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Bellino M, Antonini-Canterin F, Bossone E, Faggiano P, Chirillo F, La Carrubba S, Faganello G, Cecconi M, Zito C, Dasseni N, Nistri S, Moreo A, Fabiani I, Faden G, Agostini F, Manuppelli V, Cameli M, Cresti A, Dentamaro I, Monte IP, Barbieri A, Ciampi Q, Giorgi M, Galasso G, Carerj S, Pepi M, Benedetto F, Colonna P, Citro R. Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe. Int J Cardiol 2024; 407:132000. [PMID: 38561108 DOI: 10.1016/j.ijcard.2024.132000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024]
Abstract
AIM To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)]. METHODS Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation. RESULTS Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001). CONCLUSIONS Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.
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Affiliation(s)
- Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | | | - Eduardo Bossone
- Department of Public Health, "Federico II" University of Naples, Naples, Italy
| | - Pompilio Faggiano
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Institute of Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Chirillo
- Department of Cardiology, Ospedale San Bassiano, Bassano del Grappa (VI), Italy
| | | | - Giorgio Faganello
- Cardiovascular Department, University Hospital and Health Services of Trieste, Trieste, Italy
| | - Moreno Cecconi
- Department of Cardiology and Cardiac Surgery, Azienda Ospedaliero Universitaria, Ospedali Riuniti, Ancona, Italy
| | - Concetta Zito
- Section of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino", Messina, Italy
| | - Nicolò Dasseni
- Cardiology Division, ASST Franciacorta, Chiari (BS), Italy
| | - Stefano Nistri
- Department of Cardiology, CMSR, Altavilla Vicentina (VI), Italy
| | - Antonella Moreo
- Cardiology IV, "A. De Gasperis" Department, ASST Niguarda Metropolitan Hospital, Milan, Italy
| | - Iacopo Fabiani
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | | | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alberto Cresti
- Cardiology, Cardio Neuro Vascular Department, Asl Sudest Toscana, Hospital of Grosseto, Grosseto, Italy
| | - Ilaria Dentamaro
- Cardiology Department and Cardiovascular Imaging Laboratory, Hospital Miulli, Bari, Italy
| | - Ines Paola Monte
- Department of General Surgery and Medical Surgery Specialties, University of Catania, AOU Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Andrea Barbieri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Mauro Giorgi
- Department of Cardiology, University Hospital Città della Scienza e Salute, Molinette Hospital, Turin, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | - Scipione Carerj
- Section of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino", Messina, Italy
| | - Mauro Pepi
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Frank Benedetto
- Cardiology, G.O.M. "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Paolo Colonna
- Department of Cardiology, Hospital Policlinico of Bari, Bari, Italy
| | - Rodolfo Citro
- Cardio-Thoracic and Vascular Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy; Department of Vascular Physiopathology, IRCCS Neuromed, Pozzilli (IS), Italy.
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2
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Bicuspid Aortic Valves: an Up-to-Date Review on Genetics, Natural History, and Management. Curr Cardiol Rep 2022; 24:1021-1030. [PMID: 35867195 DOI: 10.1007/s11886-022-01716-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. It has a wide spectrum of clinical manifestations including aortic regurgitation (AR), aortic stenosis, and an associated aortopathy with a small but increased risk of aortic dissection. This review describes current knowledge of BAV, from anatomy and genetics to a discussion of multifaceted strategies utilized in the management of this unique patient population. This review will also highlight critical knowledge gaps in areas of basic and clinical research to enhance further understanding of this clinical entity. RECENT FINDINGS The current knowledge regarding pathophysiologic mechanisms, screening, and surveillance guidelines for BAV and the associated aortopathy is discussed. We also discuss current management techniques for aortic valve repair versus replacement, indications for aortic surgery (root or ascending aorta), and the emergence of the Ross procedure as a viable management option not only in children, but also in adolescents and adults. The varied clinical phenotype of the BAV, resulting in its specific complex hemodynamic interactions, renders it an entity which is separate and distinct from the tricuspid aortic valve pathologies. While various aortic histopathologic and protein alterations in BAV patients have been described, it remains unclear if these changes are causal or the result of hemodynamic alterations imposed by sheer stress on the intrinsically dysfunctional BAV. Medical management for patients with BAV with AS, AI, or dilated aortic roots/ascending aortas remains challenging and needs further investigation. More than 50% of patients with BAV will undergo AVR during their lifetime, and more than 25% of patients with BAV undergo aortic surgery performed for dilation of the aortic root or ascending aorta, often concurrently with AVR. The search for the ultimate genetic or epigenetic cause of the different bicuspid phenotypes will ultimately be facilitated by the next-generation sequencing tools that allow for study of large populations at low cost. Improvements in diagnostic and stratification criteria to accurately risk assess BAV patients are critical to this process.
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3
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Lypovetska S. ACUTE CORONARY SYNDROME IN A PATIENT WITH MULTIPLY CORONARY ARTERY ECTASIA AND ASCENDING AORTIC ANEURYSM. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1792-1795. [PMID: 35962700 DOI: 10.36740/wlek202207133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
This report describes a case of multiply СAE presenting as a ST-elevation myocardial infarction in an adult patient with bicuspid aortic valve (BAV) and ascending aortic aneurysm. Coronary angiography revealed multiply ectasia in left anterior descending artery and right coronary artery. A computer tomographic aortogram confirmed the presence BAV with signs of calcification and an enlarged ascending aorta. The patient underwent coronary artery bypass grafting of left descending and circumflex coronary arteries and tube graft replacement of ascending aorta in 1 month after ACS in experienced centre. In patients with ACS due to CAE culprit, the emphasis is to restore flow. Medical treatment as well as lifestyle changes and risk factors control, and serial imaging assessment of aortic aneurysm constitute the second part of the management of these patients. We need prospective studies and registries to improve patient care and outcome.
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Affiliation(s)
- Sofiya Lypovetska
- I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY, TERNOPIL, UKRAINE
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4
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Pepe G, Giusti B, Colonna S, Fugazzaro MP, Sticchi E, De Cario R, Kura A, Pratelli E, Melchiorre D, Nistri S. When should a rare inherited connective tissue disorder be suspected in bicuspid aortic valve by primary-care internists and cardiologists? Proposal of a score. Intern Emerg Med 2021; 16:609-615. [PMID: 32949381 PMCID: PMC8049921 DOI: 10.1007/s11739-020-02458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Abstract
Size threshold for aortic surgery in bicuspid aortic valve (BAV) is debated. Connective tissue disorders (CTDs) are claimed as a clinical turning point, suggesting early surgery in BAV patients with CTD. Thus, we aimed at developing a score to detect high risk of carrying CTDs in consecutive BAVs from primary care. Ninety-eight BAVs without ectopia lentis or personal/family history of aortic dissection were studied at the Marfan syndrome Tuscany Referral Center. Findings were compared with those detected in 84 Marfan patients matched for sex and age. We selected traits with high statistical difference between MFS and BAV easily obtainable by cardiologists and primary-care internists: mitral valve prolapse, myopia ≥ 3DO, pectus carenatum, pes planus, wrist and thumb signs, and difference between aortic size at root and ascending aorta ≥ 4 mm. Clustering of ≥ 3 of these manifestations were more frequent in Marfan patients than in BAVs (71.4% vs 6.1%, p < 0.0001) resulting into an Odds Ratio to be affected by MFS of 38.3 (95% confidence intervals 14.8-99.3, p < 0.0001). We propose a score assembling simple clinical and echocardiographic variables resulting in an appropriate referral pattern of BAVs from a primary-care setting to a tertiary center to evaluate the presence of a potential, major CTD.
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Affiliation(s)
- Guglielmina Pepe
- Marfan Syndrome and Related Disorders Regional Referral Center, Careggi Hospital, Viale Gaetano Pieraccini, 50139, Florence, Italy.
- Research and Innovation Center for Marfan Syndrome and Related Disorders, Careggi Hospital, Florence, Italy.
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of Florence, Florence, Italy.
| | - Betti Giusti
- Marfan Syndrome and Related Disorders Regional Referral Center, Careggi Hospital, Viale Gaetano Pieraccini, 50139, Florence, Italy
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of Florence, Florence, Italy
- Atherothrombotic Diseases Tuscany Referral Center, Careggi Hospital, Florence, Italy
| | - Stefania Colonna
- Outpatient Cardiology Unit, Health District 1 ULSS 6, Vigonza and Carmignano di Brenta, Padua, Italy
| | | | - Elena Sticchi
- Marfan Syndrome and Related Disorders Regional Referral Center, Careggi Hospital, Viale Gaetano Pieraccini, 50139, Florence, Italy
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of Florence, Florence, Italy
- Atherothrombotic Diseases Tuscany Referral Center, Careggi Hospital, Florence, Italy
| | - Rosina De Cario
- Marfan Syndrome and Related Disorders Regional Referral Center, Careggi Hospital, Viale Gaetano Pieraccini, 50139, Florence, Italy
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of Florence, Florence, Italy
- Atherothrombotic Diseases Tuscany Referral Center, Careggi Hospital, Florence, Italy
| | - Ada Kura
- Marfan Syndrome and Related Disorders Regional Referral Center, Careggi Hospital, Viale Gaetano Pieraccini, 50139, Florence, Italy
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of Florence, Florence, Italy
- Atherothrombotic Diseases Tuscany Referral Center, Careggi Hospital, Florence, Italy
| | - Elisa Pratelli
- Specialization in Physical and Rehabilitation Medicine, Recovery and Rehabilitation Agency, Careggi Hospital, Florence, Italy
| | - Daniela Melchiorre
- Department of Experimental and Clinical Medicine, Section of Rheumatology, University of Florence, Florence, Italy
| | - Stefano Nistri
- Cardiology Service, CMSR Veneto Medica, Altavilla Vicentina, Italy
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5
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Peterson JC, Wisse LJ, Wirokromo V, van Herwaarden T, Smits AM, Gittenberger-de Groot AC, Goumans MJTH, VanMunsteren JC, Jongbloed MRM, DeRuiter MC. Disturbed nitric oxide signalling gives rise to congenital bicuspid aortic valve and aortopathy. Dis Model Mech 2020; 13:dmm.044990. [PMID: 32801116 PMCID: PMC7541347 DOI: 10.1242/dmm.044990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
Patients with a congenital bicuspid aortic valve (BAV), a valve with two instead of three aortic leaflets, have an increased risk of developing thoracic aneurysms and aortic dissection. The mechanisms underlying BAV-associated aortopathy are poorly understood. This study examined BAV-associated aortopathy in Nos3−/− mice, a model with congenital BAV formation. A combination of histological examination and in vivo ultrasound imaging was used to investigate aortic dilation and dissections in Nos3−/− mice. Moreover, cell lineage analysis and single-cell RNA sequencing were used to observe the molecular anomalies within vascular smooth muscle cells (VSMCs) of Nos3−/− mice. Spontaneous aortic dissections were found in ascending aortas located at the sinotubular junction in ∼13% of Nos3−/− mice. Moreover, Nos3−/− mice were prone to developing aortic dilations in the proximal and distal ascending aorta during early adulthood. Lower volumes of elastic fibres were found within vessel walls of the ascending aortas of Nos3−/− mice, as well as incomplete coverage of the aortic inner media by neural crest cell (NCC)-derived VSMCs. VSMCs of Nos3−/− mice showed downregulation of 15 genes, of which seven were associated with aortic aneurysms and dissections in the human population. Elastin mRNA was most markedly downregulated, followed by fibulin-5 expression, both primary components of elastic fibres. This study demonstrates that, in addition to congenital BAV formation, disrupted endothelial-mediated nitric oxide (NO) signalling in Nos3−/− mice also causes aortic dilation and dissection, as a consequence of inhibited elastic fibre formation in VSMCs within the ascending aorta. Summary: Nitric oxide defects link bicuspid aortic valve formation and aortopathy through inhibition of elastic fibre formation in vascular smooth muscle cells within the ascending aorta of Nos3−/− mice.
