1
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Pereira SC, Abrantes AL, António PS, Morais P, Sousa C, David C, Pinto FJ, Almeida AG, Caldeira D. Infective endocarditis risk in patients with bicuspid aortic valve: Systematic review and meta-analysis. IJC HEART & VASCULATURE 2023; 47:101249. [PMID: 37547264 PMCID: PMC10400861 DOI: 10.1016/j.ijcha.2023.101249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023]
Abstract
Background Antibiotic prophylaxis in bicuspid aortic valve patients is currently a matter of debate. Although it is no longer recommended by international guidelines, some studies indicate a high risk of infective endocarditis. We aim to evaluate the risk of native valve infective endocarditis in bicuspid aortic valve patients and compare to individuals with tricuspid aortic valve. Methods Study search of longitudinal studies regarding infective endocarditis incidence in bicuspid aortic valve patients (compared with tricuspid aortic valve/overall population) was conducted through OVID in the following electronic databases: MEDLINE, CENTRAL, EMBASE; from inception until October 2020. The outcomes of interest were the incidence rate and relative risk of infective endocarditis. The relative risk and incidence rate (number of cases for each 10 000 persons-year) with their 95 % confidence intervals (95 %CI) were estimated using a random effects model meta-analysis. The study protocol was registered at PROSPERO CRD42020218639. Results Eight cohort studies were selected, with a total of 5351 bicuspid aortic valve patients. During follow up, 184 bicuspid aortic valve patients presented infective endocarditis, with an incidence rate of 48.13 per 10,000 patients-year (95 %CI 22.24-74.02), and a 12-fold (RR: 12.03, 95 %CI 5.45-26.54) increased risk compared with general population, after adjusted estimates. Conclusions This systematic review and meta-analysis suggests that bicuspid aortic valve patients have a significant high risk of native valve infective endocarditis. Large prospective high-quality studies are required to estimate more accurately the incidence of infective endocarditis, the relative risk and the potential benefit of antibiotic prophylaxis.
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Affiliation(s)
- Sara Couto Pereira
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
| | - Ana Lobato Abrantes
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
| | | | - Pedro Morais
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
| | - Catarina Sousa
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
- Centro Cardiovascular da Universidade de Lisboa – CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Cláudio David
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
| | - Fausto J. Pinto
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
- Centro Cardiovascular da Universidade de Lisboa – CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Ana G. Almeida
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
- Centro Cardiovascular da Universidade de Lisboa – CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Daniel Caldeira
- Cardiology Department, Hospital Universitário de Santa Maria – CHULN, Portugal
- Centro Cardiovascular da Universidade de Lisboa – CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal
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2
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Szöcs K, Toprak B, Schön G, Rybczynski M, Brinken T, Mahlmann A, Girdauskas E, Blankenberg S, von Kodolitsch Y. Concomitant cardiovascular malformations in isolated bicuspid aortic valve disease: a retrospective cross-sectional study and meta-analysis. Cardiovasc Diagn Ther 2022; 12:400-414. [PMID: 36033227 PMCID: PMC9412207 DOI: 10.21037/cdt-22-112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/21/2022] [Indexed: 11/22/2022]
Abstract
Background Congenital bicuspid aortic valve affects up to 2% of the general population. It occurs in complex congenital heart defects or in syndromes such as Turner, Marfan, or Loeys-Dietz. However, the majority of bicuspid aortic valves are considered to manifest as isolated malformations. Methods We aimed to assess retrospectively associated cardiovascular malformations in 200 individuals with bicuspid aortic valve considered to occur as an isolated manifestation. All individuals underwent transthoracic echocardiography, 164 thoracoabdominal tomographic imaging, and 84 coronary artery imaging. In addition, we also performed a meta-analysis of data from the literature to assess the occurrence of associate malformations. Results In our retrospective cross-sectional study collective, the mean age was 45±15 years, 154 (77%) individuals were male. Anatomy of bicuspid aortic valve according to Schaefer was type 1 in 142 (71%), type 2 in 35 (18%), type 3 in 2 (1%), unicuspid in 6 (3%), and unclassified in 15 (8%) individuals. Coarctation of the aorta had 4.2% of individuals, 3.6% had coronary anomalies. No individual had a patent ductus arteriosus, 0.5% had atrial and ventricular septal defect each, 1.5% mitral valve prolapse. No individual had a tricuspid valve prolapse. Our meta-analysis identified in cohorts with isolated bicuspid aortic valve 11.8% (95% CI: 7.7–16.0%) individuals with aortic coarctation, 3.7% (95% CI: 1.2–6.1%) with coronary anomalies, 3.3% (95% CI: 0.0–6.7%) with patent ductus arteriosus, 5.9% (95% CI: 1.3–10.5%) with ventricular septal defect and 1.6% (95% CI: 1.1–2.1%) with mitral valve prolapse. Conclusions Individuals with isolated bicuspid aortic valve may exhibit a variety of associated cardiovascular malformations and therefore screening for associated malformations may be warranted.
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Affiliation(s)
- Katalin Szöcs
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Betül Toprak
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Meike Rybczynski
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatjana Brinken
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adrian Mahlmann
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Vascular Medicine, Clinic for Angiology, St. Josefs-Hospital, Katholisches Krankenhaus Hagen gem. GmbH, Hagen, Germany
| | - Evaldas Girdauskas
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg at University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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Guedeney P, Collet JP. [Aortic stenosis: An update]. Rev Med Interne 2022; 43:145-151. [PMID: 35181161 DOI: 10.1016/j.revmed.2021.06.003] [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: 05/11/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
Aortic stenosis remains one of the most frequent valvulopathy worldwide, burdened with great mortality and morbidity, and for which there is not yet an effective preventive approach, although the pathophysiological mechanisms involved in its development are better understood nowadays. Its cure, however, has been revolutionized in the last decade by the advent of transcatheter aortic valve implantation, or TAVI (also named transcatheter aortic valve replacement or TAVR). The technique of TAVI has been refined and its indications has been extended, following the publication of large randomized controlled trials where it was compared to surgical aortic valve replacement with favorable results. Consequently, transfemoral TAVR has become the first line of treatment in case of symptomatic severe aortic valve stenosis. In this review, we describe the pathophysiological mechanisms leading to severe aortic stenosis and the main ongoing randomized controlled trials targeting them. We describe the indication for surgical or percutaneous aortic valve replacement and the main complications following the procedure.
