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Balint B, Bernstorff IGL, Schwab T, Schäfers HJ. Smooth muscle cell phenotypic switching occurs independent of aortic dilation in bicuspid aortic valve-associated ascending aortas. PLoS One 2024; 19:e0306515. [PMID: 38954721 PMCID: PMC11218944 DOI: 10.1371/journal.pone.0306515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/13/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Bicuspid aortic valves (BAV) are frequently associated with ascending aortic aneurysms. The etiology is incompletely understood, but genetic factors, in addition to flow perturbations, are likely involved. Since loss of contractility and elaboration of extracellular matrix in the vessel wall are features of BAV-associated aortopathy, phenotypic modulation of smooth muscle cells (SMCs) may play a role. METHODS Ascending aortic tissue was collected intra-operatively from 25 individuals with normal (i.e., tricuspid) aortic valves (TAV) and from 25 individuals with BAVs. For both TAV and BAV, 10 patients had non-dilated (ND) and 15 patients had dilated (D) aortas. SMCs were isolated and cultured from a subset of patients from each group. Aortic tissue and SMCs were fluorescently immunolabeled for SMC phenotypic markers (i.e., alpha-smooth muscle actin (ASMA, contractile), vimentin (synthetic) and p16INK4a and p21Cip1 (senescence). SMCs were also analyzed for replicative senescence in culture. RESULTS In normal-sized and dilated BAV aortas, SMCs switched from the contractile state to either synthetic or senescent phenotypes, as observed by loss of ASMA (ND: P = 0.001, D: P = 0.002) and associated increases in vimentin (ND: P = 0.03, D: P = 0.004) or p16/p21 (ND: P = 0.03, D: P<0.0001) compared to TAV. Dilatation of the aorta exacerbated SMC phenotypic switching in both BAV and TAV aortas (all P<0.05). In SMCs cultured from normal and dilated aortas, those isolated from BAV reached replicative senescence faster than those from TAV aortas (all P = 0.02). Furthermore, there was a stark inverse correlation between ASMA and cell passage number in BAV SMCs (ND: P = 0.0006, D: P = 0.01), but not in TAV SMCs (ND: P = 0.93, D: P = 0.20). CONCLUSIONS The findings of this study provide direct evidence from cell culture studies implying that SMCs switch from the contractile state to either synthetic or senescent phenotypes in the non-dilated BAV aorta. In cultured SMCs from both non-dilated and dilated aortas, we found that this process may precede dilatation and accompany aneurysm development in BAV. Our findings suggest that therapeutically targeting SMC phenotypic modulation in BAV patients may be a viable option to prevent or delay ascending aortic aneurysm formation.
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Affiliation(s)
- Brittany Balint
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | | | - Tanja Schwab
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saar, Germany
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Mariucci E, Guidarini M, Bartolacelli Y, Tchana B, Careddu L, Gargiulo G, Esposito SMR, Donti A. Is there a role for angiotensin II–receptor blockers for ascending aorta dilatation in pediatric patients with normally functioning bicuspid aortic valve? INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Franco P, Sotelo J, Guala A, Dux-Santoy L, Evangelista A, Rodríguez-Palomares J, Mery D, Salas R, Uribe S. Identification of hemodynamic biomarkers for bicuspid aortic valve induced aortic dilation using machine learning. Comput Biol Med 2021; 141:105147. [PMID: 34929463 DOI: 10.1016/j.compbiomed.2021.105147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 01/06/2023]
Abstract
Recent advances in medical imaging have confirmed the presence of altered hemodynamics in bicuspid aortic valve (BAV) patients. Therefore, there is a need for new hemodynamic biomarkers to refine disease monitoring and improve patient risk stratification. This research aims to analyze and extract multiple correlation patterns of hemodynamic parameters from 4D Flow MRI data and find which parameters allow an accurate classification between healthy volunteers (HV) and BAV patients with dilated and non-dilated ascending aorta using machine learning. Sixteen hemodynamic parameters were calculated in the ascending aorta (AAo) and aortic arch (AArch) at peak systole from 4D Flow MRI. We used sequential forward selection (SFS) and principal component analysis (PCA) as feature selection algorithms. Then, eleven machine-learning classifiers were implemented to separate HV and BAV patients (non- and dilated ascending aorta). Multiple correlation patterns from hemodynamic parameters were extracted using hierarchical clustering. The linear discriminant analysis and random forest are the best performing classifiers, using five hemodynamic parameters selected with SFS (velocity angle, forward velocity, vorticity, and backward velocity in AAo; and helicity density in AArch) a 96.31 ± 1.76% and 96.00 ± 0.83% accuracy, respectively. Hierarchical clustering revealed three groups of correlated features. According to this analysis, we observed that features selected by SFS have a better performance than those selected by PCA because the five selected parameters were distributed according to 3 different clusters. Based on the proposed method, we concluded that the feature selection method found five potentially hemodynamic biomarkers related to this disease.
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Affiliation(s)
- Pamela Franco
- Biomedical Imaging Center, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile; Electrical Engineering Department, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Cardio, MR, Chile
| | - Julio Sotelo
- Biomedical Imaging Center, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Cardio, MR, Chile; School of Biomedical Engineering, Universidad de Valparaíso, Valparaíso, Chile
| | - Andrea Guala
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lydia Dux-Santoy
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Rodríguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Domingo Mery
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago, Chile; Instituto Milenio Intelligent Healthcare Engineering, Chile
| | - Rodrigo Salas
- School of Biomedical Engineering, Universidad de Valparaíso, Valparaíso, Chile; Instituto Milenio Intelligent Healthcare Engineering, Chile
| | - Sergio Uribe
- Biomedical Imaging Center, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile; Millennium Nucleus for Cardiovascular Magnetic Resonance, Cardio, MR, Chile; Radiology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Instituto Milenio Intelligent Healthcare Engineering, Chile.
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Lopez A, Dentamaro I, Galian L, Calvo F, Alegret JM, Sanchez V, Citro R, Moreo A, Chirillo F, Colonna P, Carrero MC, Bossone E, Moral S, Sao-Aviles A, Gutiérrez L, Teixido-Tura G, Rodríguez-Palomares J, Evangelista A. Predictors of Ascending Aorta Enlargement and Valvular Dysfunction Progression in Patients with Bicuspid Aortic Valve. J Clin Med 2021; 10:5264. [PMID: 34830546 PMCID: PMC8621265 DOI: 10.3390/jcm10225264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 12/01/2022] Open
Abstract
Bicuspid aortic valve (BAV) patients are at high risk of developing progressive aortic valve dysfunction and ascending aorta dilation. However, the progression of the disease is not well defined. We aimed to assess mid-long-term aorta dilation and valve dysfunction progression and their predictors. Patients were referred from cardiac outpatient clinics to the echocardiographic laboratories of 10 tertiary hospitals and followed clinically and by echocardiography for >5 years. Seven hundred and eighteen patients with BAV (median age 47.8 years [IQR 33-62], 69.2% male) were recruited. BAV without raphe was observed in 11.3%. After a median follow-up of 7.2 years [IQR5-8], mean aortic root growth rate was 0.23 ± 0.15 mm/year. On multivariate analysis, rapid aortic root dilation (>0.35 mm/year) was associated with male sex, hypertension, presence of raphe and aortic regurgitation. Annual ascending aorta growth rate was 0.43 ± 0.32 mm/year. Rapid ascending aorta dilation was related only to hypertension. Variables associated with aortic stenosis and regurgitation progression, adjusted by follow-up time, were presence of raphe, hypertension and dyslipidemia and basal valvular dysfunction, respectively. Intrinsic BAV characteristics and cardiovascular risk factors were associated with aorta dilation and valvular dysfunction progression, taking into account the inherent limitations of our study-design. Strict and early control of cardiovascular risk factors is mandatory in BAV patients.