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Affiliation(s)
- Joshua C Peterson
- Department of Anatomy and Embryology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Lambertus J Wisse
- Department of Anatomy and Embryology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Valerie Wirokromo
- Department of Anatomy and Embryology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Tessa van Herwaarden
- Department of Chemical Cell Biology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Anke M Smits
- Department of Chemical Cell Biology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | | | - Marie-José T H Goumans
- Department of Chemical Cell Biology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - J Conny VanMunsteren
- Department of Anatomy and Embryology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy and Embryology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands.,Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Marco C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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6
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Skeffington KL, Bond AR, Bigotti MG, AbdulGhani S, Iacobazzi D, Kang SL, Heesom KJ, Wilson MC, Stoica S, Martin R, Caputo M, Suleiman MS, Ghorbel MT. Changes in inflammation and oxidative stress signalling pathways in coarcted aorta triggered by bicuspid aortic valve and growth in young children. Exp Ther Med 2020; 20:48. [PMID: 32973936 PMCID: PMC7506967 DOI: 10.3892/etm.2020.9171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
Neonates with coarctation of the aorta (CoA) combined with a bicuspid aortic valve (BAV) show significant structural differences compared to neonatal CoA patients with a normal tricuspid aortic valve (TAV). These effects are likely to change over time in response to growth. This study investigated proteomic differences between coarcted aortic tissue of BAV and TAV patients in children older than one month. Aortic tissue just proximal to the coarctation site was collected from 10 children (BAV; n=6, 1.9±1.7 years, TAV; n=4, 1.7±1.5 years, (mean ± SEM, P=0.92.) Tissue were snap frozen, proteins extracted, and the extracts used for proteomic and phosphoproteomic analysis using Tandem Mass Tag (TMT) analysis. A total of 1811 protein and 76 phosphoprotein accession numbers were detected, of which 40 proteins and 6 phosphoproteins were significantly differentially expressed between BAV and TAV patients. Several canonical pathways involved in inflammation demonstrated enriched protein expression, including acute phase response signalling, EIF2 signalling and macrophage production of IL12 and reactive oxygen species. Acute phase response signalling also demonstrated enriched phosphoprotein expression, as did Th17 activation. Other pathways with significantly enriched protein expression include degradation of superoxide radicals and several pathways involved in apoptosis. This work suggests that BAV CoA patients older than one month have an altered proteome consistent with changes in inflammation, apoptosis and oxidative stress compared to TAV CoA patients of the same age. There is no evidence of structural differences, suggesting the pathology associated with BAV evolves with age in paediatric CoA patients.
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Affiliation(s)
- Katie L Skeffington
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Andrew R Bond
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - M Giulia Bigotti
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Safa AbdulGhani
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK.,Department of Congenital Heart Disease, Bristol Children's Hospital, Bristol BS2 8JB, UK
| | - Dominga Iacobazzi
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Sok-Leng Kang
- Department of Physiology, Faculty of Medicine, Al-Quds University, P.O Box 89, Abu Dis, Palestine
| | - Kate J Heesom
- Proteomics Facility, University of Bristol, Bristol BS8 1RJ, UK
| | | | - Serban Stoica
- Department of Physiology, Faculty of Medicine, Al-Quds University, P.O Box 89, Abu Dis, Palestine
| | - Robin Martin
- Department of Physiology, Faculty of Medicine, Al-Quds University, P.O Box 89, Abu Dis, Palestine
| | - Massimo Caputo
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK.,Department of Physiology, Faculty of Medicine, Al-Quds University, P.O Box 89, Abu Dis, Palestine
| | - M Saadeh Suleiman
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Mohamed T Ghorbel
- Bristol Heart Institute, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
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Martínez-Micaelo N, Ligero C, Antequera-González B, Junza A, Yanes O, Alegret JM. Plasma Metabolomic Profiling Associates Bicuspid Aortic Valve Disease and Ascending Aortic Dilation with a Decrease in Antioxidant Capacity. J Clin Med 2020; 9:jcm9072215. [PMID: 32668689 PMCID: PMC7408840 DOI: 10.3390/jcm9072215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/17/2020] [Accepted: 07/02/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The bicuspid aortic valve (BAV) is the most common cardiac congenital disease and is associated with an increased risk of developing ascending aorta dilation; which can have fatal consequences. Currently; no established risk biomarkers exist to facilitate the diagnosis and prognosis of BAV. METHODS Using an untargeted metabolomic approach; we identified the levels of metabolites in plasma samples and compared them depending on the bicuspid or tricuspid morphology of the aortic valve. Including those patients with ascending aortic dilation and/or aortic stenosis (n = 212), we analyzed the role possibly played by alpha-Tocopherol in BAV disease; considering its association with the pathophysiological characteristics of BAV and biomarkers related to inflammation, oxidative stress and endothelial damage, as well as characteristics related to alpha-Tocopherol functionality and metabolism. RESULTS We found that BAV patients; especially those with ascending aortic dilation; presented lower antioxidant capacity; as determined by decreased plasma levels of alpha-Tocopherol; paraoxonase 1 and high-density lipoprotein (HDL), as well as increased levels of C-reactive protein (CRP; a biomarker of inflammation) and endothelial microparticles (EMPs; an endothelial damage biomarker). By applying random forest analyses; we evaluated the significant screening capacity of alpha-Tocopherol; CRP and EMPs to classify patients depending on the morphology of the aortic valve. DISCUSSION Our findings support the role of decreased antioxidant capacity; increased inflammation and endothelial damage in the pathogenesis of BAV and the progression of aortic dilation. Moreover; determining the plasma levels of alpha-Tocopherol; CRP and EMPs could improve BAV diagnosis in large populations.
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Affiliation(s)
- Neus Martínez-Micaelo
- Grup de Recerca Cardiovascular, Institut d’Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, 43201 Reus, Spain; (C.L.); (B.A.-G.)
- Correspondence: (N.M.-M.); (J.M.A.); Tel.: +34-977310300 (N.M.-M.); Fax: +34-977315144 (N.M.-M.)
| | - Carme Ligero
- Grup de Recerca Cardiovascular, Institut d’Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, 43201 Reus, Spain; (C.L.); (B.A.-G.)
- Servei de Cardiologia, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43201 Reus, Spain
| | - Borja Antequera-González
- Grup de Recerca Cardiovascular, Institut d’Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, 43201 Reus, Spain; (C.L.); (B.A.-G.)
| | - Alexandra Junza
- Metabolomics Platform, Institut d’Investigació Sanitària Pere Virgili (IISPV), Department of Electronic Engineering, Universitat Rovira i Virgili, 43007 Tarragona, Spain; (A.J.); (O.Y.)
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), 28029 Madrid, Spain
| | - Oscar Yanes
- Metabolomics Platform, Institut d’Investigació Sanitària Pere Virgili (IISPV), Department of Electronic Engineering, Universitat Rovira i Virgili, 43007 Tarragona, Spain; (A.J.); (O.Y.)
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), 28029 Madrid, Spain
| | - Josep M. Alegret
- Grup de Recerca Cardiovascular, Institut d’Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, 43201 Reus, Spain; (C.L.); (B.A.-G.)
- Servei de Cardiologia, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, 43201 Reus, Spain
- Correspondence: (N.M.-M.); (J.M.A.); Tel.: +34-977310300 (N.M.-M.); Fax: +34-977315144 (N.M.-M.)
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8
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Alegria S, Simões O, Almeida AR, Silva E Castro J, Laranjeira Á, Pereira H. An unexpected association in a patient with heart failure presenting a surgical challenge. J Card Surg 2019; 35:431-432. [PMID: 31816112 DOI: 10.1111/jocs.14393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Bicuspid aortic valve (BAV) is the most common form of congenital heart disease and frequently leads to premature valvular dysfunction. BAV is associated with aortic wall abnormalities and a high prevalence of ascending aorta dilatation and coarctation of the aorta (CoA). Consequently, in patients with BAV a careful assessment of the valve, and also of the aortic root and the ascending aorta, should be performed. The most feared complication is aortic dissection, however, the actual incidence of this complication is low. We report the case of a 58-year-old man who presented with New York Heart Association class III heart failure. The work-up revealed BAV with severe stenosis and severe compromise of left ventricle systolic function. In addition, CoA in the isthmus region, and type B dissection of the aorta were diagnosed.