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Affiliation(s)
- P Guedeney
- Sorbonne université, ACTION Study Group, institut de cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47, boulevard de l'hôpital, 75013 Paris, France.
| | - J-P Collet
- Sorbonne université, ACTION Study Group, institut de cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47, boulevard de l'hôpital, 75013 Paris, France.
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4
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Prognostic Implications of Bicuspid and Tricuspid Aortic Valve Phenotype on Progression of Moderate Aortic Stenosis and Ascending Aorta Dilatation. Am J Cardiol 2021; 161:76-83. [PMID: 34627597 DOI: 10.1016/j.amjcard.2021.08.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/10/2021] [Accepted: 08/16/2021] [Indexed: 11/20/2022]
Abstract
Studies on the impact of aortic valve anatomy (bicuspid aortic valve [BAV] or tricuspid aortic valve [TAV]) on the progression of moderate aortic stenosis (AS) and ascending aorta (AA) dilatation and its prognostic implications are limited. From 1991 to 2016, 288 asymptomatic patients with moderate AS detected during index echocardiography with at least 1 year of echocardiographic follow-up were retrospectively studied. Baseline clinical and echocardiographic characteristics were compared between patients with BAV (n = 80) and patients with TAV (n = 208). Co-primary outcomes were 1-year hemodynamic and anatomic progression of AS and AA dilatation. Secondary end points were the incidence of AA rapid progressors, all-cause mortality, aortic valve replacement, and congestive heart failure. Determinants of AS progression, AA diameters, AA dilatation, and prognostic outcomes were evaluated. Similar 1-year progression of the aortic valve peak velocity, Vmax (9 ± 18 vs 9 ± 23 cm/s), mean gradient (1.5 ± 2.3 vs 1.3 ± 3.2 mm Hg), and aortic valve area (AVA) (-0.04 ± 0.09 vs -0.05 ± 0.10 cm2) were noted for BAV and TAV groups, respectively. One-year progressions of AA were similar at Valsalva (0.11 ± 0.88 vs 0.14 ± 1.10 mm) and tubular levels (0.12 ± 0.68 vs 0.30 ± 1.51 mm) in BAV and TAV groups, respectively. A trend toward increased rapid AA progression in patients with BAV (31.3%) was observed compared with patients with TAV (14.8%, p = 0.099). BAV was associated with progression of Vmax (β = 0.17, p = 0.036), the dimensionless index (β = -0.17, p = 0.008), and AVA (β = -0.14, p = 0.048), but not mean gradient after adjusting for age, baseline severity indexes, gender, hypertension, diabetes, and body surface area. Although BAV was a determinant of larger baseline AA diameter, there was no significant association between BAV and AA rapid progressors. Adjusted Kaplan-Meier curves demonstrated no differences in congestive heart failure, aortic valve replacement, or mortality between valve morphology. In conclusion, there was a similar 1-year disease progression in terms of AVA, Vmax, mean gradient, and AA diameters between patients with BAV and patients with TAV. BAV was associated with a significant increase in Vmax, dimensionless index, and AVA after adjusting for important confounders. Close and prolonged follow-up is warranted in both groups of patients.
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5
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Shen M, Tastet L, Capoulade R, Arsenault M, Bédard É, Clavel MA, Pibarot P. Effect of bicuspid aortic valve phenotype on progression of aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 21:727-734. [PMID: 32386199 DOI: 10.1093/ehjci/jeaa068] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS To compare the progression of aortic stenosis (AS) in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV). METHODS AND RESULTS One hundred and forty-one patients with mild-to-moderate AS, recruited prospectively in the PROGRESSA study, were included in this sub-analysis. Baseline clinical, Doppler echocardiography and multidetector computed tomography characteristics were compared between BAV (n = 32) and TAV (n = 109) patients. The 2-year haemodynamic [i.e. peak aortic jet velocity (Vpeak) and mean transvalvular gradient (MG)] and anatomic [i.e. aortic valve calcification density (AVCd) and aortic valve calcification density ratio (AVCd ratio)] progression of AS were compared between the two valve phenotypes. The 2-year progression rate of Vpeak was: 16 (-0 to 40) vs. 17 (3-35) cm/s, P = 0.95; of MG was: 1.8 (-0.7 to 5.8) vs. 2.6 (0.4-4.8) mmHg, P = 0.56; of AVCd was 32 (2-109) vs. 52 (25-85) AU/cm2, P = 0.15; and of AVCd ratio was: 0.08 (0.01-0.23) vs. 0.12 (0.06-0.18), P = 0.16 in patients with BAV vs. TAV. In univariable analyses, BAV was not associated with AS progression (all, P ≥ 0.26). However, with further adjustment for age, AS baseline severity, and several risk factors (i.e. sex, history of hypertension, creatinine level, diabetes, metabolic syndrome), BAV was independently associated with faster haemodynamic (Vpeak: β = 0.31, P = 0.02) and anatomic (AVCd: β = 0.26, P = 0.03 and AVCd ratio: β = 0.26, P = 0.03) progression of AS. CONCLUSION In patients with mild-to-moderate AS, patients with BAV have faster haemodynamic and anatomic progression of AS when compared to TAV patients with similar age and risk profile. This study highlights the importance and necessity to closely monitor patients with BAV and to adequately control and treat their risk factors. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov Unique identifier: NCT01679431.