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Affiliation(s)
- Angela Lopez
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Ilaria Dentamaro
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Laura Galian
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Francisco Calvo
- Cardiology Department, Hospital Alvaro Cunqueiro, 36213 Vigo, Spain;
| | - Josep M. Alegret
- Cardiology Department, Hospital Universitari Sant Joan de Reus, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain;
| | - Violeta Sanchez
- Cardiology Department, University Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Rodolfo Citro
- Cardiology Department, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84125 Salerno, Italy;
| | - Antonella Moreo
- Cardiology Department, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy;
| | - Fabio Chirillo
- Cardiology Department, Bassano del Grappa General Hospital, 36061 Bassano Del Grappa, Italy;
| | - Paolo Colonna
- Cardiology Department, Polyclinic Hospital of Bari, 70124 Bari, Italy;
| | - María Celeste Carrero
- Instituto Cardiovascular San Isidro, Sanatorio Las Lomas, Buenos Aires 3031, Argentina;
| | - Eduardo Bossone
- Cardiology Department, Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, 80131 Napoli, Italy;
| | - Sergio Moral
- Servei de Cardiologia, Hospital Josep Trueta, 17007 Girona, Spain;
| | - Augusto Sao-Aviles
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Laura Gutiérrez
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Gisela Teixido-Tura
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Jose Rodríguez-Palomares
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
| | - Arturo Evangelista
- Department of Cardiology, University Hospital Vall d’Hebron, CIBERCV, 08035 Barcelona, Spain; (A.L.); (I.D.); (L.G.); (A.S.-A.); (L.G.); (G.T.-T.); (J.R.-P.)
- Heart Institute, Teknon Medical Center-Quirón Salud, 08022 Barcelona, Spain
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Mai Z, Guan L, Mu Y. Association between bicuspid aortic valve phenotype and patterns of valvular dysfunction: A meta-analysis. Clin Cardiol 2021; 44:1683-1691. [PMID: 34734421 PMCID: PMC8715397 DOI: 10.1002/clc.23736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/12/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background Valvular dysfunction is a common complication in patients with bicuspid aortic valves (BAV). The aim of this study was to determine the relationship between BAV morphology patterns and valve dysfunction. Methods We searched the PubMed, The Cochrane Library, Web of Science, and CNKI until May 31, 2020, to identify all studies investigating the morphology of BAV and valvular dysfunction, and data were extracted according to the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA). Data were analyzed using Stata 15.1 software. The additional characteristics (gender, mean age) were collected to perform a meta‐regression analysis. Results Thirteen studies on BAV‐RL (n = 2002) versus BAV‐RN (n = 1254) and raphe (n = 4001) versus without raphe (n = 673) were included. The BAV‐RL patients showed a higher incidence of aortic regurgitation than BAV‐RN patients (OR = 1.46; 95% CI: 1.12 to 1.90, p = .005), while the BAV‐RL patients showed a lower incidence of aortic stenosis than BAV‐RN patients (OR = 0.66, 95% CI: 0.58 to 0.76, p = .000); BAV patients with raphe presents a higher incidence of aortic regurgitation than those without raphe (OR = 1.95, 95% CI: 1.12–3.39, p = .017). No differences were found between raphe and without raphe group in the incidence of aortic stenosis (OR = 0.97, 95% CI: 0.53 to 1.76, p = .907). Mean age and gender had no influence on observed differences. Conclusions Our results confirmed a relationship between different BAV phenotypes and aortic valve dysfunction. BAV‐RL and BAV with raphe are more likely to develop aortic regurgitation, while patients with BAV‐RN present a higher possibility to develop aortic stenosis.
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Affiliation(s)
- Zhenzhen Mai
- Department of Echocardiography, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Lina Guan
- Department of Echocardiography, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yuming Mu
- Department of Echocardiography, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Weininger G, Chan SM, Zafar M, Ziganshin BA, Elefteriades JA. Risk reduction and pharmacological strategies to prevent progression of aortic aneurysms. Expert Rev Cardiovasc Ther 2021; 19:619-631. [PMID: 34102944 DOI: 10.1080/14779072.2021.1940958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION While size thresholds exist to determine when aortic aneurysms warrant surgical intervention, there is no consensus on how best to treat this disease before aneurysms reach the threshold for intervention. Since a landmark study in 1994 first suggested ß-blockers may be useful in preventing aortic aneurysm growth, there has been a surge in research investigating different pharmacologic therapies for aortic aneurysms - with very mixed results. AREAS COVERED We have reviewed the existing literature on medical therapies used for thoracic and abdominal aortic aneurysms in humans. These include ß-blockers, angiotensin II receptor blockers, and angiotensin-converting enzyme inhibitors as well as miscellaneous drugs such as tetracyclines, macrolides, statins, and anti-platelet medications. EXPERT OPINION While multiple classes of drugs have been explored for risk reduction in aneurysm disease, with few exceptions results have been disappointing with an abundance of contradictory findings. The vast majority of studies have been done in patients with abdominal aortic aneurysms or thoracic aortic aneurysm patients with Marfan Syndrome. There exists a striking gap in the literature when it comes to pharmacologic management of non-Marfan Syndrome patients with thoracic aortic aneurysms. Given the differences in pathogenesis, this is an important future direction for aortic aneurysm research.
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Affiliation(s)
- Gabe Weininger
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Shin Mei Chan
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
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Non-aneurysmal ascending aorta diameter changes after aortic valve replacement in patients with stenotic bicuspid and tricuspid aortic valve. Gen Thorac Cardiovasc Surg 2021; 70:33-43. [PMID: 34115319 DOI: 10.1007/s11748-021-01669-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The appropriate timing of aortic repair in patients with bicuspid aortic valve-related aortopathy remains controversial. We describe the changes in diameter of the non-aneurysmal ascending aorta after aortic valve replacement for bicuspid or tricuspid aortic valve stenosis. METHODS This retrospective review included 189 patients who had undergone aortic valve replacement for severe stenotic aortic valve with a non-aneurysmal ascending aorta diameter of 45 mm or less between January 2008 and December 2018. A linear mixed-effect model was used to analyze and compare the enlargement rates of the non-aneurysmal ascending aorta at the tubular portion after aortic valve replacement in bicuspid and tricuspid aortic valve patients. RESULTS The enlargement rate of the non-aneurysmal ascending aorta after aortic valve replacement was significantly greater in the bicuspid aortic valve group than in the tricuspid aortic valve group (0.36 mm/year vs. 0.09 mm/year, p < 0.001). The specific form of bicuspid aortic valve also affected aorta diameter enlargement: the enlargement rate of 0.85 mm/year in the Type 0 (according to Sievers' classification) group was approximately five times that in the Non-Type 0 group (p < 0.001). No aortic events were observed, and no patients needed reoperations for the ascending aorta, in either the bicuspid or tricuspid aortic valve groups. CONCLUSION The persistent possibility of progressive ascending aortic dilatation after aortic valve replacement for bicuspid aortic valve stenosis, especially in Type 0 bicuspid aortic valve patients, demands careful post-procedural evaluation of the ascending aorta.
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Mani P, Reyaldeen R, Xu B. Multimodality imaging assessment of bicuspid aortic valve disease, thoracic aortic ectasia, and thoracic aortic aneurysmal disease. Cardiovasc Diagn Ther 2021; 11:896-910. [PMID: 34295712 DOI: 10.21037/cdt-20-279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/31/2021] [Indexed: 11/06/2022]
Abstract
Acute aortic syndromes have extremely high mortality rates and those with aortic dilation are at increased risk for these often catastrophic events. Serial monitoring of patients with aortic dilation is critical to determine the appropriate timing of preventative interventions. The thoracic aorta can be imaged and measured using multiple imaging modalities including transthoracic echocardiography, transesophageal echocardiography, multidetector cardiac computed tomography, and magnetic resonance imaging. There has not been agreement on the specific techniques that should be used to measure thoracic aortic dimensions with each imaging modality, leading to potential errors and challenges in comparing changes in measurements over time. It is critical to understand the current recommendations on thoracic aortic measurements for each imaging modality and cardiovascular imaging specialists need to be explicit about the methods that they have used to derive the thoracic aortic measurements. In those at high risk for aortic pathology, such as those with connective tissue diseases or bicuspid aortic valve, a multimodality imaging strategy incorporating echocardiography including three-dimensional measurements along with cardiac computed tomography or magnetic resonance imaging should be used to establish aortic dimensions and for continued monitoring to avoid progression to acute aortic syndromes.
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Affiliation(s)
- Preethi Mani
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Reza Reyaldeen
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 548] [Impact Index Per Article: 182.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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11
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35-e71. [PMID: 33332149 DOI: 10.1161/cir.0000000000000932] [Citation(s) in RCA: 345] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 782] [Impact Index Per Article: 260.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Aortic dilatation is common in patients with congenital heart disease and is seen in patients with bicuspid aortic valve and those with conotruncal congenital heart defects. It is important to identify patients with bicuspid aortic valve at high risk for aortic dissection. High-risk patients include those with the aortic root phenotype and those with syndromic or familial aortopathies including Marfan syndrome, Loeys-Dietz syndrome, and Turner syndrome. Aortic dilatation is common in patients with conotruncal congenital heart defects and rarely results in aortic dissection.