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Affiliation(s)
- Sofia Alegria
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Otília Simões
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Ana Rita Almeida
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | | | - Álvaro Laranjeira
- Department of Cardiovascular Surgery, Hospital de Santa Marta, Lisboa, Portugal
| | - Hélder Pereira
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
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Singh A, Horsfield MA, Bekele S, Greenwood JP, Dawson DK, Berry C, Hogrefe K, Kelly DJ, Houston JG, Guntur Ramkumar P, Uddin A, Suzuki T, McCann GP. Aortic stiffness in aortic stenosis assessed by cardiovascular MRI: a comparison between bicuspid and tricuspid valves. Eur Radiol 2018; 29:2340-2349. [PMID: 30488106 PMCID: PMC6443917 DOI: 10.1007/s00330-018-5775-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK.
| | | | - Soliana Bekele
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular & Metabolic Medicine, Leeds University, Leeds, LS2 9JT, UK
| | - Dana K Dawson
- Cardiovascular Medicine Research Unit, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Kai Hogrefe
- Cardiology Department, Kettering General Hospital Foundation Trust, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Damian J Kelly
- Cardiology Department, Royal Derby Hospital, Uttoxeter Rd, Derby, DE22 3NE, UK
| | - John G Houston
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Prasad Guntur Ramkumar
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Akhlaque Uddin
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular & Metabolic Medicine, Leeds University, Leeds, LS2 9JT, UK
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK
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10
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Abstract
UNLABELLED AimWe investigated dimensions and elasticity of whole aorta in patients with bicuspid aortic valve and influence of valve phenotype. METHOD The study group included 44 patients and 42 controls. Patients were divided into groups according to the type of valve opening as horizontal - fusion between right and left coronary cusps - and vertical - fusion between right-non-coronary cusps; according to age they were divided into younger (5-10 years) and older patients (11-16 years). Our study did not include valve phenotype with fusion between left and non-coronary cusps. Systolic-diastolic diameters of aortic annulus, sinus valsalva, sinutubular junction, arcus, and ascending-descending and abdominal aorta were measured and z-scores were obtained. Aortic strain, distensibility, and stiffness index were calculated. Flow-mediated dilatation of brachial artery was studied. RESULTS z-Scores at annulus, sinus valsalva, sinutubular junction, and ascending aorta were higher in study patients (p=0.001, p=0.0001, p=0.0001, p=0.0001, respectively). z-Scores of sinus valsalva and sinotubular junction were higher in the horizontal group than in the vertical group (p=0.006, p=0.023, respectively). z-Score was over +2 in 51% of patients with horizontal morphology and 33% of patients with vertical morphology (p=0.0001). Ascending aorta was more distensible and less stiff in the study group (11.3±5.63 versus 7.91±4.5, p=0.002; 4.76±3.60 versus 6.19±3.44 cm2.dyn-1.10-6, p=0.033, respectively). Stiffness index of ascending, arcus, and abdominal aorta were higher in the horizontal group (p=0.004, p=0.038, p=0.006, respectively). Ascending aorta was more distensible and less stiff in the younger group (p=0.007, p=0.027, respectively) but did not differ in the older group compared with the control group. CONCLUSION Aortic dimensions are enlarged in patients with bicuspid aortic valve starting from childhood, suggesting the presence of generalised aortopathy. Aortic elasticity is increased at young age and decreased with age.
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11
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Farag ES, van Ooij P, Planken RN, Dukker KC, de Heer F, Bouma BJ, Robbers‐Visser D, Groenink M, Nederveen AJ, de Mol BA, Kluin J, Boekholdt SM. Aortic valve stenosis and aortic diameters determine the extent of increased wall shear stress in bicuspid aortic valve disease. J Magn Reson Imaging 2018; 48:522-530. [PMID: 29451963 PMCID: PMC6099246 DOI: 10.1002/jmri.25956] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/05/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Use of 4-dimensional flow magnetic resonance imaging (4D-flow MRI) derived wall shear stress (WSS) heat maps enables identification of regions in the ascending aorta with increased WSS. These regions are subject to dysregulation of the extracellular matrix and elastic fiber degeneration, which is associated with aortic dilatation and dissection. PURPOSE To evaluate the effect of the presence of aortic valve stenosis and the aortic diameter on the peak WSS and surface area of increased WSS in the ascending aorta. STUDY TYPE Prospective. SUBJECTS In all, 48 bicuspid aortic valve (BAV) patients (38.1 ± 12.4 years) and 25 age- and gender-matched healthy individuals. FIELD STRENGTH/SEQUENCE Time-resolved 3D phase contrast MRI with three-directional velocity encoding at 3.0T. ASSESSMENT Peak systolic velocity, WSS, and aortic diameters were assessed in the ascending aorta and 3D heat maps were used to identify regions with elevated WSS. STATISTICAL TESTS Comparisons between groups were performed by t-tests. Correlations were investigated by univariate and multivariate regression analysis. RESULTS Elevated WSS was present in 15 ± 11% (range; 1-35%) of the surface area of the ascending aorta of BAV patients with aortic valve stenosis (AS) (n = 10) and in 6 ± 8% (range; 0-31%) of the ascending aorta of BAV patients without AS (P = 0.005). The mid-ascending aortic diameter negatively correlated with the peak ascending aortic WSS (R = -0.413, P = 0.004) and the surface area of elevated WSS (R = -0.419, P = 0.003). Multivariate linear regression analysis yielded that the height of peak WSS and the amount of elevated WSS depended individually on the presence of aortic valve stenosis and the diameter of the ascending aorta. DATA CONCLUSION The extent of increased WSS in the ascending aorta of BAV patients depends on the presence of aortic valve stenosis and aortic dilatation and is most pronounced in the presence of AS and a nondilated ascending aorta. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2018;48:522-530.
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Affiliation(s)
- Emile S. Farag
- Department of Cardiothoracic SurgeryAcademic Medical CenterAmsterdamthe Netherlands
| | - Pim van Ooij
- Department of RadiologyAcademic Medical CenterAmsterdamthe Netherlands
| | - R. Nils Planken
- Department of RadiologyAcademic Medical CenterAmsterdamthe Netherlands
| | | | - Frederiek de Heer
- Department of Cardiothoracic SurgeryAcademic Medical CenterAmsterdamthe Netherlands
| | - Berto J. Bouma
- Department of CardiologyAcademic Medical CenterAmsterdamthe Netherlands
| | | | - Maarten Groenink
- Department of RadiologyAcademic Medical CenterAmsterdamthe Netherlands
- Department of CardiologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Aart J. Nederveen
- Department of RadiologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Bas A.J.M. de Mol
- Department of Cardiothoracic SurgeryAcademic Medical CenterAmsterdamthe Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic SurgeryAcademic Medical CenterAmsterdamthe Netherlands
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12
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Citro R, Cecconi M, La Carrubba S, Bossone E, Antonini-Canterin F, Nistri S, Chirillo F, Dentamaro I, Bellino M, Posteraro A, Giorgi M, Petrella L, Monte I, Manuppelli V, Mantero A, Carerj S, Benedetto F, Colonna P. Bicuspid Aortic Valve Registry of the Italian Society of Echocardiography and Cardiovascular Imaging (REgistro della valvola aortica bicuspide della società italiana di ECocardiografia e CArdiovascular imaging): Rationale and Study Design. J Cardiovasc Echogr 2018; 28:78-89. [PMID: 29911003 PMCID: PMC5989554 DOI: 10.4103/jcecho.jcecho_5_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5%–2% of the general population. It is associated not only with notable valvular risk (aortic stenosis and/or regurgitation, endocarditis) but also with aortopathy with a wide spectrum of unpredictable clinical presentations, including aneurysmal dilation of the aortic root and/or ascending thoracic aorta, isthmic coarctation, aortic dissection, or wall rupture. Methods: The REgistro della Valvola Aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging is a retrospective (from January 1, 2010)/prospective, multicenter, observational registry, expected to enroll 3000 patients with definitive diagnosis of BAV made by transthoracic and/or transesophageal echocardiography, computed tomography, cardiovascular magnetic resonance, or at surgery. Inclusion criteria were definitive diagnosis of BAV. Patients will be enrolled regardless of the presence and severity of aortic valve dysfunction or aortic vessel disease and the coexistence of other congenital cardiovascular malformations. Exclusion criteria were uncertain BAV diagnosis, impossibility of obtaining informed consent, inability to carry out the follow-up. Anamnestic, demographic, clinical, and instrumental data collected both at first evaluation and during follow-up will be integrated into dedicated software. The aim is to derive a data set of unselected BAV patients with the main purpose of assessing the current clinical presentation, management, and outcomes of BAV. Conclusions: A multicenter registry covering a large population of BAV patients could have a profound impact on the understanding of the natural history of this disease and could influence its management.