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Affiliation(s)
- Mylène Shen
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Lionel Tastet
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Romain Capoulade
- Inserm UMR 1087/CNRS UMR 6291, IRS-UN, L'institut du thorax, CHU Nantes, UNIV Nantes, 8 quai Moncousu, BP 70721, 44007 Nantes Cedex 1, France
| | - Marie Arsenault
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Élisabeth Bédard
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Marie-Annick Clavel
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Philippe Pibarot
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
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6
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Song S, Seo J, Cho I, Hong GR, Ha JW, Shim CY. Progression and Outcomes of Non-dysfunctional Bicuspid Aortic Valve: Longitudinal Data From a Large Korean Bicuspid Aortic Valve Registry. Front Cardiovasc Med 2021; 7:603323. [PMID: 33505993 PMCID: PMC7829218 DOI: 10.3389/fcvm.2020.603323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/07/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Using echocardiographic surveillance, many patients are diagnosed with bicuspid aortic valve (BAV) without significant valve dysfunction. Limited data are available regarding the progression and outcomes of non-dysfunctional BAV. Methods and Results: We investigated 1,307 BAV patients (984 male, mean age 56 years) diagnosed from Jan 2003 through Dec 2018 in a single tertiary center. Seven hundred sixty-one patients underwent follow-up echocardiography at ≥1 year post-diagnosis. Non-dysfunctional BAV was defined as BAV without moderate aortic stenosis (AS) or aortic regurgitation (AR). The presence of aortopathy was defined as an ascending aorta diameter >37mm. Progression to significant BAV dysfunction, progression to severe aortopathy (ascending aorta diameter ≥45mm), and incidence of valve or aorta operation were analyzed. One hundred eighty-seven (25%) patients showed non-dysfunctional BAV. Among them, 104 (56%) had mild AS or AR, and 81 (43%) had aortopathy at indexed echocardiography. At 6.0 ± 3.8 years post-diagnosis, 56 (29%) progressed to dysfunctional BAV, 28 (15%) progressed to severe aortopathy, 22 (12%) underwent valve operation, and 19 (10%) experienced aorta operation. Eighty-nine percent of patients with normal BAV function and 61% of patients with mild AS or AR maintained non-dysfunctional BAV. More patients with aortopathy progressed to severe aortopathy (35 vs. 0% without aortopathy, p < 0.001), with a higher incidence of aorta operation (21 vs. 2%, p < 0.001). Conclusions: In patients with non-dysfunctional BAV, initial BAV function and degree of aorta dilatation might be important for progression and outcomes. Patients without any dysfunction or aortopathy tend to maintain good structure and function for 6 years.
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Affiliation(s)
- Shinjeong Song
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
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7
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D'Ascenzi F, Valentini F, Anselmi F, Cavigli L, Bandera F, Benfari G, D'Andrea A, Di Salvo G, Esposito R, Evola V, Malagoli A, Elena Mandoli G, Santoro C, Galderisi M, Mondillo S, Cameli M. Bicuspid aortic valve and sports: From the echocardiographic evaluation to the eligibility for sports competition. Scand J Med Sci Sports 2020; 31:510-520. [PMID: 33260267 DOI: 10.1111/sms.13895] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/23/2020] [Accepted: 11/27/2020] [Indexed: 12/19/2022]
Abstract
Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults. Although a BAV may remain without clinical consequences for a lifetime, it can deteriorate in aortic valve stenosis and regurgitation and aortic dilatation. Unfortunately, the impact of regular training on patients with BAV and its natural course is not fully understood, although preliminary evidence suggests that the progression of valvular disease occurs primarily in an independent manner from sports practice. The current review aims to report how to perform a comprehensive echocardiographic examination in athletes with BAV and analyze the current literature on the influence of sports practice and how it impacts the aortic valve in athletes with BAV. The article also summarizes the current recommendations on sports eligibility and disqualification for competitive athletes with BAV.
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Affiliation(s)
- Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Valentini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesco Bandera
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giovanni Benfari
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I° Hospital Nocera Inferiore, Salerno, Italy
| | | | - Roberta Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Vincenzo Evola
- Department of Clinical and Experimental Medicine, University of Palermo, Palermo, Italy
| | | | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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8
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Pawade T, Sheth T, Guzzetti E, Dweck MR, Clavel MA. Why and How to Measure Aortic Valve Calcification in Patients With Aortic Stenosis. JACC Cardiovasc Imaging 2020; 12:1835-1848. [PMID: 31488252 DOI: 10.1016/j.jcmg.2019.01.045] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/26/2022]
Abstract
The first-line evaluation of aortic stenosis severity is Doppler echocardiography. However, in up to 40% of patients, resting echocardiographic assessment of aortic stenosis severity is discordant, leading to clinical uncertainty. Interest has therefore grown in aortic valve calcium scoring by multidetector computed tomography (CT-AVC) as an alternative load independent assessment of aortic stenosis severity. This paper will briefly review the pathophysiology of aortic stenosis and the crucial role that calcification plays in driving progressive obstruction of the valve. Subsequently, it will describe published reports that have investigated CT-AVC, validating this parameter against histology, and establishing its diagnostic accuracy versus echocardiography as well as its powerful independent prognostic capability. Finally, this review seeks to provide a practical guide about how best to acquire and interpret CT-AVC with a close focus on potential pitfalls and how these might be best avoided as this technique becomes more widely adopted in to clinical practice.
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Affiliation(s)
- Tania Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tej Sheth
- Division of Cardiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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9
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Qin T, Caballero A, Mao W, Barrett B, Kamioka N, Lerakis S, Sun W. The role of stress concentration in calcified bicuspid aortic valve. J R Soc Interface 2020; 17:20190893. [PMID: 32517630 DOI: 10.1098/rsif.2019.0893] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is the most common valvular heart disease in the aging population, and is now believed to be a slow, progressive, yet actively regulated process. The disease progression can be divided into two phases: initiation phase associated with lipid deposition and inflammation response, and the later propagation phase with active calcification growth. It has been hypothesized that elevated mechanical stress plays a major role in both phases of disease progression. In order to identify a direct link between leaflet stress and calcification development, we performed patient-specific finite-element (FE) analyses of six bicuspid aortic valves (BAV), where the leaflets, raphe and calcifications were all considered. The results showed that during the initiation phase, calcium buildup is likely to occur along the leaflet-root attachment curve (ATC), and the commissures, which are subject to the most drastic changes in stress during the cardiac cycle. During the propagation phase, the presence of calcification would lead to local stress concentration along its boundary, hence further calcification growth. Three patterns of calcification formation were identified on BAV leaflets: 'radial', which extended radially from ATC into the leaflet belly region; 'commissure to commissure', which extended circumferentially along the coaptation; and 'raphe', which located in the vicinity of the raphe. Furthermore, we found a strong correlation between regions with a high risk of calcium buildup and regions with elevated mechanical stress. The high-risk regions predicted at diastole on the non-calcified leaflet from FE models agreed reasonably well with the in vivo calcification locations, which indicates that patient-specific FE modelling could help us to evaluate the potential risk of calcification formation in the early stage of CAVD.
