies of aortopathy surveillance.

Bicuspid aortic valve: inter-racial difference in frequency and aortic dimensions

OBJECTIVES

The objective of this study was to examine the similarities and differences in Caucasian (C) and African-American (AA) patients with bicuspid aortic valve (BAV) with respect to morphology, severity of aortic stenosis/insufficiency, and aortic dilation.

BACKGROUND

BAV is a common congenital valve abnormality, accounting for a large number of valve replacements.

METHODS

A total of 229 patients with the diagnostic code BAV were identified retrospectively from our computerized adult echocardiographic database, which consists of 91,896 studies performed at the University of Chicago Medical Center from 1998 to 2009, representing 40,878 patients. Of those, 183 patients with BAV were included in this retrospective BAV single-center cohort study and reanalyzed with a comprehensive assessment of aortic dimensions, aortic valve morphology and function, clinical cardiovascular risk factors, and patient characteristics.

RESULTS

Of the 183 patients with BAV, 138 were C and 45 were AA. Our echocardiographic database encompasses approximately 65% AA, 31% C, and 4% other races, for an estimated frequency of BAV in AA patients of 0.17% and a frequency in C patients of 1.1% (p = 0.001). There were no significant inter-racial differences regarding sex, height, weight, hyperlipidemia, diabetes, tobacco use, cardiac medications, and left ventricular ejection fraction. The AA cohort was older (age 50 ± 17 years vs. 43 ± 17 years, p < 0.05) and had a higher prevalence of hypertension (51% vs. 24%, p < 0.05). After adjusting for comorbidities, aortic dimensions were larger in C (C vs. AA: annulus, 2.4 ± 0.4 vs. 2.1 ± 0.4 cm; sinuses of Valsalva, 3.4 ± 0.7 vs. 3.1 ± 0.6 cm; sinotubular junction, 3.0 ± 0.6 vs. 2.6 ± 0.5 cm; and ascending aorta, 3.5 ± 0.7 vs. 3.2 ± 0.5 cm; all p values <0.05).

CONCLUSIONS

This is the first study to report racial differences among patients with BAV with reduced aortic dimensions in AA patients despite the presence of more risk factors, suggestive of marked heterogeneity in the BAV population and indicating race as a potential disease modifier in BAV.

Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge

The bicuspid aortic valve is the most common congenital cardiac anomaly in developed nations. The abnormal bicuspid morphology of the aortic valve results in valvular dysfunction and subsequent hemodynamic derangements. However, the clinical presentation of bicuspid aortic valve disease remains quite heterogeneous with patients presenting from infancy to late adulthood with variable degrees of valvular stenosis and insufficiency and associated abnormalities including aortic coarctation, hypoplastic left heart structures, and ascending aortic dilatation. Emerging evidence suggests that the heterogeneous presentation of bicuspid aortic valve phenotypes may be a more complex matter related to congenital, genetic, and/or connective tissue abnormalities. Optimal management of patients with BAV disease and associated ascending aortic aneurysms often requires a thoughtful approach, carefully assessing various risk factors of the aortic valve and the aorta and discerning individual indications for ongoing surveillance, medical management, and operative intervention. We review current concepts of anatomic classification, pathophysiology, natural history, and clinical management of bicuspid aortic valve disease with associated ascending aortic aneurysms.

Bicuspid aortic valve disease: a comprehensive review

Bicuspid aortic valve is the commonest congenital cardiac abnormality in the general population. This paper article will discuss our current knowledge of the anatomy, pathophysiology, genetics, and clinical aspects of bicuspid aortic valve disease.

Aortic dilatation with bicuspid aortic valves: cusp fusion correlates to matrix metalloproteinases and inhibitors

BACKGROUND

Congenital bicuspid aortic valves (BAVs) result from fusion of 2 valve cusps, resulting in left-noncoronary (L-N), right-left (R-L), and right-noncoronary (R-N) morphologic presentations. BAVs predispose to ascending thoracic aortic aneurysms (ATAAs). This study hypothesized that ATAAs with each BAV morphologic group possess unique signatures of matrix metalloproteinases (MMPs) and endogenous tissue inhibitors of metalloproteinases (TIMPs).

METHODS

Ascending thoracic aortic aneurysm tissue from 46 patients with BAVs was examined for MMP/TIMP abundance, and global MMP activity was compared with normal aortic specimens (n=15). Proteolytic balance was calculated as the ratio of MMP abundance to a composite TIMP score. Results were stratified by valve morphologic group (L-N [n=6], R-L [n=31], and R-N [n=9]).

RESULTS

The BAV specimens (p<0.05 versus normal aorta, 100%) displayed elevated global MMP activity (273%±63%), MMP-9 (263%±47%), and decreased MMP-7 (56%±10%), MMP-8 (58%±11%), TIMP-1 (63%±7%), and TIMP-4 (38%±3%). The R-L group showed increased global MMP activity (286%±89%) and MMP-9 (267%±55%) with reduced MMP-7 (45%±7%), MMP-8 (68%±15%), TIMP-1 (58%±7%), and TIMP-4 (35%±3%). The L-N group showed elevated global MMP activity (284%±71%) and decreased MMP-8 (37%±17%) and TIMP-4 (48%±14) activity. In the R-N group, MMP-7 (46%±13%) and MMP-8 (36%±17%) and TIMP-1 (59%±10%) and TIMP-4 (42%±5%) were decreased. The R-L group demonstrated an increased proteolytic balance for MMP-1, MMP-9, and MMP-12 relative to L-N and R-N.