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Affiliation(s)
- Rodolfo Citro
- Heart Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
| | - Moreno Cecconi
- Department of Cardiovascular Science, University Hospital "Ospedali Riuniti Ancona," Ancona, Italy
| | | | - Eduardo Bossone
- Cardiology Department Hospital of Cava de' Tirreni and Costa d'Amalfi, Cava de' Tirreni, Italy
| | - Francesco Antonini-Canterin
- Division of Rehabilitation Cardiology, Rehabilitation Hospital of High Specialization ORAS, Motta di Livenza, Italy
| | - Stefano Nistri
- Cardiology Department, CMSR Veneto Medica, Altavilla Vicentina, Italy
| | - Fabio Chirillo
- Cardiology Department, Ca' Foncello Hospital, Treviso, Italy
| | - Ilaria Dentamaro
- Department of Cardiology, Hospital Policlinico of Bari, Bari, Italy
| | - Michele Bellino
- Heart Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
| | | | - Mauro Giorgi
- Cardiology Department, University Hospital Città della Salute e della Scienza di Torino, Molinette Hospital, Turin, Italy
| | - Licia Petrella
- Cardiology Department, G. Mazzini Hospital, Teramo, Italy
| | - Ines Monte
- Cardiology Department Echocardiography Laboratory, Department of Cardiothoracic and Vascular, Policlinico Vittorio Emanuele, Catania University, Catania, Italy
| | - Vincenzo Manuppelli
- Department of Cardiology, University Hospital "Ospedali Riuniti di Foggia," Foggia, Italy
| | - Antonio Mantero
- Department of Cardiology, San Paolo University Hospital, Milan, Italy
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine and Pharmacology, University of Messina, Messina, Italy
| | - Frank Benedetto
- Division of Cardiology, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Paolo Colonna
- Cardiology Department, Ca' Foncello Hospital, Treviso, Italy
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13
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Giusti B, Sticchi E, De Cario R, Magi A, Nistri S, Pepe G. Genetic Bases of Bicuspid Aortic Valve: The Contribution of Traditional and High-Throughput Sequencing Approaches on Research and Diagnosis. Front Physiol 2017; 8:612. [PMID: 28883797 PMCID: PMC5573733 DOI: 10.3389/fphys.2017.00612] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/09/2017] [Indexed: 12/20/2022] Open
Abstract
Bicuspid aortic valve (BAV) is a common (0.5-2.0% of general population) congenital heart defect with increased prevalence of aortic dilatation and dissection. BAV has an autosomal dominant inheritance with reduced penetrance and variable expressivity. BAV has been described as an isolated trait or associated with syndromic conditions [e.g., Marfan Marfan syndrome or Loeys-Dietz syndrome (MFS, LDS)]. Identification of a syndromic condition in a BAV patient is clinically relevant to personalize aortic surgery indication. A 4-fold increase in BAV prevalence in a large cohort of unrelated MFS patients with respect to general population was reported, as well as in LDS patients (8-fold). It is also known that BAV is more frequent in patients with thoracic aortic aneurysm (TAA) related to mutations in ACTA2, FBN1, and TGFBR2 genes. Moreover, in 8 patients with BAV and thoracic aortic dilation, not fulfilling the clinical criteria for MFS, FBN1 mutations in 2/8 patients were identified suggesting that FBN1 or other genes involved in syndromic conditions correlated to aortopathy could be involved in BAV. Beyond loci associated to syndromic disorders, studies in humans and animal models evidenced/suggested the role of further genes in non-syndromic BAV. The transcriptional regulator NOTCH1 has been associated with the development and acceleration of calcium deposition. Genome wide marker-based linkage analysis demonstrated a linkage of BAV to loci on chromosomes 18, 5, and 13q. Recently, a role for GATA4/5 in aortic valve morphogenesis and endocardial cell differentiation has been reported. BAV has also been associated with a reduced UFD1L gene expression or involvement of a locus containing AXIN1/PDIA2. Much remains to be understood about the genetics of BAV. In the last years, high-throughput sequencing technologies, allowing the analysis of large number of genes or entire exomes or genomes, progressively became available. The latter issue together with the development of "BigData" analysis methods improving their interpretation and integration with clinical data represents a promising opportunity to increase the disease knowledge and diagnosis in monogenic and multifactorial complex traits. This review summarized the main knowledge on the BAV genetic bases, the role of genetic diagnosis in BAV patient managements and the crucial challenges for the comprehension of genetics of BAV in research and diagnosis.
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Affiliation(s)
- Betti Giusti
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of FlorenceFlorence, Italy.,Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi HospitalFlorence, Italy.,Advanced Molecular Genetics Laboratory, Atherothrombotic Diseases Center, Careggi HospitalFlorence, Italy.,Center of Excellence for the Study at Molecular and Clinical Level of Chronic, Degenerative and Neoplastic Diseases to Develop Novel Therapies (DENOTHE), University of FlorenceFlorence, Italy
| | - Elena Sticchi
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of FlorenceFlorence, Italy.,Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi HospitalFlorence, Italy.,Advanced Molecular Genetics Laboratory, Atherothrombotic Diseases Center, Careggi HospitalFlorence, Italy.,Center of Excellence for the Study at Molecular and Clinical Level of Chronic, Degenerative and Neoplastic Diseases to Develop Novel Therapies (DENOTHE), University of FlorenceFlorence, Italy
| | - Rosina De Cario
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of FlorenceFlorence, Italy.,Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi HospitalFlorence, Italy
| | - Alberto Magi
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of FlorenceFlorence, Italy.,Advanced Molecular Genetics Laboratory, Atherothrombotic Diseases Center, Careggi HospitalFlorence, Italy
| | - Stefano Nistri
- Center of Excellence for the Study at Molecular and Clinical Level of Chronic, Degenerative and Neoplastic Diseases to Develop Novel Therapies (DENOTHE), University of FlorenceFlorence, Italy.,Cardiology Service, Centro Medico Strumentale Riabilitativo (CMSR) Veneto MedicaAltavilla Vicentina, Italy
| | - Guglielmina Pepe
- Department of Experimental and Clinical Medicine, Section of Critical Medical Care and Medical Specialities, University of FlorenceFlorence, Italy.,Marfan Syndrome and Related Disorders Regional (Tuscany) Referral Center, Careggi HospitalFlorence, Italy.,Center of Excellence for the Study at Molecular and Clinical Level of Chronic, Degenerative and Neoplastic Diseases to Develop Novel Therapies (DENOTHE), University of FlorenceFlorence, Italy
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14
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Peeters FE, Van der Linden N, Thomassen AL, Crijns HJ, Meex SJ, Kietselaer BL. Clinical and echocardiographic determinants in bicuspid aortic dilatation: Results from a longitudinal observational study. Medicine (Baltimore) 2016; 95:e5699. [PMID: 28033264 PMCID: PMC5207560 DOI: 10.1097/md.0000000000005699] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Bicuspid aortic valve (BAV) disease is associated with aortic dilatation. Timing of follow-up and surgery is challenging. Hence, there is an unmet clinical need for additional risk stratification. It is unclear whether valve morphology is associated with dilatation rates. Therefore, the objective of this study was to examine the association between clinical and echocardiographic determinants (including valve morphology) and aortic dimension and the progression rate of dilatation.Aortic dimensions were assessed on serial echocardiographic images between 1999 and 2014 in a population of 392 patients with BAVs in a tertiary care center in the Netherlands. Analyses using mixed linear models were performed.Mean age of participants was 48 ± 17 years and 69% were male. BAV morphology was associated with aortic dimensions, as well as age, sex, BSA, and valvular dysfunction. Tubular ascending aorta, sinus of Valsalva, and sinotubular junction showed a dilatation rate of 0.32, 0.18, and 0.06 mm/year, respectively. Dilatation rate was not associated with valve morphology.In the present study, there is no association between BAV morphology and aortic dilatation rates. Therefore, morphology is of limited use in prediction of aortic growth. Discovering fast progressors remains challenging.
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Affiliation(s)
| | | | | | | | - Steven J.R. Meex
- CARIM, School for Cardiovascular Diseases
- Department of Clinical Chemistry
| | - Bas L.J.H. Kietselaer
- Department of Cardiology, MUMC+
- CARIM, School for Cardiovascular Diseases
- Department of Radiology, MUMC+, Maastricht, the Netherlands
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15
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Wang W, Maimaiti A, Zhao Y, Zhang L, Tao H, Nian H, Xia L, Kong B, Wang C, Liu M, Wei L. Analysis of Serum Metabolites to Diagnose Bicuspid Aortic Valve. Sci Rep 2016; 6:37023. [PMID: 27845433 PMCID: PMC5109472 DOI: 10.1038/srep37023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/24/2016] [Indexed: 01/27/2023] Open
Abstract
Bicuspid aortic valve (BAV) is the most common congenital heart disease. The current study aims to construct a diagnostic model based on metabolic profiling as a non-invasive tool for BAV screening. Blood serum samples were prepared from an estimation group and a validation group, each consisting of 30 BAV patients and 20 healthy individuals, and analyzed by liquid chromatography-mass spectrometry (LC-MS). In total, 2213 metabolites were detected and 41 were considered different. A model for predicting BAV in the estimation group was constructed using the concentration levels of monoglyceride (MG) (18:2) and glycerophospho-N-oleoyl ethanolamine (GNOE). A novel model named Zhongshan (ZS) was developed to amplify the association between BAV and the two metabolites. The area under curve (AUC) of ZS for BAV prediction was 0.900 (0.782–0.967) and was superior to all single-metabolite models when applied to the estimation group. Using optimized cutoff (−0.1634), ZS model had a sensitivity score of 76.7%, specificity score of 90.0%, positive predictive value of 80% and negative predictive value of 85.0% for the validation group. These results support the use of serum-based metabolomics profiling method as a complementary tool for BAV screening in large populations.
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Affiliation(s)
- Wenshuo Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
| | - Aikebaier Maimaiti
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
| | - Yun Zhao
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
| | - Lingfei Zhang
- State Key Laboratory of Molecular Biology, Shanghai Key Laboratory of Molecular Andrology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, 200031, Shanghai, China
| | - Hongyue Tao
- Department of Radiology, Huashan Hospital, Fudan University. 200040, Shanghai, China
| | - Hui Nian
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
| | - Limin Xia
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
| | - Biao Kong
- Department of Chemistry, Laboratory of Advanced Materials, Fudan University, 200433, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
| | - Mofang Liu
- State Key Laboratory of Molecular Biology, Shanghai Key Laboratory of Molecular Andrology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, 200031, Shanghai, China
| | - Lai Wei
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University. 200032, Shanghai, China
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16
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Meindl C, Achatz B, Huber D, Baessler A, Hubauer U, Meisinger C, Hengstenberg C, Erdmann J, Buchner S, Maier L, Schunkert H, Debl K, Fischer M. Coronary Artery Ectasia Are Frequently Observed in Patients With Bicuspid Aortic Valves With and Without Dilatation of the Ascending Aorta. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004092. [DOI: 10.1161/circinterventions.116.004092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 09/15/2016] [Indexed: 11/16/2022]
Abstract
Background—
The presence of coronary artery ectasia (CAE) is influenced by genetic factors and related to the presence of aneurysms in other vascular beds. Bicuspid aortic valve (BAV) disease is frequently accompanied by ascending aortic aneurysm. Because the aortic valve and the proximal parts of the coronary arteries share a common embryonic origin, we hypothesized that CAE is associated with BAV disease.