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Pisano C, D'Amico F, Balistreri CR, Vacirca SR, Nardi P, Altieri C, Scioli MG, Bertoldo F, Santo L, Bellisario D, Talice M, Verzicco R, Ruvolo G, Orlandi A. Biomechanical properties and histomorphometric features of aortic tissue in patients with or without bicuspid aortic valve. J Thorac Dis 2020; 12:2304-2316. [PMID: 32642135 PMCID: PMC7330388 DOI: 10.21037/jtd.2020.03.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background We sought to investigate and compare biomechanical properties and histomorphometric findings of thoracic ascending aorta aneurysm (TAA) tissue from patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in order to clarify mechanisms underlying differences in the clinical course. Methods Circumferential sections of TAA tissue in patients with BAV (BAV-TAA) and TAV (TAV-TAA) were obtained during surgery and used for biomechanical tests and histomorphometrical analysis. Results In BAV-TAA, we observed biomechanical higher peak stress and lower Young modulus values compared with TAV-TAA wall. The right lateral longitudinal region seemed to be the most fragile zone of the TAA wall. Mechanical stress-induced rupture of BAV-TAA tissue was sudden and uniform in all aortic wall layers, whereas a gradual and progressive aortic wall breakage was described in TAV-TAA. Histomorphometric analysis revealed higher amount of collagen but not elastin in BAV-TAA tunica media. Conclusions The higher deformability of BAV-TAA tissue supports the hypothesis that increased wall shear stress doesn’t explain the increased risk of sudden onset of rupture and dissection; other mechanisms, likely related to alteration of specific genetic pathways and epigenetic signals, could be investigated to explain differences in aortic dissection and rupture in BAV patients.
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Affiliation(s)
- Calogera Pisano
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Federico D'Amico
- Anatomic Pathology, Department of Biomedicine and Prevention Tor Vergata University, Rome, Italy
| | - Carmela Rita Balistreri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Sara Rita Vacirca
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Paolo Nardi
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Claudia Altieri
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Maria Giovanna Scioli
- Anatomic Pathology, Department of Biomedicine and Prevention Tor Vergata University, Rome, Italy
| | - Fabio Bertoldo
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Loredana Santo
- Department of Industrial Engineering, Tor Vergata University, Rome, Italy
| | - Denise Bellisario
- Department of Industrial Engineering, Tor Vergata University, Rome, Italy
| | | | - Roberto Verzicco
- Department of Industrial Engineering, Tor Vergata University, Rome, Italy
| | - Giovanni Ruvolo
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Augusto Orlandi
- Anatomic Pathology, Department of Biomedicine and Prevention Tor Vergata University, Rome, Italy.,Department of Biomedical Sciences, Catholic University Our Lady of Good Counsel, Tirana, Albania
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16
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Blais S, Meloche-Dumas L, Fournier A, Dallaire F, Dahdah N. Long-Term Risk Factors for Dilatation of the Proximal Aorta in a Large Cohort of Children With Bicuspid Aortic Valve. Circ Cardiovasc Imaging 2020; 13:e009675. [DOI: 10.1161/circimaging.119.009675] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with bicuspid aortic valve (BAV) have a higher risk of developing aortic valve dysfunction and progressive proximal aorta dilatation, which can lead to aortic dissection. To this day, identification of children at risk of developing severe aortic dilatation during their pediatric follow-up is still challenging because most studies were restricted to adult subjects. The overarching goal of this study was to identify risk factors of aortic dilatation in children with BAV.
Methods:
We extracted clinical and echocardiographic data of all BAV subjects aged 0 to 20 years followed at Centre Hospitalier Universitaire Sainte-Justine between 1999 and 2016. We excluded subjects with concomitant heart defects and conditions affecting proximal aorta dimensions. Proximal aorta diameters (expressed as
Z
scores) were modeled in relation to age and potential predictive variables in a linear mixed model. The primary outcome was the rate of dilatation.
Results:
We included 761 subjects (3134 echocardiograms) in final analyses. The mean ascending aorta
Z
score progression rate for BAV patient with a normally functioning aortic valve was estimated at 0.05
Z
score unit per year. The strongest predictors of an increased dilatation rate were severe aortic stenosis, moderate and severe aortic regurgitation, and uncorrected coarctation of the aorta. Aortic valve leaflet fusion pattern and sex were not associated with progression rate.
Conclusions:
Children with a normally functioning BAV exhibited a very slow proximal aorta dilatation rate. Ascending aorta dilatation rate was significantly increased in patients with more than mild aortic valve dysfunction but was independent from BAV leaflet fusion type.
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Affiliation(s)
- Samuel Blais
- Department of Pediatrics, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Canada (S.B., F.D.)
| | - Léamarie Meloche-Dumas
- Department of General Surgery, Maisonneuve-Rosemont Hospital, Montreal, Canada (L.M.-D.)
| | - Anne Fournier
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada (A.F., N.D.)
| | - Frederic Dallaire
- Department of Pediatrics, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Canada (S.B., F.D.)
| | - Nagib Dahdah
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada (A.F., N.D.)
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17
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Kauhanen SP, Saari P, Jaakkola P, Korhonen M, Parkkonen J, Vienonen J, Vanninen R, Liimatainen T, Hedman M. High prevalence of ascending aortic dilatation in a consecutive coronary CT angiography patient population. Eur Radiol 2019; 30:1079-1087. [PMID: 31529253 PMCID: PMC6957537 DOI: 10.1007/s00330-019-06433-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 07/09/2019] [Accepted: 08/27/2019] [Indexed: 01/04/2023]
Abstract
Objectives To clarify the prevalence and risk factors of ascending aortic (AA) dilatation according to ESC 2014 guidelines. Methods This study included 1000 consecutive patients scheduled for diagnostic coronary artery computed tomographic angiography. AA diameter was retrospectively measured in 3 planes: sinus valsalva, sinotubular junction, and tubular part. The threshold for AA dilatation was set to > 40 mm which has been suggested as an upper normal limit for AA diameter in ESC 2014 guidelines on aortic diseases. Aortic size index (ASI) using the ratio between aortic diameter and body surface area (BSA) was applied as a comparative measurement. The threshold for AA dilatation was set to the upper limit of normal distribution exceeding two standard deviations (95%). Risk factors for AA dilatation were collected from medical records. Results The patients’ mean age was 52.9 ± 9.8 years (66.5% women). The prevalence of AA dilatation was 23.0% in the overall study population (52.5% males) and 15.1% in the subgroup of patients with no coronary artery disease or bicuspid (BAV)/mechanical aortic valve (n = 365). According to the normal-distributed ASI values, the threshold for sinus valsalva was defined as 23.2 mm/m2 and for tubular part 22.2 mm/m2 in the subgroup. Higher BSA was associated with larger AA dimensions (r = 0.407, p < 0.001). Male gender (p < 0.001), BAV (p < 0.001), hypertension (p = 0.009) in males, and smoking (p < 0.001) appeared as risk factors for AA dilatation. Conclusions The prevalence of AA dilatation is high with current ESC guidelines for normal AA dimension, especially in males. Body size is strongly associated with AA dimensions; it would be more reliable to use BSA-adjusted AA diameters for the definition of AA dilatation. Key Points • The prevalence of AA dilatation is high in patients who are candidates for coronary CT angiography. • Body size is strongly associated with AA dimensions.