CONCLUSIONS

Each BAV morphologic group possesses a unique signature of MMPs and TIMPs. MMP/TIMP score ratios suggest that the R-L group may be more aggressive, justifying earlier surgical intervention.

Bicuspid aortic valve and aortic root disease

Bicuspid aortic valve (BAV) is the most common form of congenital heart disease, with frequent and premature occurrence of cardiac events, dominated by significant valvular dysfunction. BAV has a high prevalence of aortic wall abnormalities such as ascending aortic dilatation. Because more rapid aortic dilatation can occur, once the ascending aorta reaches 40 mm, annual imaging with echocardiography or other imaging techniques is indicated. The most feared complication is aortic dissection. However, the actual incidence of this complication is low (4%). Although limited data exist regarding prophylactic intervention, it is suggested that elective surgical repair of BAV-associated aortic dilatation should be more aggressively recommended. In patients with BAV, the decision to indicate surgical treatment in aortic diameters between 50 and 55 mm should be based on patient age, body size, comorbidities, type of surgery, and the presence of additional risk factors.

Comparison of the structure of the aortic valve and ascending aorta in adults having aortic valve replacement for aortic stenosis versus for pure aortic regurgitation and resection of the ascending aorta for aneurysm

BACKGROUND

There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction-either aortic stenosis (AS) or pure aortic regurgitation (AR)-something not previously undertaken.

METHODS AND RESULTS

Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4+) was zero or 1+ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2+ to 4+ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13).

CONCLUSIONS

These data strongly suggest that the type of aortic valve dysfunction-AS versus pure AR-is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease.

Accuracy of transthoracic echocardiography for the measurement of the ascending aorta: comparison with transesophageal echocardiography

BACKGROUND

There has been a substantial increase in the number of imaging studies performed to assess thoracic aortic pathology. We sought to determine the accuracy of transthoracic echocardiography (TTE) compared to transesophageal echocardiography (TEE) for measuring ascending aortic size.

HYPOTHESIS

Transthoracic echocardiography is reasonably accurate for assessing ascending aortic dimension.

METHODS

Fifty-two patients with or without aortic disease underwent both TTE with nonstandard views and TEE. The ascending aorta was measured at 4 levels by 2 blinded observers for each modality. Pearson's correlation coefficients were determined and Bland-Altman plots and analyses were constructed. Inter- and intraobserver variability was determined in a random subgroup of patients.

RESULTS

The mean age of the group was 65.5 years old and 15% had aortic dilation >4.0 cm. A strong positive correlation between the 2 imaging modalities was seen at all levels with the highest correlation for the maximum diameter of the ascending aorta (r = 0.936, P < 0.0001). Interobserver and intraobserver variability showed a good intraclass correlation among readers and among the same reader at all levels.

CONCLUSIONS

Transthoracic echocardiography using nonstandard imaging windows is accurate in comparison to TEE for measurement of the ascending aorta at multiple levels in patients with or without aortic pathology. The findings of this study provide support for selected serial follow-up of patients with aortic disease by TTE only.

Valve-preserving root replacement in bicuspid aortic valves

OBJECTIVE

Bicuspid aortic valve anatomy is associated with aortic root aneurysm in a relevant proportion of patients. These patients require root replacement for prognostic reasons, and the valve may be preserved. The objective of this analysis is to analyze the early and late outcomes of root remodeling for bicuspid aortic valve.

METHODS

Between November 1995 and December 2009, 153 patients (133 male) were treated by root remodeling in the presence of a bicuspid aortic valve. Acute dissection was present in 6 individuals. In 137 instances, additional correction of cusp pathology was achieved by plication (n = 119), triangular resection (n = 59), and implantation of a pericardial patch (n = 27). Follow-up ranges from 3 months to 14.5 years (mean, 4.9 ± 3.8 years; cumulative, 757 years) and is complete in 99.3%.

RESULTS

One patient died of intracranial hemorrhage in the hospital (mortality 0.7%). Survival at 5 and 10 years was 99% and 91%, respectively. Seven patients required reoperation for stenosis (n = 1) or recurrent aortic insufficiency (n = 6) between 1 month and 11 years postoperatively. The aortic valve was re-repaired in 2 cases. Freedom from reoperation at 5 and 10 years was 95%; freedom from valve replacement was 97%. Freedom from valve-related complications was 91% at 5 and 10 years.

CONCLUSIONS

Root remodeling for aortic root aneurysm in the presence of a bicuspid aortic valve can be performed with a low morbidity and mortality. The long-term stability of the reconstructed aortic valve is excellent if normal valve configuration is achieved. The occurrence of late stenosis seems to be rare, and freedom from valve-related complications is high.