Methods and Results—
One hundred seventy-seven patients with suspected aortic valve disease (n=94 BAV, n=83 tricuspid aortic valve) underwent both cardiac magnetic resonance imaging and coronary angiography. To confirm the association of CAE with BAV, the frequency of CAE was evaluated in an in-house BAV registry (n=600, n=231 with available coronary angiogram) and compared with the frequency of CAE in the German Myocardial Infarction (MI) Family Study, in which the heritability of CAE was formerly established (n=899). Furthermore, the frequency of CAE was investigated in an observational registry of real-life patients undergoing coronary angiography for clinically indicated reasons (n=3.097) and in a subgroup of the KORA MI study (Cooperative Health Research in the Region of Augsburg), which is a population-based MI registry (n=403).
Compared with tricuspid aortic valve disease, CAE occurred more than twice as frequently in cardiac magnetic resonance–confirmed BAV disease (17% versus 44%;
P
<0.0001) and CAE was observed similarly often in subjects with BAV with (37%) and without (54%,
P
=0.11) ascending aortic pathology. The common appearance of CAE in patients with BAV could be independently confirmed in the BAV registry (frequency 37%), whereas CAE was found less frequently in family history of positive MI patients (21%), sporadic MI without familial disposition (10%), and rarely in unrelated real-life catheterization patients (6%).
Conclusions—
To our knowledge, our data show for the first time that ectatic coronary artery disease is a common appearance of BAV disease with and without ascending aortic ectasia.
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Affiliation(s)
- Christine Meindl
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Birgit Achatz
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Deborah Huber
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Andrea Baessler
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Ute Hubauer
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Christa Meisinger
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Christian Hengstenberg
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Jeanette Erdmann
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Stefan Buchner
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Lars Maier
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Heribert Schunkert
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Kurt Debl
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
| | - Marcus Fischer
- From the Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Germany (C. Meindl, B.A., D.H., A.B., U.H., S.B., L.M., K.D., M.F.); Helmholtz Zentrum München, Institute of Epidemiology II, Technische Universität München, Germany (C. Meisinger); Deutsches Herzzentrum München, Technische Universität München, Deutsches Zentrum für Herz-und Kreislaufforschung (DZHK), Partner site Munich Heart Alliance, Munich, Germany (C.H., H.S.); and Institut für Integrative und Experimentelle
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A Case Based Approach to Clinical Genetics of Thoracic Aortic Aneurysm/Dissection. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9579654. [PMID: 27314043 PMCID: PMC4897665 DOI: 10.1155/2016/9579654] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/30/2016] [Accepted: 04/19/2016] [Indexed: 12/04/2022]
Abstract
Thoracic aortic aneurysm/dissection (TAAD) is a potential lethal condition with a rising incidence. This condition may occur sporadically; nevertheless, it displays familial clustering in >20% of the cases. Family history confers a six- to twentyfold increased risk of TAAD and has to be considered in the identification and evaluation of patients needing an adequate clinical follow-up. Familial TAAD recognizes a number of potential etiologies with a significant genetic heterogeneity, in either syndromic or nonsyndromic forms of the manifestation. The clinical impact and the management of patients with TAAD differ according to the syndromic and nonsyndromic forms of the manifestation. The clinical management of TAAD patients varies, depending on the different forms. Starting from the description of patient history, in this paper, we summarized the state of the art concerning assessment of clinical/genetic profile and therapeutic management of TAAD patients.
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Abstract
The objectives of this study were to investigate left ventricular (LV) function, aortic dilation, and atherosclerosis in children with mildly deteriorated isolated bicuspid aortic valve (BAV) function using echocardiographic studies and biochemical markers of atherosclerosis and to correlate results with normal children. Biochemical analyses indicating cardiovascular risk of atherosclerosis and vascular changes in the aorta in relation to BAV were performed in 41 children aged 5-15 years old with isolated BAV and in 25 children with tricuspid aortic valves. Evaluations of aortic valve structures and functions; examinations of the LV M-mode and ascending aorta Doppler; and measurements of the LV Tei index (MPI), propagation velocity, ascending aorta at four levels, and carotid intima-media thickness (CIMT) were performed. There were no statistically significant differences in CIMTs, plasma matrix metalloproteinase-9, tissue metalloproteinase inhibitor-1 levels, or other biochemical parameters indicating cardiovascular risk or atherosclerosis between study and control groups. Deterioration of LV function, which could not be seen with M-mode echocardiography, was evident by MPI. MPI values in the study versus control groups were 0.46 ± 0.080 versus 0.40 ± 0.086 (p < 0.05). Diameters of the aorta in the study and control groups were 19.7 ± 4.7 and 17.2 ± 2.8 mm (p < 0.05) at the sinotubular junction level and 20.6 (14.4-40.5) and 18.3 (12.4-24) mm at the ascending aorta level (p < 0.05). Increased aortic valve insufficiency was related to increased aortic diameter. No sign of atherosclerosis was detected in children with BAV. Deterioration of LV function was seen using MPI, and aortic dilation was related to the severity of aortic valve insufficiency.
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Henn D, Perttunen H, Gauer S, Schmied W, Porras C, Such M, Schäfers HJ. GATA5 and endothelial nitric oxide synthase expression in the ascending aorta is related to aortic size and valve morphology. Ann Thorac Surg 2014; 97:2019-25. [PMID: 24766859 DOI: 10.1016/j.athoracsur.2014.02.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 02/08/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The pathogenesis of aortic dilatation in patients with congenital aortic valve anomalies is poorly understood. Recent studies suggest that alterations of gene expression may be related to ascending aortic aneurysm formation in these patients. Knockout of endothelial nitric oxide synthase (eNOS) and GATA5 is associated with bicuspid aortic valves in mice. To study the role of eNOS and GATA5 in human congenital aortic valve disease and aortic dilatation, we investigated their gene expression in aortic tissue from patients with unicuspid, bicuspid, and tricuspid aortic valves. METHODS Samples from 84 patients (33 tricuspid, 32 bicuspid, and 19 unicuspid) were harvested intraoperatively from the ascending aorta. GATA5 and eNOS expression was determined by real-time polymerase chain reaction. RESULTS GATA5 and eNOS expression in the aortic wall from patients with unicuspid aortic valves (GATA5: mean [M], 2.14; standard deviation [SD], 1.72; eNOS: M, 3.40; SD, 3.83) was significantly higher than in tricuspid aortic valves (GATA5: M, 1.12; SD, 0.80; eNOS: M, 1.00; SD, 0.74; each p < 0.05). Patients with bicuspid aortic valves (GATA5: M, 1.29, SD, 1.33; eNOS: M, 1.66; SD, 1.31) had a significantly higher eNOS expression than patients with tricuspid aortic valves (p < 0.05). The expression levels of eNOS and GATA5 correlated positively with each other and negatively with the ascending aortic diameter. CONCLUSIONS Our data suggest that GATA5, possibly through upregulation of eNOS, plays a role in the development of aortic dilatation in patients with unicuspid and bicuspid aortic valves. The differential gene expression in patients with unicuspid compared with bicuspid aortic valves suggests that the pathogenesis of both aortic valve anomalies may be different.
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Affiliation(s)
- Dominic Henn
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Hilja Perttunen
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Simon Gauer
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Wolfram Schmied
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Carlos Porras
- Department of Cardiovascular Surgery, Hospital Virgen de la Victoria, Campus de Teatinos, Málaga, Spain
| | - Miguel Such
- Department of Cardiovascular Surgery, Hospital Virgen de la Victoria, Campus de Teatinos, Málaga, Spain
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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A fatal outcome of thoracic aortic aneurysm in a male patient with bicuspid aortic valve. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2014; 9:265-71. [PMID: 24570730 PMCID: PMC3915982 DOI: 10.5114/pwki.2013.37507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 07/10/2013] [Accepted: 07/12/2013] [Indexed: 11/20/2022] Open
Abstract
Thoracic aortic aneurysm is often an asymptomatic but potentially lethal disease if its most catastrophic complication – aortic dissection – occurs. Thoracic aortic dissection is associated with a high mortality rate despite ongoing improvement in its management. We report a fatal outcome of thoracic aortic aneurysm in a male patient with bicuspid aortic valve. The patient was qualified for elective surgery of the ascending aorta and aortic valve at the age of 39 but he did not agree to undergo the proposed procedure. Three years later, he experienced acute aortic dissection and died despite a prompt diagnosis and complex management.
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21
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Alghamdi AA, Van Arsdell GS. Replacement of aortic root and ascending aorta in adult congenital heart disease. Expert Rev Cardiovasc Ther 2014; 5:1087-94. [DOI: 10.1586/14779072.5.6.1087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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22
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Maleki S, Björck HM, Paloschi V, Kjellqvist S, Folkersen L, Jackson V, Franco-Cereceda A, Eriksson P. Aneurysm Development in Patients With Bicuspid Aortic Valve (BAV): Possible Connection to Repair Deficiency? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2013; 1:13-22. [PMID: 26798668 DOI: 10.12945/j.aorta.2013.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 02/15/2013] [Indexed: 01/25/2023]
Affiliation(s)
- Shohreh Maleki
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hanna M Björck
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Valentina Paloschi
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sanela Kjellqvist
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lasse Folkersen
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Jackson
- Cardiothoracic Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Cardiothoracic Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Per Eriksson
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Khoo C, Cheung C, Jue J. Patterns of aortic dilatation in bicuspid aortic valve-associated aortopathy. J Am Soc Echocardiogr 2013; 26:600-5. [PMID: 23562085 DOI: 10.1016/j.echo.2013.02.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Clarence Khoo
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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Aortic disease in the young: genetic aneurysm syndromes, connective tissue disorders, and familial aortic aneurysms and dissections. Int J Vasc Med 2013; 2013:267215. [PMID: 23401778 PMCID: PMC3557640 DOI: 10.1155/2013/267215] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 12/13/2012] [Accepted: 12/18/2012] [Indexed: 01/15/2023] Open
Abstract
There are many genetic syndromes associated with the aortic aneurysmal disease which include Marfan syndrome (MFS), Ehlers-Danlos syndrome (EDS), Loeys-Dietz syndrome (LDS), familial thoracic aortic aneurysms and dissections (TAAD), bicuspid aortic valve disease (BAV), and autosomal dominant polycystic kidney disease (ADPKD). In the absence of familial history and other clinical findings, the proportion of thoracic and abdominal aortic aneurysms and dissections resulting from a genetic predisposition is still unknown. In this study, we propose the review of the current genetic knowledge in the aortic disease, observing, in the results that the causative genes and molecular pathways involved in the pathophysiology of aortic aneurysm disease remain undiscovered and continue to be an area of intensive research.