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Affiliation(s)
- Tongran Qin
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Andrés Caballero
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Wenbin Mao
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Brian Barrett
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | | | - Stamatios Lerakis
- School of Medicine, Emory University, Atlanta, GA, USA.,Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wei Sun
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
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10
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Katsi V, Georgiopoulos G, Oikonomou D, Aggeli C, Grassos C, Papadopoulos DP, Thomopoulos C, Marketou M, Dimitriadis K, Toutouzas K, Nihoyannopoulos P, Tsioufis C, Tousoulis D. Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension. Curr Vasc Pharmacol 2020; 17:180-190. [PMID: 29295699 DOI: 10.2174/1570161116666180101165306] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve. OBJECTIVE To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease. METHODS We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease. RESULTS Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis. CONCLUSION Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.
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Affiliation(s)
- V Katsi
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - G Georgiopoulos
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - D Oikonomou
- Department of Cardiology, 'Evaggelismos' General Hospital, Athens, Greece
| | - C Aggeli
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - C Grassos
- Department of Cardiology, 'KAT' General Hospital, Athens, Greece
| | - D P Papadopoulos
- Department of Cardiology, 'Laiko' General Hospital, Athens, Greece
| | - C Thomopoulos
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
| | - M Marketou
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
| | - K Dimitriadis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - K Toutouzas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - P Nihoyannopoulos
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - C Tsioufis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - D Tousoulis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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11
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Groudeva VV, Atzev BG, Petkov DG. Management of Late-Presenting Congenital Combined Heart Defect - Bicuspid Aortic Valve and Ventricular Septal Aneurysm. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e919766. [PMID: 32165609 PMCID: PMC7081954 DOI: 10.12659/ajcr.919766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Female, 68-year-old Final Diagnosis: Bicuspid aortic valve and ventricular septal aneurysm Symptoms: Cough Medication:— Clinical Procedure: Plastic repair of ascending aorta and interventricular anurysm Specialty: Cardiac surgery
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Affiliation(s)
- Violeta V Groudeva
- Department of Diagnostic Imaging, University Hospital "St. Ekaterina", Sofia, Medical University, Sofia, Bulgaria
| | - Borislav G Atzev
- Department of Cardiology, University Hospital "St. Ekaterina", Sofia, Medical University, Sofia, Bulgaria
| | - Dimitar G Petkov
- Department of Cardiac Surgery, University Hospital "St. Ekaterina", Sofia, Medical University, Sofia, Bulgaria
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12
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Predicting Disease Progression in Patients with Bicuspid Aortic Stenosis Using Mathematical Modeling. J Clin Med 2019; 8:jcm8091302. [PMID: 31450580 PMCID: PMC6780906 DOI: 10.3390/jcm8091302] [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: 07/11/2019] [Accepted: 08/22/2019] [Indexed: 11/17/2022] Open
Abstract
We aimed to develop a mathematical model to predict the progression of aortic stenosis (AS) and aortic dilatation (AD) in bicuspid aortic valve patients. Bicuspid AS patients who underwent at least two serial echocardiograms from 2005 to 2017 were enrolled. Mathematical modeling was undertaken to assess (1) the non-linearity associated with the disease progression and (2) the importance of first visit echocardiogram in predicting the overall prognosis. Models were trained in 126 patients and validated in an additional cohort of 43 patients. AS was best described by a logistic function of time. Patients who showed an increase in mean pressure gradient (MPG) at their first visit relative to baseline (denoted as rapid progressors) showed a significantly faster disease progression overall. The core model parameter reflecting the rate of disease progression, α, was 0.012/month in the rapid progressors and 0.0032/month in the slow progressors (p < 0.0001). AD progression was best described by a simple linear function, with an increment rate of 0.019 mm/month. Validation of models in a separate prospective cohort yielded comparable R squared statistics for predicted outcomes. Our novel disease progression model for bicuspid AS significantly increased prediction power by including subsequent follow-up visit information rather than baseline information alone.
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13
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Song J, Zheng Q, Ma X, Zhang Q, Xu Z, Zou C, Wang Z. Predictive Roles of Neutrophil-to-Lymphocyte Ratio and C-Reactive Protein in Patients with Calcific Aortic Valve Disease. Int Heart J 2019; 60:345-351. [PMID: 30745535 DOI: 10.1536/ihj.18-196] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) are emerging indirect blood markers to roughly reflect the inflammation level in our body while some pathological changes occurring in aortic valve tissue. Few recent studies demonstrated that NLR is related to calcific aortic valve disease (CAVD). However, the extent of the relationship between them and the impact of CRP on CAVD are not clear. This study aimed to investigate the diagnostic influence and surgical predictive effect of NLR and CRP on CAVD.A total of 278 consecutive patients with CAVD (123 patients with bicuspid aortic valve and others with tricuspid aortic valve) and 108 healthy individuals who were included in the control group were enrolled in the study. The NLR was calculated from the complete blood count, and the CRP was measured from peripheral blood samples. Echocardiography was used to evaluate the severity of aortic stenosis. Intraoperation/postoperation indicators were collected in 166 patients from the total consecutive patients who underwent aortic valve replacement (AVR) alone.Significantly higher NLR was measured in both the BAV group (1.96 ± 0.78 versus 0.97 ± 0.15, P < 0.001) and the TAV group (2.51 ± 2.03 versus 0.97 ± 0.15, P < 0.001) compared with the control group. Moreover, the NLR level was significantly higher (P < 0.001) and the CRP level was significantly lower (P = 0.007) of the TAV group than that of the BAV group; a significant positive correlation between the NLR and the maximum gradient of aortic valve was detected. Furthermore, there was a moderate correlation between the NLR and the postoperative mechanical ventilation time.Our results indicated that the NLR and CRP were novel and useful predictive factors in patients with CAVD, and these two potential factors have guiding significance for the prediction of different pathological typing (BAV or TAV). Higher NLR level will not extend the cardiopulmonary bypass time (CPB); however, it will prolong the operation time and the postoperative mechanical ventilation time.