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Affiliation(s)
- S Petteri Kauhanen
- Doctoral Programme of Clinical Research, University of Eastern Finland, Kuopio, Finland. .,Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, PO Box 100, Puijonlaaksontie 2, 70029, Kuopio, KYS, Finland.
| | - Petri Saari
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, PO Box 100, Puijonlaaksontie 2, 70029, Kuopio, KYS, Finland
| | - Pekka Jaakkola
- Department of Heart and Thoracic Surgery, Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, PO Box 100, Puijonlaaksontie 2, 70029, Kuopio, KYS, Finland
| | - Johannes Parkkonen
- School of Medicine, Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Juska Vienonen
- School of Medicine, Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, PO Box 100, Puijonlaaksontie 2, 70029, Kuopio, KYS, Finland.,School of Medicine, Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Timo Liimatainen
- Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland.,Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, PO Box 100, Puijonlaaksontie 2, 70029, Kuopio, KYS, Finland
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18
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Pasipoularides A. Clinical-pathological correlations of BAV and the attendant thoracic aortopathies. Part 1: Pluridisciplinary perspective on their hemodynamics and morphomechanics. J Mol Cell Cardiol 2019; 133:223-232. [PMID: 31150733 DOI: 10.1016/j.yjmcc.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/10/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Clinical BAV manifestations pertain to faulty aortic valve (AOV) function, the associated aortopathy, and other complications such as endocarditis, thrombosis and thromboembolism. BAV arises during valvulogenesis when 2 of the 3 leaflets/cusps of the AOV are fused together. Ensuing asymmetric BAV morphologies alter downstream ejection jet flow-trajectories. Based on BAV morphologies, ejection-flows exhibit different wall-impingement and scouring patterns in the proximal aorta, with excessive hydrodynamic wall-shear that correlates closely with mural vascular smooth muscle cell and extracellular matrix disruptions, revealing hemodynamic participation in the pathogenesis of BAV-associated aortopathies. Since the embryologic regions implicated in both BAV and aortopathies derive from neural crest cells and second heart field cells, there may exist a common multifactorial/polygenic embryological basis linking the abnormalities. The use of Electronic Health Records - encompassing integrated NGS variant panels and phenotypic data - in clinical studies could speed-up comprehensive understanding of multifactorial genetic-phenotypic and environmental factor interactions. This Survey represents the first in a 2-article pluridisciplinary work. Taken in toto, the series covers hemodynamic/morphomechanical and environmental (milieu intérieur) aspects in Part 1, and molecular, genetic and associated epigenetic aspects in Part 2. Together, Parts 1-2 should serve as a reference-milestone and driver for further pluridisciplinary research and its urgent translations in the clinical setting.
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Affiliation(s)
- Ares Pasipoularides
- Duke/NSF Center for Emerging Cardiovascular Technologies, Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School, Durham, NC, USA.
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19
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Howard C, Picca L, Smith T, Sharif M, Bashir M, Harky A. The bicuspid aortic valve: Is it an immunological disease process? J Card Surg 2019; 34:482-494. [PMID: 31012137 DOI: 10.1111/jocs.14050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 01/03/2023]
Abstract
Bicuspid aortic valves (BAVs) are the most common congenital cardiac condition and are characterized by a structural abnormality whereby the aortic valve is composed of two leaflets instead of being trileaflet. It is linked to an increased risk for a variety of complications of the aorta, many with an immunological pathogenesis. The aim of this study is to review and analyze the literature regarding immunological processes involving BAVs, associated common pathologies, and their incidence in the population. This study will also examine current trends in surgical and therapeutic approaches to treatment and discuss the future direction of BAV treatment.
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Affiliation(s)
- Callum Howard
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Leonardo Picca
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tristan Smith
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Monira Sharif
- Department of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital, Dundee, UK
| | - Mohamad Bashir
- Department of Emergency Medicine and Surgery, Macclesfield General Hospital, Macclesfield, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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20
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Thijssen CGE, Bons LR, Gökalp AL, Van Kimmenade RRJ, Mokhles MM, Pelliccia A, Takkenberg JJM, Roos-Hesselink JW. Exercise and sports participation in patients with thoracic aortic disease: a review. Expert Rev Cardiovasc Ther 2019; 17:251-266. [DOI: 10.1080/14779072.2019.1585807] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Carlijn G. E. Thijssen
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lidia R. Bons
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arjen L. Gökalp
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Mostafa M. Mokhles
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Antonio Pelliccia
- Department of Cardiology, Institute of Sports Medicine & Science, Rome, Italy
| | - Johanna J. M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jolien W. Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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21
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He YX, Fan JQ, Zhu QF, Zhou QJ, Jiang JB, Wang LH, Ng S, Liu XB, Wang JA. Ascending aortic dilatation rate after transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis: A multidetector computed tomography follow-up study. World J Emerg Med 2019; 10:197-204. [PMID: 31534592 DOI: 10.5847/wjem.j.1920-8642.2019.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Current data is lacking about the progression of ascending aortic dilatation after transcatheter aortic valve replacement (TAVR) in aortic stenosis (AS) patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV). This study aims to assess the ascending aortic dilatation rate (mm/year) after TAVR in patients with BAV versus TAV using a multidetector computed tomography (MDCT) follow-up and to determine the predictors of ascending aortic dilatation rate. METHODS Severe AS patients undergoing TAVR from March 2013 to March 2018 at our center with MDCT follow-ups were included. BAV and TAV were identified using baseline MDCT. Baseline and follow-up MDCT images were analyzed, and the diameters of ascending aorta were measured. Study end point is ascending aortic dilatation rate (mm/year). Furthermore, factors predicting ascending aortic dilatation rate were also investigated. RESULTS Two hundred and eight patients were included, comprised of 86 BAV and 122 TAV patients. Five, 4, 3, 2, and 1-year MDCT follow-ups were achieved in 7, 9, 30, 46, and 116 patients. The ascending aortic diameter was significantly increased after TAVR in both BAV group (43.7±4.4 mm vs. 44.0±4.5 mm; P<0.001) and TAV group (39.1±4.8 mm vs. 39.7±5.1 mm; P<0.001). However, no difference of ascending aortic dilatation rate was found between BAV and TAV group (0.2±0.8 mm/year vs. 0.3±0.8 mm/year, P=0.592). Multivariate linear regression revealed paravalvular leakage (PVL) grade was independently associated with ascending aortic dilatation rate in the whole population and BAV group, but not TAV group. No aortic events occurred during follow-ups. CONCLUSION Ascending aortic size continues to grow after TAVR in BAV patients, but the dilatation rate is mild and comparable to that of TAV patients. PVL grade is associated with ascending aortic dilatation rate in BAV patients post-TAVR.
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Affiliation(s)
- Yu-Xin He
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jia-Qi Fan
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Qi-Feng Zhu
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Qi-Jing Zhou
- Department of Radiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ju-Bo Jiang
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Li-Han Wang
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Stella Ng
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xian-Bao Liu
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jian-An Wang
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
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22
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4-D flow MRI aortic 3-D hemodynamics and wall shear stress remain stable over short-term follow-up in pediatric and young adult patients with bicuspid aortic valve. Pediatr Radiol 2019; 49:57-67. [PMID: 30203126 PMCID: PMC6430639 DOI: 10.1007/s00247-018-4257-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/13/2018] [Accepted: 09/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Children with bicuspid aortic valve (BAV) are at risk for serious complications including aortic valve stenosis and aortic rupture. Most studies investigating biomarkers predictive of BAV complications are focused on adults. OBJECTIVE To investigate whether hemodynamic parameters change over time in children and young adults with BAV by comparing baseline and follow-up four-dimensional (4-D) flow MRI examinations. MATERIALS AND METHODS We retrospectively included 19 children and young adults with BAV who had serial 4-D flow MRI exams (mean difference in scan dates 1.8±1.0 [range, 0.6-3.4 years]). We compared aortic peak blood flow velocity, three-dimensional (3-D) wall shear stress, aortic root and ascending aortic (AAo) z-scores between baseline and follow-up exams. We generated systolic streamlines for all patients and visually compared their baseline and follow-up exams. RESULTS The only significant difference between baseline and follow-up exams occurred in AAo z-scores (3.12±2.62 vs. 3.59±2.76, P<0.05) indicating growth of the AAo out of proportion to somatic growth. There were no significant changes in either peak velocity or 3-D wall shear stress between baseline and follow-up exams. Ascending aortic peak velocity at baseline correlated with annual change in AAo z-score (r=0.58, P=0.009). Visual assessment revealed abnormal blood flow patterns, which were unique to each patient and remained stable between baseline and follow-up exams. CONCLUSION In our pediatric and young adult BAV cohort, hemodynamic markers and systolic blood flow patterns remained stable over short-term follow-up despite significant AAo growth, suggesting minimal acute disease progression. Baseline AAo peak velocity was a predictor of AAo dilation and might help in determining pediatric patients with BAV who are at risk of increased AAo growth.