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Current indications for surgical repair in patients with bicuspid aortic valve and ascending aortic ectasia. Cardiol Res Pract 2012; 2012:313879. [PMID: 23050195 PMCID: PMC3461294 DOI: 10.1155/2012/313879] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/12/2012] [Indexed: 01/15/2023] Open
Abstract
Preventive surgical repair of the moderately dilated ascending aorta/aortic root in patients with bicuspid aortic valve (BAV) is controversial. Most international reference centers are currently proposing a proactive approach for BAV patients with a maximum ascending aortic/root diameter of 45 mm since the risk of dissection/rupture raises significantly with an aneurysm diameter >50 mm. Current guidelines of the European Society of Cardiology (ESC) and the joint guidelines of the American College of Cardiology (ACC)/American Heart Association (AHA) recommend elective repair in symptomatic patients with dysfunctional BAV (aortic diameter ≥45 mm). In asymptomatic patients with a well-functioning BAV, elective repair is recommended for diameters ≥50 mm, or if the aneurysm is rapidly progressing (rate of 5 mm/year), or in case of a strong family history of dissection/rupture/sudden death, or with planned pregnancy. As diameter is likely not the most reliable predictor of rupture and dissection and the majority of BAV patients may never experience an aortic catastrophe at small diameters, an overly aggressive approach almost certainly will put some patients with BAV unnecessarily at risk of operative and early mortality. This paper discusses the indications for preventive, elective repair of the aortic root, and ascending aorta in patients with a BAV and a moderately dilated—or ectatic—ascending aorta.
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Cardiac evaluation of collegiate student athletes: a medical and legal perspective. Am J Med 2012; 125:742-52. [PMID: 22840661 DOI: 10.1016/j.amjmed.2012.02.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 02/09/2012] [Accepted: 02/09/2012] [Indexed: 11/20/2022]
Abstract
Physicians participate in the screening, routine medical supervision, and disqualification process of collegiate student athletes today. Physicians and universities evaluating collegiate student athletes for athletic participation should understand the meticulous medical process necessary to make eligibility/disqualification decisions and the associated liability issues. It is the responsibility of a team physician to take the lead role in the college sports medical evaluation process. The first duty of a team physician and institution is to protect the health and well-being of their collegiate student athletes. The potential liability associated with the evaluation process requires institutions of higher education and physicians to develop sound and reasonable administrative strategies regarding college athletes and their participation in intercollegiate athletics. Reducing this liability risk requires an understanding of the evolving judicial framework and compliance with standard case law and available guidelines. As medical professional standards evolve, so will responsibilities under legal standards.
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Raffa GM, Malvindi PG, Ornaghi D, Basciu A, Barbone A, Tarelli G, Settepani F. Postsurgical aortic false aneurysm: pathogenesis, clinical presentation and surgical strategy. J Cardiovasc Med (Hagerstown) 2012; 14:593-6. [PMID: 22499001 DOI: 10.2459/jcm.0b013e32835369f2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postsurgical aortic false aneurysm occurs in less than 0.5% of all cardiac surgical cases and its management is a challenge in terms of preoperative evaluation and surgical approach. Although infections are well recognized as risk factors, technical aspects of a previous operation may have a role in pseudoaneurysm formation. The risk factors and clinical presentation of pseudoaneurysms and the surgical strategy are revisited in this article.
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Affiliation(s)
- Giuseppe M Raffa
- Cardiac Surgery Unit, Istituto Clinico Humanitas IRCCS, Rozzano, Milan, Italy.
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28
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Hartog AW, Franken R, Zwinderman AH, Groenink M, Mulder BJM. Current and future pharmacological treatment strategies with regard to aortic disease in Marfan syndrome. Expert Opin Pharmacother 2012; 13:647-62. [PMID: 22397493 DOI: 10.1517/14656566.2012.665446] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Marfan syndrome is a multisystemic connective tissue disorder caused mainly by mutations in the fibrillin-1 gene. The entire cardiovascular system is affected in patients with Marfan syndrome. Aortic root dilatation, aortic valve regurgitation or - the most feared and life-threatening symptom - aortic root dissection are the most common manifestations. Therapeutic strategies, such as prophylactic aortic root surgery and pharmacological therapy, focus on the prevention of aortic dissection. Currently, the standard medicinal treatments targeting aortic dilatation and dissection consist of agents generally used to lower blood pressure and/or the inotropic state of the heart. By these means, the cyclic repetitive forces exerted on the aortic wall are diminished and thus the onset of aortic dilatation is potentially prevented. Although these pharmacological agents may offer some benefit in reduction of aortic aneurysm expansion rate, they do not target the underlying cause of the progressive aortic degradation. AREAS COVERED This review discusses the effectiveness of frequently prescribed medications used to prevent and delay aortic complications in Marfan syndrome. New insights on the biochemical pathways leading to aortic disease are also discussed to highlight new targets for pharmacological therapy. EXPERT OPINION Recent insights in the transforming growth factor beta signaling pathway and inflammatory mechanisms in a well-established mouse model of Marfan syndrome, have led to studies exploring new pharmacological treatment strategies with doxycycline, statins and angiotensin II receptor blockers. Pharmacological therapy is focused more on prevention than on delay of aortic wall pathology in Marfan syndrome. Of the new pharmacological treatment strategies targeting aortic pathology in Marfan syndrome, angiotensin receptor type 1 blockers are promising candidates, with several clinical trials currently ongoing.
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Affiliation(s)
- Alexander W Hartog
- Academic Medical Center, Department of Cardiology, B2-240, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Zomer A, Verheugt C, Vaartjes I, Uiterwaal C, Langemeijer M, Koolbergen D, Hazekamp M, van Melle J, Konings T, Bellersen L, Grobbee D, Mulder B. Surgery in Adults With Congenital Heart Disease. Circulation 2011; 124:2195-201. [DOI: 10.1161/circulationaha.111.027763] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A.C. Zomer
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - C.L. Verheugt
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - I. Vaartjes
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - C.S.P.M. Uiterwaal
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - M.M. Langemeijer
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - D.R. Koolbergen
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - M.G. Hazekamp
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - J.P. van Melle
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - T.C. Konings
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - L. Bellersen
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - D.E. Grobbee
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
| | - B.J.M. Mulder
- From the Departments of Cardiology (A.C.Z., B.J.M.M.) and Pediatric Cardiac Surgery (D.R.K., M.G.H.), Academic Medical Center, Amsterdam; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (A.C.Z., I.V., C.S.P.M.U., D.E.G.); Interuniversity Cardiology Institute of the Netherlands, Utrecht (A.C.Z., M.M.L., B.J.M.M.); Departments of Internal Medicine (C.L.V.), and Cardiology (T.C.K.), VU University Medical Center, Amsterdam; Department of Cardiothoracic
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Park CB, Greason KL, Suri RM, Michelena HI, Schaff HV, Sundt TM. Should the proximal arch be routinely replaced in patients with bicuspid aortic valve disease and ascending aortic aneurysm? J Thorac Cardiovasc Surg 2011; 142:602-7. [DOI: 10.1016/j.jtcvs.2010.08.086] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 08/18/2010] [Accepted: 08/29/2010] [Indexed: 10/18/2022]
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Cook JR, Nistala H, Ramirez F. Drug-based therapies for vascular disease in Marfan syndrome: from mouse models to human patients. ACTA ACUST UNITED AC 2011; 77:366-73. [PMID: 20687182 DOI: 10.1002/msj.20200] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Marfan syndrome is a congenital disorder of the connective tissue with a long history of clinical and basic science breakthroughs that have forged our understanding of vascular-disease pathogenesis. The biomedical importance of Marfan syndrome was recently underscored by the discovery that the underlying genetic lesion impairs both tissue integrity and transforming growth factor-beta regulation of cell behavior. This discovery has led to the successful implementation of the first pharmacological intervention in a connective-tissue disorder otherwise incurable by either gene-based or stem cell-based therapeutic strategies. More generally, information gathered from the study of Marfan syndrome pathogenesis has the potential to improve the clinical management of common acquired disorders of connective-tissue degeneration.
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Affiliation(s)
- Jason R Cook
- Mount Sinai School of Medicine, New York, NY, USA
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Etz CD, Borger MA, Misfeld M, Mohr FW. Patienten mit bikuspider Aortenklappe und moderat erweiterter Aorta ascendens. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00398-011-0846-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bonnichsen CR, Sundt TM, Anavekar NS, Foley TA, Morris MF, Martinez MW, Williamson EE, Glockner JF, Araoz PA. Aneurysms of the ascending aorta and arch: the role of imaging in diagnosis and surgical management. Expert Rev Cardiovasc Ther 2011; 9:45-61. [PMID: 21166528 DOI: 10.1586/erc.10.168] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thoracic aortic aneurysms tend to be asymptomatic and were previously often diagnosed only after a complication such as dissection or rupture occurred. Better imaging techniques and an increase in the use of cross-sectional imaging has led to an increase in the diagnosis of aortic aneurysms, which has allowed for elective treatment prior to the development of a complication. The location, size and etiology of an aneurysm all impact the clinical outcomes and these factors are used to determine the appropriate timing of surgical replacement. Surgeons often rely on the information obtained from preoperative imaging to determine when to intervene and what type of procedure will be necessary, making it important for the radiologist to understand these issues in order to provide the necessary information. Postoperative imaging after surgical replacement of the aorta is also important, as there are some common findings that occur in this patient population that can impact how they are treated. The purpose of this article is to review the etiology and associated findings of aneurysms of the ascending aorta and arch, with a focus on how computed tomography angiography and magnetic resonance angiography findings are used to determine the appropriate timing for elective replacement and the type of surgical procedure, as well as the role of follow-up imaging. This will include a review of the most commonly performed types of surgical procedures, to provide an understanding of how the findings of preoperative imaging studies impact what the surgeon does in the operating room, as well as the expected findings of postoperative imaging studies.