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Affiliation(s)
- Jian Song
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Qiang Zheng
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Xiaochun Ma
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Qian Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Zhenqiang Xu
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Chengwei Zou
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Zhengjun Wang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University
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Ohukainen P, Ruskoaho H, Rysa J. Cellular Mechanisms of Valvular Thickening in Early and Intermediate Calcific Aortic Valve Disease. Curr Cardiol Rev 2018; 14:264-271. [PMID: 30124158 PMCID: PMC6300797 DOI: 10.2174/1573403x14666180820151325] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 01/23/2023] Open
Abstract
Background: Calcific aortic valve disease is common in an aging population. It is an ac-tive atheroinflammatory process that has an initial pathophysiology and similar risk factors as athero-sclerosis. However, the ultimate disease phenotypes are markedly different. While coronary heart dis-ease results in rupture-prone plaques, calcific aortic valve disease leads to heavily calcified and ossi-fied valves. Both are initiated by the retention of low-density lipoprotein particles in the subendotheli-al matrix leading to sterile inflammation. In calcific aortic valve disease, the process towards calcifica-tion and ossification is preceded by valvular thickening, which can cause the first clinical symptoms. This is attributable to the accumulation of lipids, inflammatory cells and subsequently disturbances in the valvular extracellular matrix. Fibrosis is also increased but the innermost extracellular matrix layer is simultaneously loosened. Ultimately, the pathological changes in the valve cause massive calcifica-tion and bone formation - the main reasons for the loss of valvular function and the subsequent myo-cardial pathology. Conclusion: Calcification may be irreversible, and no drug treatments have been found to be effec-tive, thus it is imperative to emphasize lifestyle prevention of the disease. Here we review the mecha-nisms underpinning the early stages of the disease.
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Affiliation(s)
- Pauli Ohukainen
- Computational Medicine, Faculty of Medicine, University of Oulu and Biocenter Oulu, Oulu, Finland
| | - Heikki Ruskoaho
- Drug Research Program, Division of Pharmacology and Pharmacotherapy, University of Helsinki, Helsinki, Finland
| | - Jaana Rysa
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, 70211 Kuopio, Finland
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15
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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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16
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17
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Behairy NH, Saraya S, Kharabish A, El Kaffas S, Ramadan A. Congenital biscuspid aortic valve in pediatric and early adults: Does valvular phenotype affect other parameters? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2017.07.002] [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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18
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Hillebrand M, Koschyk D, Ter Hark P, Schüler H, Rybczynski M, Berger J, Gulati A, Bernhardt AM, Detter C, Girdauskas E, Blankenberg S, von Kodolitsch Y. Diagnostic accuracy study of routine echocardiography for bicuspid aortic valve: a retrospective study and meta-analysis. Cardiovasc Diagn Ther 2017; 7:367-379. [PMID: 28890873 DOI: 10.21037/cdt.2017.05.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is the standard procedure to distinguish tricuspid aortic valve (TAV) from bicuspid aortic valve (BAV). Published studies assessed the accuracy of TTE for BAV under ideal conditions. Conversely, we aimed at assessing accuracy of TTE for BAV under routine conditions. METHODS This retrospective, cross-sectional study of 216 adults included 132 men aged 62±14 years. Of these, 108 had BAV and 108 were age-matched individuals with TAV. All diagnoses were confirmed at surgery. We assessed TTE in two patient groups. First, in the (I) group of all 216 individuals, where we assessed accuracy for BAV according to the original diagnoses as documented by the primary investigators during original TTE examination. Second, we assessed accuracy for BAV according to expert re-evaluation in (II) all 158 TTE with availability of original recordings. Third, we performed a meta-analysis of published results on the accuracy of TTE for BAV according to PRISMA standards. RESULTS Sensitivity, specificity and accuracy of (I) primary investigators was 46.3%, 97.2, and 71.8% as compared to (II) expert re-evaluation with 59.7%, 93%, and 77.8%, respectively. Sensitivity was significantly higher at re-evaluation (P<0.001). TTE at a non-tertiary care center (P=0.012), presence of aortic aneurysm (P=0.001) and presence of severe aortic valve calcification (P=0.003) predicted an inaccurate diagnosis of BAV. Conversely, meta-analysis of published TTE studies identified a pooled sensitivity of 87.7% and a pooled specificity of 88.3% for BAV. CONCLUSIONS The current study shows that TTE yields almost ideal diagnostic accuracy when ideal investigators examine ideal patients. However, the study also shows that TTE yields suboptimal diagnostic accuracy under routine conditions. TTE in non-tertiary care settings, concomitant aortic aneurysm, and presence of severe aortic valve calcification predict an inaccurate diagnosis of BAV.
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Affiliation(s)
- Mathias Hillebrand
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Dietmar Koschyk
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Pia Ter Hark
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Helke Schüler
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Meike Rybczynski
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Jürgen Berger
- Department of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Amit Gulati
- Department of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Alexander M Bernhardt
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Christian Detter
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Yskert von Kodolitsch
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
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19
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Norton E, Yang B. Managing Thoracic Aortic Aneurysm in Patients with Bicuspid Aortic Valve Based on Aortic Root-Involvement. Front Physiol 2017; 8:397. [PMID: 28659818 PMCID: PMC5469203 DOI: 10.3389/fphys.2017.00397] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/26/2017] [Indexed: 02/05/2023] Open
Abstract
Bicuspid aortic valve (BAV) can be both sporadic and hereditary, is phenotypically variable, and genetically heterogeneous. The clinical presentation of BAV is diverse and commonly associated with a high prevalence of valvular dysfunction producing altered hemodynamics and aortic abnormalities (e.g., aneurysm and dissection). The thoracic aortic aneurysm (TAA) in BAV frequently involves the proximal aorta, including the aortic root, ascending aorta, and aortic arch, but spares the aorta distal to the aortic arch. While the ascending aortic aneurysm might be affected by both aortopathy and hemodynamics, the aortic root aneurysm is considered to be more of a consequence of aortopathy rather than hemodynamics, especially in younger patients. The management of aortic aneurysm in BAV has been very controversial because the molecular mechanism is unknown. Increasing evidence points toward the BAV root phenotype [aortic root dilation with aortic insufficiency (AI)] as having a higher risk of catastrophic aortic complications. We propose more aggressive surgical approaches toward the BAV with root phenotype.
