Natural history of bicuspid aortic valves and ascending aortic aneurysms: Aortic center experience

Thoracic Aortic Aneurysm Growth Rates and Predicting Factors: A Systematic Review and Meta-Analysis

BACKGROUND

Thoracic aortic aneurysm (TAA) is an indolent, potentially fatal disease, which progresses at variable rates that are influenced by pathogenesis and patient characteristics. We conducted a systematic review and meta-analysis to synthesize the current evidence on growth rate (GR) and predictive factors among patients with syndromic and nonsyndromic heritable thoracic aortic disease, bicuspid aortic valve, and sporadic TAA.

METHODS AND RESULTS

Online databases were searched for studies that reported aortic growth on adult patients with asymptomatic TAA. Pooled GRs were calculated for 3 different TAA groups: syndromic heritable thoracic aortic disease, bicuspid aortic valve, and sporadic TAA. The search yielded 6297 studies, of which 85 were included in the systematic review, and 55 in the meta-analysis of growth rate (10 syndromic heritable thoracic aortic disease, 31 bicuspid aortic valve, and 34 sporadic subgroups). Mean observed TAA GR was 0.25 mm/y (95% CI, -0.18 to 0.68) in Turner syndrome, 0.45 mm/y (95% CI, 0.00-0.90) in Marfan syndrome, and 0.81 mm/y (95% CI, -0.46 to 2.08) in Loeys-Dietz syndrome. The mean observed GR in patients with bicuspid aortic valve before aortic valve surgery was 0.37 mm/y (95% CI, 0.29-0.46), compared with 0.18 mm/y (95% CI, 0.14-0.33) in postsurgical studies. Mean observed GR in sporadic ascending TAA was 0.33 mm/y (95% CI, 0.13-0.52) and 2.71 mm/y (95% CI, 0.53-4.88) in descending TAA.

CONCLUSIONS

Considering all pathogeneses, ascending TAAs typically grow at 0.25 to 1 mm/y, and thus annual surveillance is likely too frequent to detect growth in most patients. Studies vary widely in populations, methodology, and outcomes, with few high-quality longitudinal studies and no predictors of aortic GR.

From Biomechanical Properties to Morphological Variations: Exploring the Interplay between Aortic Valve Cuspidity and Ascending Aortic Aneurysm

Background: This research explores the biomechanical and structural characteristics of ascending thoracic aortic aneurysms (ATAAs), focusing on the differences between bicuspid aortic valve aneurysms (BAV-As) and tricuspid aortic valve aneurysms (TAV-As) with non-dilated aortas to identify specific traits of ATAAs. Methods: Clinical characteristics, laboratory indices, and imaging data from 26 adult patients operated on for aneurysms (BAV-A: n = 12; TAV-A: n = 14) and 13 controls were analyzed. Biomechanical parameters (maximal aortic diameter, strain, and stress) and structural analyses (collagen fiber organization, density, fragmentation, adipocyte deposits, and immune cell infiltration) were assessed. Results: Significant differences in biomechanical parameters were observed. Median maximal strain was 40.0% (control), 63.4% (BAV-A), and 45.3% (TAV-A); median maximal stress was 0.59 MPa (control), 0.78 MPa (BAV-A), and 0.48 MPa (TAV-A). BAV-A showed higher tangential modulus and smaller diameter, with substantial collagen fragmentation (p < 0.001 vs. TAV and controls). TAV-A exhibited increased collagen density (p = 0.025), thickening between media and adventitia layers, and disorganized fibers (p = 0.036). BAV-A patients had elevated adipocyte deposits and immune cell infiltration. Conclusions: This study highlights distinct pathological profiles associated with different valve anatomies. BAV-A is characterized by smaller diameters, higher biomechanical stress, and significant collagen deterioration, underscoring the necessity for tailored clinical strategies for effective management of thoracic aortic aneurysm.

Effect of transcatheter aortic valve replacement on ascending aorta dilatation rate in patients with tricuspid and bicuspid aortic stenosis

Objectives

The aim of the present study was to assess the differences between BAV and TAV patients with chronic moderate to severe or severe AS regarding presentation, incidence of TAVR, survival, ascending aorta diameter and dilatation rate before and after TAVR.

Methods

The study included 667 consecutive patients with chronic moderate to severe or severe AS from January 2012 and December 2022. Outcomes included all-cause mortality, incidence of TAVR, and ascending aorta diameter and dilatation rate.

Results

There were 185 BAV-AS and 482 TAV-AS patients, and BAV-AS patients were younger (67 vs 78 years, P = 0.027). Total follow-up was 4.5 years (IQR: 2.7-8.9 years), 290 patients underwent TAVR, and 165 patients died. The 8-year TAVR incidence was higher in BAV-AS (55% ± 4%) vs TAV-AS (41% ± 5%; P = 0.02). The 8-year survival was higher in BAV-AS (85% ± 6%) vs TAV-AS (71% ± 6%; P < 0.0001) and became insignificant after age adjustment (P = 0.33). The dilatation rate of ascending aorta was significantly faster in BAV-AS patients compared with TAV-AS patients before TAVR. However, the ascending aorta dilatation rate for BAV-AS and TAV-AS patients was not significantly different after TAVR.

Conclusions

Compared with TAV-AS, BAV-AS patients were younger and underwent TAVR more frequently, resulting in a considerable survival advantage. After TAVR, ascending aorta dilatation rates were similar in BAV-AS and TAV-AS patients, suggesting an important role of hemodynamics on ascending aorta dilatation in BAV-AS.

Bicuspid aortic valve and its ascending aortopathy

PURPOSE OF REVIEW

To synthesize and critically assess recent clinical and research advancements in pediatric bicuspid aortic valve (BAV) and its associated aortopathy.

RECENT FINDINGS

In pediatric patients with BAV, progressive aortic dilation (i.e. bicuspid aortopathy) is commonly present and associated with increased risk for aortic aneurysm, dissection, and surgery in adulthood. Ongoing research explores the cause, incidence, and progression of bicuspid aortopathy to promote earlier diagnosis and improve preventive management. Recent findings include: high familial incidence and need for improved familial screening; safety of recreational physical activity in most affected children; potential for medical management to slow aortic growth; feasibility of pediatric registries to evaluate longitudinal outcomes; and potential genetic and hemodynamic biomarkers for disease risk stratification.

SUMMARY

Pediatric bicuspid aortopathy is an important area for investigation and preventive management to improve long-term cardiovascular outcomes. Recent literature promotes familial screening, recreational exercise, medical prophylaxis, registry-based longitudinal evaluation, and continued scientific inquiry.

Is this the final answer for the aortopathy with bicuspid aortic valve

There have been changes in the guidelines for surgical indications for aortopathy associated with bicuspid aortic valves over the last 10 years. Although the results of the last 3 years adhering to the latest guidelines have been shown to be good, careful follow-up and accumulation of new research findings are still required.