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Affiliation(s)
- Crystal R Bonnichsen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic and Mayo Foundation, 200 1st Street SW, Rochester, MN 55905, USA
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Kurtovic S, Paloschi V, Folkersen L, Gottfries J, Franco-Cereceda A, Eriksson P. Diverging alternative splicing fingerprints in the transforming growth factor-β signaling pathway identified in thoracic aortic aneurysms. Mol Med 2011; 17:665-75. [PMID: 21448509 DOI: 10.2119/molmed.2011.00018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 03/23/2011] [Indexed: 01/29/2023] Open
Abstract
Impaired regulation of the transforming growth factor-β (TGFβ) signaling pathway has been linked to thoracic aortic aneurysm (TAA). Previous work has indicated that differential splicing is a common phenomenon, potentially influencing the function of proteins. In the present study we investigated the occurrence of differential splicing in the TGFβ pathway associated with TAA in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV). Affymetrix human exon arrays were applied to 81 intima/media tissue samples from dilated (n = 51) and nondilated (n = 30) aortas of TAV and BAV patients. To analyze the occurrence of alternative splicing in the TGFβ pathway, multivariate techniques, including principal component analysis and OPLS-DA (orthogonal partial least squares to latent structures discriminant analysis), were applied on all exons (n = 614) of the TGFβ pathway. The scores plot, based on the splice index of individual exons, showed separate clusters of patients with both dilated and nondilated aorta, thereby illustrating the potential importance of alternative splicing in TAA. In total, differential splicing was detected in 187 exons. Furthermore, the pattern of alternative splicing is clearly differs between TAV and BAV patients. Differential splicing was specific for BAV and TAV patients in 40 and 86 exons, respectively, and splicings of 61 exons were shared between the two phenotypes. The occurrence of differential splicing was demonstrated in selected genes by reverse transcription-polymerase chain reaction. In summary, alternative splicing is a common feature of TAA formation. Our results suggest that dilatation in TAV and BAV patients has different alternative splicing fingerprints in the TGFβ pathway.
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Affiliation(s)
- Sanela Kurtovic
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
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Paloschi V, Kurtovic S, Folkersen L, Gomez D, Wågsäter D, Roy J, Petrini J, Eriksson MJ, Caidahl K, Hamsten A, Liska J, Michel JB, Franco-Cereceda A, Eriksson P. Impaired splicing of fibronectin is associated with thoracic aortic aneurysm formation in patients with bicuspid aortic valve. Arterioscler Thromb Vasc Biol 2010; 31:691-7. [PMID: 21148425 DOI: 10.1161/atvbaha.110.218461] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Thoracic aortic aneurysm is a common complication in patients with bicuspid aortic valve (BAV). Alternatively spliced extra domain A (EDA) of fibronectin (FN) has an essential role in tissue repair. Here we analyze the expression of FN spliceforms in dilated and nondilated ascending aorta of tricuspid aortic valve (TAV) and BAV patients. METHODS AND RESULTS The mRNA expression was analyzed in the ascending aorta by Affymetrix Exon arrays in patients with TAV (n=40) and BAV (n=69). EDA and extra domain B (EDB) expression was increased in dilated aorta from TAV patients compared with nondilated aorta (P<0.001 and P<0.05, respectively). In contrast, EDA expression was not increased in dilated aorta from BAV patients (P=0.25), whereas EDB expression was upregulated (P<0.01). The expression of EDA correlated with maximum aortic diameter in TAV (ρ=0.58) but not in BAV (ρ=0.15) patients. Protein analyses of EDA-FN showed concordant results. Transforming growth factor-β treatment influenced the splicing of FN and enhanced the formation of EDA-containing FN in cultured medial cells from TAV patients but not in cells derived from BAV patients. Gene set enrichment analysis together with multivariate and univariate data analyses of mRNA expression suggested that differences in the transforming growth factor-β signaling pathway may explain the impaired EDA inclusion in BAV patients. CONCLUSIONS Decreased EDA expression may contribute to increased aneurysm susceptibility of BAV patients.
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Affiliation(s)
- Valentina Paloschi
- Atherosclerosis Research Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Nazer RI, Elhenawy AM, Fazel SS, Garrido-Olivares LE, Armstrong S, David TE. The influence of operative techniques on the outcomes of bicuspid aortic valve disease and aortic dilatation. Ann Thorac Surg 2010; 89:1918-24. [PMID: 20494049 DOI: 10.1016/j.athoracsur.2010.02.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 02/18/2010] [Accepted: 02/22/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Bicuspid aortic valve is associated with aortic aneurysm formation that may extend beyond the ascending aorta. METHODS Between 1979 and 1997, 143 bicuspid aortic valve patients had aortic valve operations with replacement of an aneurysmal ascending aorta: 93 (65%) underwent full root replacement and 50 (35%) underwent separate valve and graft replacement. Distal aortic anastomosis was open in 42 patients (29%) and closed in 101 (71%). Late survival and complications were compared by surgical technique. RESULTS Patients undergoing full root replacement tended to be younger (mean age 46 +/- 16 vs 59 +/- 13, p < 0.001) and presented with more aortic insufficiency (80% vs 35%, p < 0.001). Three (2.1%) hospital deaths occurred. Event-free survival was 82% (95% confidence interval, 75% to 88%) at 10 years and 41% (95% confidence interval, 11% to 71%) at 20 years. At a median follow-up of 11.5 years, the incidence of new aneurysms and late aortic complications were not significantly different among the procedure groups. Age at the time of operation was the only predictor of late survival (hazard ratio, 1.07; p = 0.007). CONCLUSIONS Aortic root replacement with distal aortic reconstruction can be achieved with very low operative mortality and excellent long-term outcomes in patients with bicuspid aortic valve and dilated ascending aorta. The type of surgical procedure done in the aortic root and in the distal ascending aorta does not influence late survival, subsequent operation, or aortic complications. This is likely influenced by our patient-specific strategy when replacing the aortic root and distal ascending aorta.
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Affiliation(s)
- Rakan I Nazer
- Division of Cardiovascular Surgery of Toronto General Hospital, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada.
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Gerber J, Arcarese M. Routine Screening of Young Athletes for Aneurysm: CON. Cardiol Clin 2010; 28:229-36. [DOI: 10.1016/j.ccl.2010.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Should Aortas in Patients with Bicuspid Aortic Valve Really be Resected at an Earlier Stage than Tricuspid? PRO. Cardiol Clin 2010; 28:289-98. [DOI: 10.1016/j.ccl.2010.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Yuan SM, Jing H, Lavee J. The bicuspid aortic valve and its relation to aortic dilation. Clinics (Sao Paulo) 2010; 65:497-505. [PMID: 20535368 PMCID: PMC2882544 DOI: 10.1590/s1807-59322010000500007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 02/08/2010] [Accepted: 02/25/2010] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A bicuspid aortic valve (BAV) is a common congenital heart disease, which affects 1-2% of the population. However, the relationship between BAVs and aortic dilation has not been sufficiently elucidated. METHODS A total of 241 BAV patients who were referred to this hospital for cardiac surgery over a 4.75-year period were included in this study. In addition to the clinical characteristics of the included patients, the morphological features of the aortic valve and aorta, the length of the left main coronary artery, and the laboratory findings (the coagulation and hematological parameters as well as the total cholesterol concentration) were determined and compared with those of the tricuspid aortic valve (TAV) patients. RESULTS The BAV patients were younger than the TAV patients for a valve surgery in the last 3 months of the study period. The BAV patients were predominantly male. Most of the BAVs that were surgically treated were stenotic, regurgitant, or combined, and only 19 (7.88%) were normally functioning valves. According to echocardiography or operative records, 148 (78.31%) were type A, 31 (16.40%) were type B, and 10 (5.29%) were type C. The left main coronary artery was much shorter in the BAV patients than it was in the TAV patients. There was no significant difference between BAV and TAV patients in the total cholesterol concentrations; whereas differences were noted between patients receiving lipid-lowering therapy and those not receiving lipid-lowering therapy. The dimensions of the aortic root, sinotubular junction, and ascending aorta were beyond normal limits, while they were significantly smaller in the BAV patients than in the TAV patients. They were also much smaller in patients receiving statin therapy than those not receiving statin therapy in both groups. Moreover, the aortic dilation in the BAV group was found to be significantly associated with patient age. CONCLUSIONS The BAV patients developed aortic wall and aortic valve disorders at a younger age than the TAV patients and were predominantly male. Aortic dilation was observed in the aortic root, sinotubular junction, and ascending aortic segments in both the BAV and TAV patients undergoing surgical aortic valve replacement, although the BAV patients had a smaller degree of dilation than the TAV patients, and dilation was also significantly age-related in this group. The shorter left main coronary artery that the BAV patients possess may contribute to the progressive course of aortic dilation that these patients experience. Statin therapy did not affect the aortic annulus in either group, but did decrease the dimensions of the aortic root, sinotubular junction and ascending aorta. In general, statin therapy had a better effect on the aortas of the TAV patients than it did on those of the BAV patients.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiac and Thoracic Surgery, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel
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Jassal DS, Bhagirath KM, Tam JW, Sochowski RA, Dumesnil JG, Giannoccaro PJ, Jue J, Pandey AS, Joyner CD, Teo KK, Chan KL. Association of Bicuspid Aortic Valve Morphology and Aortic Root Dimensions: A Substudy of the Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin (ASTRONOMER) Study. Echocardiography 2010; 27:174-9. [DOI: 10.1111/j.1540-8175.2009.00993.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Barker AJ, Lanning C, Shandas R. Quantification of hemodynamic wall shear stress in patients with bicuspid aortic valve using phase-contrast MRI. Ann Biomed Eng 2009; 38:788-800. [PMID: 19953319 DOI: 10.1007/s10439-009-9854-3] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 11/19/2009] [Indexed: 11/25/2022]
Abstract
Bicuspid aortic valve (BAV) is often concomitant with aortic dilatation, aneurysm, and dissection. This valve lesion and its complications may affect positional and temporal wall shear stress (WSS), a parameter reported to regulate transcriptional events in vascular remodeling. Thus, this pilot study seeks to determine if the WSS in the ascending aorta (AAo) of BAV patients differs from control patients. Phase-contrast magnetic resonance imaging (PC-MRI) was used to perform flow analysis at the level of the AAo in 15 BAV and 15 control patients. Measurement of the aorta dimensions, flow rates, regurgitant fraction (RF), flow reversal ratio (FRR), temporal and spatial WSS, and shear range indices (SRI) were performed. The BAV and control group showed a significant difference between the circumferentially averaged WSS (p=0.03) and positional WSS at systole (minimum p<0.001). Regressions found that SRI (r=0.77, p<0.001), RF (r=0.68, p<0.001), and WSS at systole (r=0.66, p<0.001) were correlated to AAo size. The spatial distribution and magnitude of systolic WSS in BAV patients (-6.7+/-4.3 dynes/cm2) differed significantly from control patients (-11.5+/-6.6 dynes/cm2, p=0.03). The SRI metric, a measure of shear symmetry along the lumen circumference, was also significantly different (p=0.006) and indicated a heterogenic pattern of dilatation in the BAV patients.