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Affiliation(s)
- Elizabeth Norton
- Department of Internal Medicine, Michigan MedicineAnn Arbor, MI, United States
| | - Bo Yang
- Department of Cardiac Surgery, Michigan MedicineAnn Arbor, MI, United States
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20
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Pawade TA, Newby DE, Dweck MR. Calcification in Aortic Stenosis. J Am Coll Cardiol 2015; 66:561-77. [DOI: 10.1016/j.jacc.2015.05.066] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 01/08/2023]
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Abstract
Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, University of Washington, Seattle 98109, USA.
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22
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Weiss RM, Miller JD, Heistad DD. Fibrocalcific aortic valve disease: opportunity to understand disease mechanisms using mouse models. Circ Res 2013; 113:209-22. [PMID: 23833295 DOI: 10.1161/circresaha.113.300153] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Studies in vitro and in vivo continue to identify complex-regulated mechanisms leading to overt fibrocalcific aortic valve disease (FCAVD). Assessment of the functional impact of those processes requires careful studies of models of FCAVD in vivo. Although the genetic basis for FCAVD is unknown for most patients with FCAVD, several disease-associated genes have been identified in humans and mice. Some gene products which regulate valve development in utero also protect against fibrocalcific disease during postnatal aging. Valve calcification can occur via processes that resemble bone formation. But valve calcification can also occur by nonosteogenic mechanisms, such as formation of calcific apoptotic nodules. Anticalcific interventions might preferentially target either osteogenic or nonosteogenic calcification. Although FCAVD and atherosclerosis share several risk factors and mechanisms, there are fundamental differences between arteries and the aortic valve, with respect to disease mechanisms and responses to therapeutic interventions. Both innate and acquired immunity are likely to contribute to FCAVD. Angiogenesis is a feature of inflammation, but may also contribute independently to progression of FCAVD, possibly by actions of pericytes that are associated with new blood vessels. Several therapeutic interventions seem to be effective in attenuating the development of FCAVD in mice. Therapies which are effective early in the course of FCAVD, however, are not necessarily effective in established disease.
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Affiliation(s)
- Robert M Weiss
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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23
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Clair M, Fernandes SM, Khairy P, Graham DA, Krieger EV, Opotowsky AR, Singh MN, Colan SD, Meijboom EJ, Landzberg MJ. Aortic valve dysfunction and aortic dilation in adults with coarctation of the aorta. CONGENIT HEART DIS 2013; 9:235-43. [PMID: 23764014 DOI: 10.1111/chd.12109] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the prevalence of aortic valve dysfunction, aortic dilation, and aortic valve and ascending aortic intervention in adults with coarctation of the aorta (CoA). BACKGROUND Aortic valve dysfunction and aortic dilation are rare among children and adolescents with CoA. With longer follow-up, adults may be more likely to have progressive disease. METHODS We retrospectively reviewed all adults with CoA, repaired or unrepaired, seen at our center between 2004 and 2010. RESULTS Two hundred sixteen adults (56.0% male) with CoA were identified. Median age at last evaluation was 28.3 (range 18.0 to 75.3) years. Bicuspid aortic valve (BAV) was present in 65.7%. At last follow-up, 3.2% had moderate or severe aortic stenosis, and 3.7% had moderate or severe aortic regurgitation. Dilation of the aortic root or ascending aorta was present in 28.0% and 41.6% of patients, respectively. Moderate or severe aortic root or ascending aortic dilation (z-score > 4) was present in 8.2% and 13.7%, respectively. Patients with BAV were more likely to have moderate or severe ascending aortic dilation compared with those without BAV (19.5% vs. 0%; P < 0.001). Age was associated with ascending aortic dilation (P = 0.04). At most recent follow-up, 5.6% had undergone aortic valve intervention, and 3.2% had aortic root or ascending aortic replacement. CONCLUSION In adults with CoA, significant aortic valve dysfunction and interventions during early adulthood were uncommon. However, aortic dilation was prevalent, especially of the ascending aorta, in patients with BAV.
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Affiliation(s)
- Mathieu Clair
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA
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Sun L, Chandra S, Sucosky P. Ex vivo evidence for the contribution of hemodynamic shear stress abnormalities to the early pathogenesis of calcific bicuspid aortic valve disease. PLoS One 2012; 7:e48843. [PMID: 23119099 PMCID: PMC3485349 DOI: 10.1371/journal.pone.0048843] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 10/01/2012] [Indexed: 12/22/2022] Open
Abstract
The bicuspid aortic valve (BAV) is the most common congenital cardiac anomaly and is frequently associated with calcific aortic valve disease (CAVD). The most prevalent type-I morphology, which results from left-/right-coronary cusp fusion, generates different hemodynamics than a tricuspid aortic valve (TAV). While valvular calcification has been linked to genetic and atherogenic predispositions, hemodynamic abnormalities are increasingly pointed as potential pathogenic contributors. In particular, the wall shear stress (WSS) produced by blood flow on the leaflets regulates homeostasis in the TAV. In contrast, WSS alterations cause valve dysfunction and disease. While such observations support the existence of synergies between valvular hemodynamics and biology, the role played by BAV WSS in valvular calcification remains unknown. The objective of this study was to isolate the acute effects of native BAV WSS abnormalities on CAVD pathogenesis. Porcine aortic valve leaflets were subjected ex vivo to the native WSS experienced by TAV and type-I BAV leaflets for 48 hours. Immunostaining, immunoblotting and zymography were performed to characterize endothelial activation, pro-inflammatory paracrine signaling, extracellular matrix remodeling and markers involved in valvular interstitial cell activation and osteogenesis. While TAV and non-coronary BAV leaflet WSS essentially maintained valvular homeostasis, fused BAV leaflet WSS promoted fibrosa endothelial activation, paracrine signaling (2.4-fold and 3.7-fold increase in BMP-4 and TGF-β1, respectively, relative to fresh controls), catabolic enzyme secretion (6.3-fold, 16.8-fold, 11.7-fold, 16.7-fold and 5.5-fold increase in MMP-2, MMP-9, cathepsin L, cathepsin S and TIMP-2, respectively) and activity (1.7-fold and 2.4-fold increase in MMP-2 and MMP-9 activity, respectively), and bone matrix synthesis (5-fold increase in osteocalcin). In contrast, BAV WSS did not significantly affect α-SMA and Runx2 expressions and TIMP/MMP ratio. This study demonstrates the key role played by BAV hemodynamic abnormalities in CAVD pathogenesis and suggests the dependence of BAV vulnerability to calcification on the local degree of WSS abnormality.