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23
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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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24
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Affiliation(s)
- Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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25
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Abnormal aortic stiffness in patients with bicuspid aortic valve: phenotypic variation determined by magnetic resonance imaging. Int J Cardiovasc Imaging 2018; 35:133-141. [PMID: 30187149 DOI: 10.1007/s10554-018-1433-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
Abstract
The aim of this study was to assess aortic stiffness in patients with bicuspid aortic valve (BAV), and to determine if differences exist among the BAV phenotypes. Stiffness was measured by pulse wave velocity (PWV) determined using velocity-encoded magnetic resonance imaging (VENC-MRI). VENC-MRI was performed in 100 BAV patients and 45 normal controls. PWV was determined between the mid ascending and mid descending aorta. The BAV phenotypes were characterized using steady-state free precession (SSFP) images acquired across the face of the aortic valve, and classified as follows: right-left cusp (R-L) fusion, right and non-coronary cusp (R-NC) fusion, and left and non-coronary cusp (L-NC) fusion. The following BAV phenotypes were identified: 76 R-L, 23 R-NC, and 1 L-NC fusion. BAV patients demonstrated significantly greater PWV compared to normal controls, after adjusting for age (9.16 vs. 3.83 m/s; p < 0.0001). Furthermore, PWV was significantly greater in patients with R-NC fusion than those with R-L fusion phenotype (12.27 vs. 7.97 m/s; p < 0.001). There was significantly increased PWV from VENC-MRI in BAV patients compared to normal controls. Thisis the first to demonstrate the association of different BAV phenotypes and aortic stiffness. VENC-MRI PWV assessment potentially represents a novel parameter for enhanced surveillance and may alter surgical triage of aorta in this high risk group.
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26
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Guo MH, Appoo JJ, Saczkowski R, Smith HN, Ouzounian M, Gregory AJ, Herget EJ, Boodhwani M. Association of Mortality and Acute Aortic Events With Ascending Aortic Aneurysm: A Systematic Review and Meta-analysis. JAMA Netw Open 2018; 1:e181281. [PMID: 30646119 PMCID: PMC6324275 DOI: 10.1001/jamanetworkopen.2018.1281] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The natural history of ascending aortic aneurysm (AsAA) is currently not well characterized. OBJECTIVE To summarize and analyze existing literature on the natural history of AsAA. DATA SOURCES A search of Ovid MEDLINE (January 1, 1946, to May 31, 2017) and Embase (January 1, 1974, to May 31, 2017) was conducted. STUDY SELECTION Studies including patients with AsAA were considered for inclusion; studies were excluded if they considered AsAA, arch, and descending thoracic aneurysm as 1 entity or only included descending aneurysms, patients with heritable or genetic-related aneurysms, patients with replaced bicuspid aortic valves, patients with acute aortic syndrome, or those with mean age less than 16 years. Two independent reviewers identified 20 studies from 7198 unique studies screened. DATA EXTRACTION AND SYNTHESIS Data extraction was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline; 2 reviewers independently extracted the relevant data. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance-weighted random-effects model. Metaregression was performed to assess the relationship between initial aneurysm size, etiology, and the primary outcomes. MAIN OUTCOMES AND MEASURES The primary composite outcome was incidence of all-cause mortality, aortic dissection, and aortic rupture. Secondary outcomes were growth rate, incidence of proximal aortic dissection or rupture, elective ascending aortic repair, and all-cause mortality. RESULTS Twenty studies consisting of 8800 patients (mean [SD] age, 57.75 [9.47] years; 6653 [75.6%] male) with a total follow-up time of 31 823 patient-years were included. The mean AsAA size at enrollment was 42.6 mm (range, 35.5-56.0 mm). The combined effect estimate of annual aneurysm growth rate was 0.61 mm/y (95% CI, 0.23-0.99 mm/y). The pooled incidence of elective aortic surgery was 13.82% (95% CI, 6.45%-21.41%) over a median (interquartile range) follow-up of 4.2 (2.9-15.0) years. The linearized mortality rate was 1.99% per patient-year (95% CI, 0.83%-3.15% per patient-year), and the linearized rate of the composite outcome of all-cause mortality, aortic dissection, and aortic rupture was 2.16% per patient-year (95% CI, 0.79%-3.55% per patient year). There was no significant relationship between year of study completion and the initial aneurysm size and primary outcomes. CONCLUSIONS AND RELEVANCE The growth rate of AsAA is slow and has implications for the interval of imaging follow-up. The data on the risk of dissection, rupture, and death of ascending aortic aneurysm are limited. A randomized clinical trial may be required to understand the benefit of surgical intervention compared with surveillance for patients with moderately dilated ascending aorta.
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Affiliation(s)
- Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jehangir J. Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Richard Saczkowski
- Department of Cardiac Sciences, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Holly N. Smith
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Eric J. Herget
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Finsterer J. Aortic root ectasia as a phenotypic feature of a mitochondrial disorder. Clin Case Rep 2018; 6:1501-1503. [PMID: 30147891 PMCID: PMC6099020 DOI: 10.1002/ccr3.1652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 05/16/2018] [Accepted: 05/29/2018] [Indexed: 01/14/2023] Open
Abstract
Mitochondrial disorder (MID) can be suspected upon application of the mitochondrial multiorgan disorder syndrome score; aortic root ectasia (ARE) can be a phenotypic feature of MIDs; ARE in a MID may result from affection of vascular smooth muscle cells by the metabolic defect; ARE requires long-term follow-up not to miss the point at which ARE transforms to an aneurysm requiring vascular surgery.
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28
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Yamauchi MSW, Puchalski MD, Weng HT, Pinto NM, Etheridge SP, Presson AP, Tani LY, Minich LL, Williams RV. Disease progression and variation in clinical practice for isolated bicuspid aortic valve in children. CONGENIT HEART DIS 2018; 13:432-439. [PMID: 29468829 PMCID: PMC10550100 DOI: 10.1111/chd.12591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/27/2017] [Accepted: 11/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Disease progression of an isolated bicuspid aortic valve (BAV) in children is poorly understood and adult management guidelines may not be applicable. Thus, we sought to evaluate disease progression of pediatric isolated BAV and its relationship to current management practices. METHODS Children with a BAV and ≤mild aortic stenosis (AS) and/or aortic regurgitation (AR) at the time of initial evaluation were included in this retrospective cohort study (1/2005-12/2014). Outcomes included change in z-scores for aortic root and ascending aorta diameters, cardiac interventions, adverse outcomes, recommended follow-up interval, and frequency of cardiac imaging studies at each follow up evaluation, as well as AS/AR severity at final evaluation. Outcomes were analyzed using generalized mixed-effect models with subject and provider clustering. RESULTS BAV disease progression was evaluated in 294 subjects over 4.1 ± 2.4 (range 0.2-9.5) years. Ascending aorta z-scores increased by 0.1/year (P < .001) but aortic root diameter z-scores were unchanged. AS and/or AR progressed to >mild in 9 (3%), 1 subject underwent cardiac intervention, and none had a major complication. Management was evaluated in 454 subjects (1343 encounters) with 27 different cardiologists. The average recommended follow-up interval was 1.5 ± 0.9 years. Younger age at diagnosis, greater aortic root or ascending aorta z-score at diagnosis, ≥mild AS/AR at follow-up, and earlier diagnosis era were associated with shorter recommended follow-up interval (P < .001 for all). Imaging was obtained at 87% of follow-up encounters and was associated with age at encounter with children ≥12 years most frequently imaged (P < .001). Provider accounted for 14% of variability in recommended follow-up interval and 24% of imaging variability (P < .001 for both). CONCLUSIONS We found little to no evidence of disease progression in children with an isolated BAV. Given the low risk, close follow-up and frequent cardiac imaging for BAV surveillance may not be warranted for children.
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Affiliation(s)
- Melissa S W Yamauchi
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Michael D Puchalski
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Hsin Ti Weng
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Nelangi M Pinto
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Susan P Etheridge
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Angela P Presson
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Lloyd Y Tani
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - L LuAnn Minich
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Richard V Williams
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
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Grewal N, Gittenberger-de Groot AC. Pathogenesis of aortic wall complications in Marfan syndrome. Cardiovasc Pathol 2018; 33:62-69. [PMID: 29433109 DOI: 10.1016/j.carpath.2018.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/01/2018] [Accepted: 01/09/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients with Marfan (MFS) syndrome and patients with a bicuspid aortic valve (BAV) are more prone to develop aortic dilation and dissection compared to persons with a tricuspid aortic valve (TAV). To elucidate potential common as well as distinct pathways of clinical relevance, we compared the histopathological substrates of aortic pathology. PATIENT AND METHODS Ascending aortic wall specimen were divided in five groups: BAV (n=36) and TAV (n=23) without and with dilation and non-dilated MFS (n=8). We performed routine histology to study aortic wall features based on the aortic consensus statement. Immunohistological markers for vascular smooth muscle cell (VSMC) maturation, and expression of fibrillin-1 were additionally investigated for the underlying pathogenesis. RESULTS On basis of the routine histology the aorta in MFS was similar to the aorta in dilated TAVs (overall medial degeneration, elastic fiber fragmentation, loss and disorganization, , and VSMC nuclei loss). The other markers aided in clustering the MFS and BAV patients with a significantly lower fibrillin-1 expression as compared to the TAVs (p<0.05), a lower level of differentiated VSMC markers (p<0.05) and elastic fiber thinning. CONCLUSIONS Pathogenesis of aortopathy in MFS overlaps with mechanisms seen in BAV and TAV, leading to a so called double hit hypothesis for aortic complications in MFS. The ascending aortic wall in MFS is immature with undifferentiated VSMCs and low levels of fibrillin-1. The immature media becomes even more vulnerable for aortopathy due to other degenerative features which develop probably as a direct consequence of the fibrillin-1 mutation.