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Affiliation(s)
- Alex J Barker
- Department of Mechanical Engineering, University of Colorado, Boulder, CO 80309, USA.
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Cotrufo M, Della Corte A. The association of bicuspid aortic valve disease with asymmetric dilatation of the tubular ascending aorta: identification of a definite syndrome. J Cardiovasc Med (Hagerstown) 2009; 10:291-7. [DOI: 10.2459/jcm.0b013e3283217e29] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lin AE, Basson CT, Goldmuntz E, Magoulas PL, McDermott DA, McDonald-McGinn DM, McPherson E, Morris CA, Noonan J, Nowak C, Pierpont ME, Pyeritz RE, Rope AF, Zackai E, Pober BR. Adults with genetic syndromes and cardiovascular abnormalities: clinical history and management. Genet Med 2008; 10:469-94. [PMID: 18580689 PMCID: PMC2671242 DOI: 10.1097/gim.0b013e3181772111] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Cardiovascular abnormalities, especially structural congenital heart defects, commonly occur in malformation syndromes and genetic disorders. Individuals with syndromes comprise a significant proportion of those affected with selected congenital heart defects such as complete atrioventricular canal, interrupted arch type B, supravalvar aortic stenosis, and pulmonary stenosis. As these individuals age, they contribute to the growing population of adults with special health care needs. Although most will require longterm cardiology follow-up, primary care providers, geneticists, and other specialists should be aware of (1) the type and frequency of cardiovascular abnormalities, (2) the range of clinical outcomes, and (3) guidelines for prospective management and treatment of potential complications. This article reviews fundamental genetic, cardiac, medical, and reproductive issues associated with common genetic syndromes that are frequently associated with a cardiovascular abnormality. New data are also provided about the cardiac status of adults with a 22q11.2 deletion and with Down syndrome.
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Affiliation(s)
- Angela E Lin
- Genetics Unit, Department of Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts 02114, USA.
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Nistri S, Galderisi M, Faggiano P, Antonini-Canterin F, Ansalone G, Dini FL, Di Salvo G, Gallina S, Mele D, Montisci R, Sciomer S, Di Bello V, Mondillo S, Marino PN. Practical echocardiography in aortic valve stenosis. J Cardiovasc Med (Hagerstown) 2008; 9:653-65. [DOI: 10.2459/jcm.0b013e3282f27d49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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45
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Giada F, Biffi A, Agostoni P, Anedda A, Belardinelli R, Carlon R, Carù B, DʼAndrea L, Delise P, De Francesco A, Fattirolli F, Guglielmi R, Guiducci U, Pelliccia A, Penco M, Perticone F, Thiene G, Vona M, Zeppilli P. Exercise prescription for the prevention and treatment of cardiovascular diseases: part II. J Cardiovasc Med (Hagerstown) 2008; 9:641-52. [DOI: 10.2459/jcm.0b013e3282f7ca96] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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46
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Fazel SS, Mallidi HR, Lee RS, Sheehan MP, Liang D, Fleischman D, Herfkens R, Mitchell RS, Miller DC. The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. J Thorac Cardiovasc Surg 2008; 135:901-7, 907.e1-2. [DOI: 10.1016/j.jtcvs.2008.01.022] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 12/22/2007] [Accepted: 01/23/2008] [Indexed: 01/15/2023]
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Reece TB, Singh RR, Stiles BM, Peeler BB, Kern JA, Tribble CG, Kron IL. Replacement of the Proximal Aorta Adds No Further Risk to Aortic Valve Procedures. Ann Thorac Surg 2007; 84:473-8; discussion 478. [PMID: 17643618 DOI: 10.1016/j.athoracsur.2007.04.059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 04/13/2007] [Accepted: 04/16/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve pathology is often associated with proximal aortic dilatation. Even after valve surgery, the proximal aorta can continue to dilate and thus be at risk for rupture, dissection, or later aortic replacement. We hypothesized that the addition of proximal aortic intervention adds no further risk to aortic valve surgery, which may avoid subsequent proximal aortic procedures or catastrophes. METHODS Between 1996 and 2004, 430 aortic valve interventions alone and 146 aortic valves with proximal aortic replacements were identified in elective adult patients. The age in the valve-alone patients (68.8 years) was slightly higher than the valve-plus-aorta group (valve/aorta, 60.5 years; p < 0.01), but comorbidities were similar between groups. We compared groups based on hospital mortality and incidence of complications. RESULTS The 30-day mortality was similar between groups (valve-alone, 3.8% versus valve/aorta, 2.7%; p = 0.5), as were rates for bleeding and operative revision (valve-alone, 6.7% versus valve/aorta, 9.5%; p = 0.5). Pulmonary (valve-alone, 23.0% versus valve/aorta, 11.6%) and renal complications (valve-alone, 8.2% versus valve/aorta, 2.7%) were higher in the valve-alone group (p = 0.02). Logistic regression demonstrated no additional risk of death, neurologic, or cardiac event with replacement of the proximal aorta. CONCLUSIONS Proximal aortic replacement adds no risk to the patient beyond the aortic valve intervention alone. These findings suggest proximal aortic replacement is safe for patients undergoing valve operations. Patients with a moderately enlarged proximal aorta that may dilate further should also be considered for aortic replacement at the time of valve procedures.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia, USA
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Grotenhuis HB, Ottenkamp J, Westenberg JJM, Bax JJ, Kroft LJM, de Roos A. Reduced Aortic Elasticity and Dilatation Are Associated With Aortic Regurgitation and Left Ventricular Hypertrophy in Nonstenotic Bicuspid Aortic Valve Patients. J Am Coll Cardiol 2007; 49:1660-1665. [PMID: 17433959 DOI: 10.1016/j.jacc.2006.12.044] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Revised: 12/06/2006] [Accepted: 12/07/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study sought to assess elasticity and dimensions of the aorta and their impact on aortic valve competence and left ventricular (LV) function in patients with a nonstenotic bicuspid aortic valve (BAV). BACKGROUND Intrinsic pathology of the aortic wall is a possible explanation for reduced aortic elasticity and aortic dilatation in patients with BAVs, even in the absence of a stenotic aortic valve. The relationship between aortic wall elasticity, aortic dimensions, aortic valve competence, and LV function in patients with BAVs has not previously been studied with magnetic resonance imaging. METHODS Magnetic resonance imaging was performed in 20 patients with nonstenotic BAVs (mean +/- SD, age 27 +/- 11 years) and 20 matched control patients. RESULTS The BAV patients showed reduced aortic elasticity as indicated by increased pulse wave velocity in the aortic arch and descending aorta (5.6 +/- 1.3 m/s vs. 4.5 +/- 1.1 m/s, p = 0.01; and 5.2 +/- 1.8 m/s vs. 4.3 +/- 0.9 m/s, p = 0.03, respectively), and reduced aortic root distensibility (3.1 +/- 1.2 x 10(-3) mm Hg(-1) vs. 5.6 +/- 3.2 x 10(-3) mm Hg(-1), p < 0.01). In addition, BAV patients showed aortic root dilatation as compared with control patients (mean difference 3.6 to 4.2 mm, p < or = 0.04 at all 4 predefined levels). Minor degrees of aortic regurgitation (AR) were present in 11 patients (AR fraction 6 +/- 8% vs. 1 +/- 1%, p < 0.01). The LV ejection fraction was normal (55 +/- 8% vs. 56 +/- 6%, p = 0.61), whereas LV mass was significantly increased in patients (54 +/- 12 g/m2 vs. 46 +/- 12 g/m2, p = 0.04). Dilatation at the level of the aortic annulus (r = 0.45, p = 0.044) and reduced aortic root distensibility (r = 0.37, p = 0.041) correlated with AR fraction. Increased pulse wave velocity in the aortic arch correlated with increased LV mass (r = 0.42, p = 0.041). CONCLUSIONS Reduced aortic elasticity and aortic root dilatation were frequently present in patients with nonstenotic BAVs. In addition, reduced aortic wall elasticity was associated with severity of AR and LV hypertrophy.
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Affiliation(s)
- Heynric B Grotenhuis
- Department of Radiology, Center for Congenital Anomalies of the Heart, Leiden, the Netherlands; Department of Paediatric Cardiology, Center for Congenital Anomalies of the Heart, Leiden, the Netherlands; Emma Children's Hospital/AMC, Amsterdam, the Netherlands; VU Medical Center, Amsterdam, the Netherlands
| | - Jaap Ottenkamp
- Department of Paediatric Cardiology, Center for Congenital Anomalies of the Heart, Leiden, the Netherlands; Emma Children's Hospital/AMC, Amsterdam, the Netherlands; VU Medical Center, Amsterdam, the Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Center for Congenital Anomalies of the Heart, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Center for Congenital Anomalies of the Heart, Leiden, the Netherlands
| | - Albert de Roos
- Department of Radiology, Center for Congenital Anomalies of the Heart, Leiden, the Netherlands.
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