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Affiliation(s)
- Ling Sun
- Department of Aerospace and Mechanical Engineering, University of Notre Dame, Notre Dame, Indiana, United States of America
- Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Santanu Chandra
- Department of Aerospace and Mechanical Engineering, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Philippe Sucosky
- Department of Aerospace and Mechanical Engineering, University of Notre Dame, Notre Dame, Indiana, United States of America
- Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
- * E-mail:
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Calcific aortic stenosis: a disease of the valve and the myocardium. J Am Coll Cardiol 2012; 60:1854-63. [PMID: 23062541 DOI: 10.1016/j.jacc.2012.02.093] [Citation(s) in RCA: 436] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 01/31/2012] [Accepted: 02/14/2012] [Indexed: 02/07/2023]
Abstract
Although aortic stenosis is a common condition associated with major morbidity, mortality, and health economic costs, there are currently no medical interventions capable of delaying or halting its progression. Re-evaluation of the underlying pathophysiology is therefore required so that novel therapeutic strategies can be developed. Aortic stenosis is characterized by progressive aortic valve narrowing and secondary left ventricular hypertrophy. Both processes are important because in combination they drive the development of symptoms and adverse events that characterize the latter stages of the disease. In this review, the authors examine the pathophysiology of aortic stenosis with respect to both the valve and the myocardium. In particular, the authors focus on the role of inflammation, fibrosis, and calcification in progressive valve narrowing and then examine the development of left ventricular hypertrophy, its subsequent decompensation, and the transition to heart failure. Finally the authors discuss potential therapeutic strategies on the basis of similarities aortic stenosis shares with other pathological conditions.
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Bodegard J, Skretteberg PT, Gjesdal K, Pyörälä K, Kjeldsen SE, Liestøl K, Erikssen G, Erikssen J. Low-grade systolic murmurs in healthy middle-aged individuals: innocent or clinically significant? A 35-year follow-up study of 2014 Norwegian men. J Intern Med 2012; 271:581-8. [PMID: 22061296 DOI: 10.1111/j.1365-2796.2011.02480.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether a low-grade systolic murmur, found at heart auscultation, in middle-aged healthy men influences the long-term risk of aortic valve replacement (AVR) and death from cardiovascular disease (CVD). Setting and subjects. During 1972-1975, 2014 apparently healthy men aged 40-59 years underwent an examination programme including case history, clinical examination, blood tests and a symptom-limited exercise ECG test. Heart auscultation was performed under standardized conditions, and murmurs were graded on a scale from I to VI. No men were found to have grade V/VI murmurs. Participants were followed for up to 35 years. RESULTS A total of 1541 men had no systolic murmur; 441 had low-grade murmurs (grade I/II) and 32 had moderate-grade murmurs (grade III/IV). Men with low-grade murmurs had a 4.7-fold [95% confidence interval (CI) 2.1-11.1] increased age-adjusted risk of AVR, but no increase in risk of CVD death. Men with moderate-grade murmurs had an 89.3-fold (95% CI 39.2-211.2) age-adjusted risk of AVR and a 1.5-fold (95% CI 0.8-2.5) age-adjusted increased risk of CVD death. CONCLUSIONS Low-grade systolic murmur was detected at heart auscultation in 21.9% of apparently healthy middle-aged men. Men with low-grade murmur had an increased risk of AVR, but no increase in risk of CVD death. Only 1.6% of men had moderate-grade murmur; these men had a very high risk of AVR and a 1.5-fold albeit non-significant increase in risk of CVD death.
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Affiliation(s)
- J Bodegard
- Department of Cardiology, Oslo University Hospital, Ullevaal Faculty of Medicine, University of Oslo, Oslo, Norway.
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Baber U, Kini AS, Moreno PR, Sharma SK. Calcific Aortic Stenosis: Pathology and Role of Balloon Aortic Valvuloplasty. Interv Cardiol Clin 2012; 1:1-9. [PMID: 28582059 DOI: 10.1016/j.iccl.2011.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Calcific aortic stenosis (AS) is a common expression of aortic valve disease and increases in prevalence with advancing age. Recent studies have shown that calcific deposition in aortic valve leaflets is an actively regulated process with many pathophysiologic similarities to atherosclerosis. Surgical valve replacement is the definitive treatment of calcific AS, but many patients do not undergo surgery because of prohibitive comorbidities or other high-risk features. Balloon aortic valvuloplasty remains an option for temporary palliation and symptomatic relief, and continues to serve as a bridge to aortic valve replacement in certain patients with AS requiring temporary hemodynamic stabilization.
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Affiliation(s)
- Usman Baber
- Cardiac Catheterization Laboratory, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Annapoorna S Kini
- Cardiac Catheterization Laboratory, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Pedro R Moreno
- Cardiac Catheterization Laboratory, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Samin K Sharma
- Cardiac Catheterization Laboratory, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA.
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Mahler GJ, Butcher JT. Inflammatory regulation of valvular remodeling: the good(?), the bad, and the ugly. Int J Inflam 2011; 2011:721419. [PMID: 21792386 PMCID: PMC3139860 DOI: 10.4061/2011/721419] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 06/16/2011] [Accepted: 06/20/2011] [Indexed: 01/30/2023] Open
Abstract
Heart valve disease is unique in that it affects both the very young and very old, and does not discriminate by financial affluence, social stratus, or global location. Research over the past decade has transformed our understanding of heart valve cell biology, yet still more remains unclear regarding how these cells respond and adapt to their local microenvironment. Recent studies have identified inflammatory signaling at nearly every point in the life cycle of heart valves, yet its role at each stage is unclear. While the vast majority of evidence points to inflammation as mediating pathological valve remodeling and eventual destruction, some studies suggest inflammation may provide key signals guiding transient adaptive remodeling. Though the mechanisms are far from clear, inflammatory signaling may be a previously unrecognized ally in the quest for controlled rapid tissue remodeling, a key requirement for regenerative medicine approaches for heart valve disease. This paper summarizes the current state of knowledge regarding inflammatory mediation of heart valve remodeling and suggests key questions moving forward.