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Affiliation(s)
- Nimrat Grewal
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Adriana C Gittenberger-de Groot
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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Abnormal Longitudinal Growth of the Aorta in Children with Familial Bicuspid Aortic Valve. Pediatr Cardiol 2017; 38:1709-1715. [PMID: 28948327 PMCID: PMC5798863 DOI: 10.1007/s00246-017-1740-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 09/15/2017] [Indexed: 12/31/2022]
Abstract
Bicuspid aortic valve (BAV) is the most common type of congenital heart defect (CHD) and is associated with clinically significant cardiovascular complications including valve calcification and ascending aortopathy (AscAo), predominantly occurring in adulthood. While a limited number of genetic etiologies for BAV have been defined, family members of affected individuals display BAV along with other left-sided CHD. This has led to guidelines from the American Heart Association and American College of Cardiology that recommend echocardiographic screening of first-degree relatives of affected adults. While potentially beneficial in adults, the yield of such screening in children is unknown. The purpose of this study was to investigate a cohort of children with familial BAV to determine the frequency of development of AscAo, and to identify risk factors that contribute to abnormal aortic growth. Echocardiograms over a 10-year follow-up period were reviewed on 26 patients with familial BAV [22 male, 4 female; 22 with isolated BAV, 6 with BAV and aortic coarctation (CoA)]. All had a family history of CHD and were recruited from 2005 to 2010 as part of a genetics research study. Four aortic segments (annulus, root, sinotubular junction, ascending aorta) on parasternal long-axis echocardiographic images were measured by a single observer. The mean age at first echocardiogram was 7.1 ± 5.5 and that was 13.8 ± 6.2 years at the last echocardiogram. Only patients with > 2 echocardiograms in the 10-year period were included. Z score measurements of the aorta were plotted over time and based on these the cohort was divided into two groups: Group 1 (abnormal)-Z score for any segment > 2 or a change in Z score > 2 over follow-up; Group 2 (normal)-Z score < 2 throughout follow-up and change in Z score < 2. Nineteen out of 26 children displayed abnormal aortic growth or dilation of the aorta. BAV with right/left cusp fusion was more frequent in Group 1 (15/18) versus Group 2 (3/7) (p < 0.05). There were no significant differences in gender, aortic valve dysfunction, presence of CoA, family history, cardiac function, presence of left ventricular hypertrophy, or medication use between the 2 groups. In our longitudinal study of children with familial BAV, the majority display evidence of abnormal growth of the ascending aorta during the follow-up period consistent with AscAo and support the extension of current adult guidelines to the pediatric population. While we find that right/left cusp fusion is a risk factor for abnormal aortic growth, additional studies are needed to identify other factors to better select children who require serial screening.
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Kim M, Shim CY, You SC, Cho IJ, Hong GR, Ha JW, Chung N. Characteristics of Carotid Artery Structure and Mechanical Function and Their Relationships with Aortopathy in Patients with Bicuspid Aortic Valves. Front Physiol 2017; 8:622. [PMID: 28970802 PMCID: PMC5609542 DOI: 10.3389/fphys.2017.00622] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/11/2017] [Indexed: 12/03/2022] Open
Abstract
Patients with a bicuspid aortic valve (BAV) often have proximal aortic dilatation and systemic vascular dysfunction. We hypothesized that BAV patients would have different carotid artery structural and functional characteristics compared to tricuspid aortic valve (TAV) patients. In 28 patients with surgically confirmed BAV and 27 patients with TAV, intima media thickness (IMT), number of plaques, fractional area change (FAC), global circumferential strain (GCS), and standard deviation of CS (SD-CS) in both common carotid arteries were assessed using duplex ultrasound and velocity vector imaging (VVI). Patients with BAV were younger and had less co-morbidity, but showed a significantly larger ascending aorta (43.3 ± 7.5 vs. 37.0 ± 6.2 mm, p < 0.001) and a higher prevalence of aortopathy (61 vs. 30%, p = 0.021) than those with TAV. BAV patients showed a significantly lower IMT and fewer plaques. Although FAC and GCS were not significantly different between the two groups, they tended to be lower in the BAV group when each group was divided into three subgroups according to age. There was a significant age-dependent increase in IMT and decreases in FAC and GCS in the TAV group (p = 0.005, p = 0.001, p = 0.002, respectively), but this phenomenon was not evident in the BAV group (p = 0.074, p = 0.248, p = 0.394, respectively). BAV patients with aortopathy showed a higher SD-CS than those without aortopathy (p = 0.040), reflecting disordered mechanical function. In conclusion, BAV patients have different carotid artery structure and function compared with TAV patients, suggesting intrinsic vascular abnormalities that are less affected by established cardiovascular risk factors and more strongly related to the presence of aortopathy.
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Affiliation(s)
- Mihyun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
| | - Seong-Chan You
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
| | - In-Jeong Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
| | - Namsik Chung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of MedicineSeoul, South Korea
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Roman MJ, Pugh NL, Devereux RB, Eagle KA, Holmes K, LeMaire SA, Milewski RK, Morris SA, Prakash SK, Pyeritz RE, Ravekes WJ, Shohet RV, Song HK, Asch FM. Aortic Dilatation Associated With Bicuspid Aortic Valve: Relation to Sex, Hemodynamics, and Valve Morphology (the National Heart Lung and Blood Institute-Sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions). Am J Cardiol 2017; 120:1171-1175. [PMID: 28802510 PMCID: PMC5593782 DOI: 10.1016/j.amjcard.2017.06.061] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/31/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
Abstract
This study analyzed the impact of sex, hemodynamic profile, and valve fusion pattern on aortopathy associated with bicuspid aortic valve (BAV). The National Heart Lung and Blood Institute-sponsored National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) provided comprehensive information on a large population of well-characterized patients with BAV. Of 969 enrolled patients with BAV, 551 (57%, 77% male) had already undergone valvular and/or aortic surgery. Echocardiographic imaging data were available on 339 unoperated or preoperative participants who formed the basis of this study. BAV function was normal in 45 (14%), with a predominant aortic regurgitation (AR) in 127 (41%) and a predominant aortic stenosis (AS) in 76 (22%). Moderate-severe AR was associated with larger sinus of Valsalva (SOV) diameters compared with normal function and AS (all p <0.01). Moderate-severe AS was associated with a larger ascending aortic (AscAo) diameter compared with normal function (p = 0.003) but not with AR. The SOV diameter was larger in men than in women (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001), whereas AscAo diameters were comparable (3.9 ± 0.9 vs 3.7 ± 0.9 cm, p = 0.08). Right-left commissural fusion was associated with a larger SOV diameter (3.7 ± 0.7 vs 3.3 ± 0.6 cm, p <0.0001) compared with a right-noncoronary fusion pattern. Predominant AR was more common in men (45% vs 27%, p = 0.004), whereas AS was more common in women (29% vs 18%, p = 0.04). In conclusion, in the GenTAC Registry, AR was associated with diffuse (annular, SOV, and AscAo) enlargement, whereas moderate-severe AS was only associated with AscAo enlargement. Male sex and right-left cusp pattern of cusp fusion were associated with larger SOV diameters and a greater likelihood of AR, whereas women had a higher prevalence of AS.
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Affiliation(s)
- Mary J Roman
- Division of Cardiology, Weill Cornell Medicine, New York, New York.
| | - Norma L Pugh
- Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland
| | | | - Kim A Eagle
- Division of Cardiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Kathryn Holmes
- Department of Pediatrics, Oregon Health & Sciences University, Portland, Oregon
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Rita K Milewski
- Division of Cardiothoracic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Siddharth K Prakash
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Reed E Pyeritz
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph V Shohet
- Department of Medicine, John A. Burns School of Medicine, Honolulu, Hawaii
| | - Howard K Song
- Division of Cardiothoracic Surgery, Oregon Health & Sciences University, Portland, Oregon
| | - Federico M Asch
- MedStar Health Research Institute, Washington, District of Columbia
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Kwon MH, Sundt TM. Bicuspid Aortic Valvulopathy and Associated Aortopathy: a Review of Contemporary Studies Relevant to Clinical Decision-Making. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:68. [DOI: 10.1007/s11936-017-0569-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
BACKGROUND Bicuspid aortic valve is the most common CHD. Its association with early valvular dysfunction, endocarditis, thoracic aorta dilatation, and aortic dissection is well established. OBJECTIVE The aim of this study was to assess the incidence and predictors of cardiac events in adults with bicuspid aortic valve. METHODS We carried out a retrospective analysis of cardiac outcomes in ambulatory adults with bicuspid aortic valve followed-up in a tertiary hospital centre. Outcomes were defined as follows: interventional - intervention on the aortic valve or thoracic aorta; medical - death, aortic dissection, aortic valve endocarditis, congestive heart failure, arrhythmias, or ischaemic heart disease requiring hospital admission; and a composite end point of both. Kaplan-Meier curves were generated to determine event rates, and predictors of cardiac events were determined by multivariate analysis. RESULTS A total of 227 patients were followed-up over 13±9 years; 29% of patients developed severe aortic valve dysfunction and 12.3% reached ascending thoracic aorta dimensions above 45 mm. At least one cardiac outcome occurred in 38.8% of patients, with an incidence rate at 20 years of follow-up of 47±4%; 33% of patients were submitted to an aortic valve or thoracic aorta intervention. Survival 20 years after diagnosis was 94±2%. Independent predictors of the composite end point were baseline moderate-severe aortic valve dysfunction (hazard ratio, 3.19; 95% confidence interval, 1.35-7.54; p<0.01) and aortic valve leaflets calcification (hazard ratio, 4.72; 95% confidence interval, 1.91-11.64; p<0.005). CONCLUSIONS In this study of bicuspid aortic valve, the long-term survival was excellent but with occurrence of frequent cardiovascular events. Baseline aortic valve calcification and dysfunction were the only independent predictors of events.
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Yiğit H, Önder A, Özgür S, Aycan Z, Karademir S, Doğan V. Cardiac MRI and 3D contrast-enhanced MR angiography in pediatric and young adult patients with Turner syndrome. Turk J Med Sci 2017; 47:127-133. [PMID: 28263479 DOI: 10.3906/sag-1511-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 05/14/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM This study aimed to describe the spectrum and frequency of cardiovascular abnormalities in pediatric and young adult patients with Turner syndrome (TS) using cardiac MRI and MR angiography. MATERIALS AND METHODS This prospective study consisted of 47 female patients of pediatric age and young adults with a karyotypically confirmed diagnosis of TS. All patients underwent cardiac MRI and contrast-enhanced MR angiography. A second examination after 9-26 months was performed for 28 of these patients. RESULTS Elongation of the transverse aortic arch (ETA) was the most frequent abnormality with a rate of 37%. The rate of partial anomalous pulmonary venous connection (PAPVC) was 21.7%, bicuspid aortic valve (BAV) was 19.6%, coarctation was 6.5%, ascending aorta dilatation was 28.3%, and descending aorta dilatation was 15.2%. The diameters of the aorta and the rate of aortic dilatation per unit of time was greater in the patients with BAV (P < 0.05). ETA was less observed in the patients who were receiving growth hormone therapy (P < 0.05). CONCLUSION The most common cardiovascular abnormalities in TS patients are aortic arch anomalies such as ETA and coarctation, aortic dilatation, PAPVCs, and BAV. The presence of BAV is an important risk factor for the aortic dilatation.
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Affiliation(s)
- Hasan Yiğit
- Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Aşan Önder
- Department of Pediatric Endocrinology, Dr. Sami Ulus Children's Hospital, Ankara, Turkey
| | - Senem Özgür
- Department of Pediatric Cardiology, Dr. Sami Ulus Children's Hospital, Ankara, Turkey
| | - Zehra Aycan
- Department of Pediatric Endocrinology, Dr. Sami Ulus Children's Hospital, Ankara, Turkey
| | - Selmin Karademir
- Department of Pediatric Cardiology, Dr. Sami Ulus Children's Hospital, Ankara, Turkey
| | - Vehbi Doğan
- Department of Pediatric Cardiology, Dr. Sami Ulus Children's Hospital, Ankara, Turkey
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Liu S, Shi Y, Liu R, Tong M, Luo X, Xu J. Early Prognosis of Reduction Ascending Aortoplasty in Patients With Aortic Valve Disease: A Single Center’s Experience. Ann Thorac Surg 2017; 103:511-516. [DOI: 10.1016/j.athoracsur.2016.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 11/29/2022]
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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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Robertson EN, van der Linde D, Sherrah AG, Vallely MP, Wilson M, Bannon PG, Jeremy RW. Familial non-syndromal thoracic aortic aneurysms and dissections - Incidence and family screening outcomes. Int J Cardiol 2016; 220:43-51. [PMID: 27372041 DOI: 10.1016/j.ijcard.2016.06.086] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/18/2016] [Accepted: 06/21/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Non-syndromal thoracic aortic aneurysm and dissection (ns-TAAD) is a genetic aortopathy, with uncertain incidence. This study documented the incidence of ns-TAAD and outcomes of family screening over 15years. METHODS Consecutive series of 2385 patients with aortic disease in prospective registry (2000 to 2014), including 675 undergoing surgery. Diagnosis of ns-TAAD included family history, aortic imaging, tissue pathology and mutation testing. Screening was offered to relatives of ns-TAAD probands, with follow-up for affected individuals. RESULTS There were 270 ns-TAAD probands (74% males), including 116 (43%) presenting with aortic dissection. Among surgical cases, a diagnosis of ns-TAAD was established for 116 (17%). Age of probands was 50.4±14.1years, with aortic diameter of 51±12mm. Screening of 581 at-risk relatives identified 216 new ns-TAAD cases (detection rate=37%). Among 71 probands with known family history, screening identified 130 new affected relatives and among 53 probands with no family history, screening identified 86 new affected relatives. Mean age of new affected relatives at diagnosis was 44±18years, with aortic diameter of 42±7mm, including 42 with diameter>50mm. Ten-year mortality was similar for probands without dissection (7.7±3.1%) and new affected relatives (11.4±4.0%) but greater for probands surviving initial dissection (27.6±7.8%, p=0.003). CONCLUSIONS Up to 1 in 6 patients undergoing aortic surgery have features of ns-TAAD, frequently presenting as aortic dissection but at later age than other genetic aortopathies. Family screening identifies affected relatives in up to half of ns-TAAD probands, many of whom already have significant aortic dilatation.
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Affiliation(s)
| | | | - Andrew G Sherrah
- Sydney Medical School, University of Sydney, Australia; The Baird Institute, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, University of Sydney, Australia; The Baird Institute, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Australia
| | - Michael Wilson
- The Baird Institute, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Australia
| | - Paul G Bannon
- Sydney Medical School, University of Sydney, Australia; The Baird Institute, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richmond W Jeremy
- Sydney Medical School, University of Sydney, Australia; The Baird Institute, Royal Prince Alfred Hospital, Sydney, Australia.
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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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Yamanaka T, Fukatsu T, Ichinohe Y, Komatsu H, Seki M, Sasaki K, Takai H, Kunihara T, Hirata Y. An Adult Case of Unicommissural Unicuspid Aortic Valve Diagnosed Based on the Intraoperative Findings. Intern Med 2016; 55:2643-8. [PMID: 27629961 DOI: 10.2169/internalmedicine.55.6861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report an adult case of unicommissural unicuspid aortic valve (UAV). A 59-year-old man, who was noted to have a cardiac murmur at 31 years of age, was admitted to our hospital due to acute heart failure. Severe calcification in the aortic valve with severe low-flow/low-gradient aortic stenosis and moderate aortic regurgitation was observed and thought to be the cause of heart failure, however, the etiology of aortic valve dysfunction was not clear. Aortic valve replacement was subsequently performed, and unicommissural UAV was diagnosed according to the intraoperative findings. UAV is very rare congenital aortic valve disease which is rarely diagnosed preoperatively.
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Affiliation(s)
- Tetsuo Yamanaka
- Department of Cardiovascular Medicine, Tokyo Teishin Hospital, Japan
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Avadhani SA, Martin-Doyle W, Shaikh AY, Pape LA. Predictors of ascending aortic dilation in bicuspid aortic valve disease: a five-year prospective study. Am J Med 2015; 128:647-52. [PMID: 25644322 DOI: 10.1016/j.amjmed.2014.12.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 12/31/2014] [Accepted: 12/31/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bicuspid aortic valves are associated with aortic dilation and dissection. There is a paucity of prospective studies evaluating changes in aortic size over time in adult subjects with bicuspid aortic valves. METHODS A total of 115 subjects with asymptomatic bicuspid aortic valves were enrolled from 2003 to 2008 and followed prospectively over 5 years. Clinical and family histories, as well as transthoracic echocardiograms, were obtained at baseline, and echocardiograms were performed annually thereafter. RESULTS The mean age of subjects was 41.8 ± 12.8 years, and 61% were male. Ascending aortic size at baseline averaged 35.5 ± 5.6 mm and increased in 71.1% of subjects (mean, 0.66 ± 0.05 mm/y; range, 0.2-2.3 mm/y) over an average of 4.8 years. In 15.6% of subjects, the rate of change exceeded 1 mm/y. The average rate of ascending aortic dilation for all subjects was 0.47 ± 0.05 mm/y (P < .001). A family history of aortic valve disease was associated with progression in both unadjusted (P = .029) and logistic regression analyses adjusted for age, gender, and body surface area (odds ratio, 13.7; P = .021). Multivariate analysis did not find leaflet orientation or moderate to severe aortic valve dysfunction as independent predictors of aortic dilation. CONCLUSIONS We found that in subjects with bicuspid aortic valve, studied prospectively, there was an annual rate of ascending aortic dilation of 0.47 mm/y. In contrast to previous reports, leaflet orientation and aortic valve dysfunction were not independent predictors of aortic dilation. A family history of aortic valve disease was associated with a significantly increased risk of increasing ascending aortic size.
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Affiliation(s)
- Sriya A Avadhani
- Department of Medicine, State University of New York Downstate Health Science Center, Brooklyn, NY
| | | | - Amir Y Shaikh
- Department of Medicine, University of Massachusetts Medical School, Worcester, Mass
| | - Linda A Pape
- Department of Medicine, University of Massachusetts Medical School, Worcester, Mass.
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Saliba E, Sia Y. The ascending aortic aneurysm: When to intervene? IJC HEART & VASCULATURE 2015; 6:91-100. [PMID: 38598654 PMCID: PMC5497177 DOI: 10.1016/j.ijcha.2015.01.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 01/10/2015] [Accepted: 01/13/2015] [Indexed: 01/15/2023]
Abstract
Background Thoracic ascending aorta aneurysms (TAA) are an important cause of mortality in adults but are a relatively less studied subject compared to abdominal aortic aneurysms (AAA). The purpose of this review is to explain the main aspects (etiology, pathophysiology, diagnosis) of this disease and to summarize the most recent developments in its management. Methodology Literature was obtained through online health related search engines (PubMed, MEDLINE) by including the following keywords: ascending aorta aneurysm, thoracic aneurysms, Marfan syndrome, bicuspid aortic valve, familial thoracic syndrome, aortic dissection, aorta imaging and aortic aneurysm guidelines. We included articles dating from 1980 to 2014. Findings Literature revealed how lethal this disease can be and how simple steps such as follow-up and prophylactic surgery can significantly reduce morbidity and mortality. This review also allowed us to realize the many developments that have been made in recent years in the understanding of pathologic mechanisms of this disease. Conclusion TAA is a silent disease that needs to be recognized early in its course and followed closely in order to recommend appropriate preventive and prophylactic therapy in a timely manner.
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Affiliation(s)
- Emile Saliba
- Hôtel Dieu de Montreal, CHUM — Centre Hospitalier de
l'Université de Montréal, 3840 St Urbain St, Montreal, QC H2W 1T8,
Canada
| | - Ying Sia
- Hôtel Dieu de Montreal, CHUM — Centre Hospitalier de
l'Université de Montréal, 3840 St Urbain St, Montreal, QC H2W 1T8,
Canada
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Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:119-82. [DOI: 10.1016/j.echo.2014.11.015] [Citation(s) in RCA: 409] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Bicuspid aortic valves are associated with increased wall and turbulence shear stress levels compared to trileaflet aortic valves. Biomech Model Mechanobiol 2014; 14:577-88. [DOI: 10.1007/s10237-014-0623-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 09/11/2014] [Indexed: 12/14/2022]
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Nakamura Y, Ryugo M, Shikata F, Okura M, Okamura T, Yasugi T, Izutani H. The analysis of ascending aortic dilatation in patients with a bicuspid aortic valve using the ratio of the diameters of the ascending and descending aorta. J Cardiothorac Surg 2014; 9:108. [PMID: 24947564 PMCID: PMC4229942 DOI: 10.1186/1749-8090-9-108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 06/16/2014] [Indexed: 01/15/2023] Open
Abstract
Background A bicuspid aortic valve (BAV) is associated with premature valve dysfunction and abnormalities of the ascending aorta. The aim of our study was to assess the degree of ascending aortic dilatation by measuring the ratio of the dimension of the AAo to that of the descending aorta (DAo) using preoperative computerized tomography (CT). Methods A review of our institutional clinical database identified 76 patients undergoing aortic valve replacement (AVR) and 73 control patients undergoing off-pump coronary artery bypass (OPCAB group) between September 2009 and April 2012. Results There were 17 patients diagnosed with BAV (BAV group), and the remaining 59 patients had a tricuspid aortic valve (TAV group). The ratios of the dimensions of the AAo to that of the DAo (AAo/DAo) for each group were: BAV, 1.58 ± 0.25; TAV, 1.32 ± 0.11; and OPCAB, 1.29 ± 0.12. Interestingly, the AAo/DAo of the BAV group was significantly larger than that of the other groups. Conclusions Although progressive AAo dilatation for BAV is well documented, the diameter of the AAo is currently the only estimate of aortic dilatation. In this study, we report that the ratio of the AAo and DAo diameters in patients with BAV can be a new index for assessing the dilatation of the AAo and differentiating the patients with BAV from those with TAV.
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Affiliation(s)
| | | | | | | | | | | | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon City, Ehime 791-0295, Japan.
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Ali OA, Chapman M, Nguyen TH, Chirkov YY, Heresztyn T, Mundisugih J, Horowitz JD. Interactions between inflammatory activation and endothelial dysfunction selectively modulate valve disease progression in patients with bicuspid aortic valve. Heart 2014; 100:800-5. [PMID: 24743038 DOI: 10.1136/heartjnl-2014-305509] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Bicuspid aortic valve (BAV) is associated with increased risk of valvular degeneration and ascending aortic aneurysm formation and rupture. We sought to evaluate the roles of endothelial dysfunction and inflammatory activation in modulating these processes. METHODS We performed a case-control study of patients with BAV together with a multivariate analysis within the BAV group to identify factors associated with: development of significant valvular disease; dilatation of the ascending aorta; differential valve relative to aortic disease. Endothelial function of patients and controls was evaluated via flow-mediated dilatation (FMD) and plasma concentrations of asymmetric dimethylarginine (ADMA). Correlations with inflammatory markers and endothelial progenitor cell counts were also examined. Morphological and physiological assessment of the valve and ascending aorta was performed with transthoracic echocardiography and MRI. RESULTS Patients with BAV (n=43) and controls (n=25) were matched for age and gender. FMD was significantly lower in patients than controls (7.85±3.48% vs 11.58±3.98%, p=0.001), and these differences were age-independent. Within the BAV cohort, multivariate correlates of peak aortic valve velocity were plasma concentrations of ADMA and myeloperoxidase (MPO) (both p<0.01), while increasing age was an independent correlate of ascending aortic diameter (p<0.05). Furthermore, both low FMD and inflammatory activation were multivariate correlates of selectivity for valvular disease. CONCLUSIONS BAV is associated with endothelial dysfunction. The extent of inflammatory activation (specifically MPO release) and that of endothelial dysfunction impact primarily on integrity of the valve rather than aortic structure.
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Affiliation(s)
- Onn Akbar Ali
- Department of Cardiology, The Queen Elizabeth Hospital, , Adelaide, Australia
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Aboulhosn J, Child JS. Echocardiographic Evaluation of Congenital Left Ventricular Outflow Obstruction. Echocardiography 2014; 32 Suppl 2:S140-7. [DOI: 10.1111/echo.12181] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Center; Division of Cardiology; Department of Medicine; David Geffen School of Medicine at UCLA; Los Angeles California
| | - John S. Child
- Ahmanson/UCLA Adult Congenital Heart Center; Division of Cardiology; Department of Medicine; David Geffen School of Medicine at UCLA; Los Angeles California
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