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Affiliation(s)
| | - Jonathan T. Butcher
- Department of Biomedical Engineering, Cornell University, 304 Weill Hall, Ithaca, NY 14853, USA
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Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol 2010; 55:2789-800. [PMID: 20579534 DOI: 10.1016/j.jacc.2009.12.068] [Citation(s) in RCA: 629] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 11/06/2009] [Accepted: 12/17/2009] [Indexed: 12/13/2022]
Abstract
Bicuspid aortic valve (BAV) disease is the most common congenital cardiac defect. While the BAV can be found in isolation, it is often associated with other congenital cardiac lesions. The most frequent associated finding is dilation of the proximal ascending aorta secondary to abnormalities of the aortic media. Changes in the aortic media are present independent of whether the valve is functionally normal, stenotic, or incompetent. Although symptoms often manifest in adulthood, there is a wide spectrum of presentations ranging from severe disease detected in utero to asymptomatic disease in old age. Complications can include aortic valve stenosis or incompetence, endocarditis, aortic aneurysm formation, and aortic dissection. Despite the potential complications, 2 large contemporary series have demonstrated that life expectancy in adults with BAV disease is not shortened when compared with the general population. Because BAV is a disease of both the valve and the aorta, surgical decision making is more complicated, and many undergoing aortic valve replacement will also need aortic root surgery. With or without surgery, patients with BAV require continued surveillance. Recent studies have improved our understanding of the genetics, the pathobiology, and the clinical course of the disease, but questions are still unanswered. In the future, medical treatment strategies and timing of interventions will likely be refined. This review summarizes our current understanding of the pathology, genetics, and clinical aspects of BAV disease with a focus on BAV disease in adulthood.
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Affiliation(s)
- Samuel C Siu
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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Michelena HI, Desjardins VA, Avierinos JF, Russo A, Nkomo VT, Sundt TM, Pellikka PA, Tajik AJ, Enriquez-Sarano M. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation 2008; 117:2776-84. [PMID: 18506017 DOI: 10.1161/circulationaha.107.740878] [Citation(s) in RCA: 391] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bicuspid aortic valve is frequent and is reported to cause numerous complications, but the clinical outcome of patients diagnosed with normal or mildly dysfunctional valve is undefined. METHODS AND RESULTS In 212 asymptomatic community residents from Olmsted County, Minn (age, 32+/-20 years; 65% male), bicuspid aortic valve was diagnosed between 1980 and 1999 with ejection fraction > or =50% and aortic regurgitation or stenosis, absent or mild. Aortic valve degeneration at diagnosis was scored echocardiographically for calcification, thickening, and mobility reduction (0 to 3 each), with scores ranging from 0 to 9. At diagnosis, ejection fraction was 63+/-5% and left ventricular diameter was 48+/-9 mm. Survival 20 years after diagnosis was 90+/-3%, identical to the general population (P=0.72). Twenty years after diagnosis, heart failure, new cardiac symptoms, and cardiovascular medical events occurred in 7+/-2%, 26+/-4%, and 33+/-5%, respectively. Twenty years after diagnosis, aortic valve surgery, ascending aortic surgery, or any cardiovascular surgery was required in 24+/-4%, 5+/-2%, and 27+/-4% at a younger age than the general population (P<0.0001). No aortic dissection occurred. Thus, cardiovascular medical or surgical events occurred in 42+/-5% 20 years after diagnosis. Independent predictors of cardiovascular events were age > or =50 years (risk ratio, 3.0; 95% confidence interval, 1.5 to 5.7; P<0.01) and valve degeneration at diagnosis (risk ratio, 2.4; 95% confidence interval, 1.2 to 4.5; P=0.016; >70% events at 20 years). Baseline ascending aorta > or =40 mm independently predicted surgery for aorta dilatation (risk ratio, 10.8; 95% confidence interval, 1.8 to 77.3; P<0.01). CONCLUSIONS In the community, asymptomatic patients with bicuspid aortic valve and no or minimal hemodynamic abnormality enjoy excellent long-term survival but incur frequent cardiovascular events, particularly with progressive valve dysfunction. Echocardiographic valve degeneration at diagnosis separates higher-risk patients who require regular assessment from lower-risk patients who require only episodic follow-up.
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Affiliation(s)
- Hector I Michelena
- Divisions of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Vallely MP, Semsarian C, Bannon PG. Management of the ascending aorta in patients with bicuspid aortic valve disease. Heart Lung Circ 2008; 17:357-63. [PMID: 18514024 DOI: 10.1016/j.hlc.2008.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 12/05/2007] [Accepted: 01/23/2008] [Indexed: 01/11/2023]
Abstract
Bicuspid aortic valve (BAV) disease is the most common form of congenital heart disease, affecting 1-2% of the population. Only 20% of patients will maintain normal valve function throughout their life and more than 30% of patients will develop serious morbidity. It is a highly heritable condition, with transmission likely to be autosomal dominant. Patients with BAV have a 10-fold risk of aortic dissection when compared to the normal population. Management of BAV associated aortopathy represents a significant clinical challenge.
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Fazel SS, Mallidi HR, Lee RS, Sheehan MP, Liang D, Fleischman D, Herfkens R, Mitchell RS, Miller DC. The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. J Thorac Cardiovasc Surg 2008; 135:901-7, 907.e1-2. [DOI: 10.1016/j.jtcvs.2008.01.022] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 12/22/2007] [Accepted: 01/23/2008] [Indexed: 01/15/2023]
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Yap SC, Kouwenhoven GC, Takkenberg JJM, Galema TW, Meijboom FJ, van Domburg R, Simoons ML, Roos-Hesselink JW. Congenital aortic stenosis in adults: Rate of progression and predictors of clinical outcome. Int J Cardiol 2007; 122:224-31. [PMID: 17291609 DOI: 10.1016/j.ijcard.2006.11.092] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Revised: 11/02/2006] [Accepted: 11/09/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little data are available on the natural history of young adults with congenital valvular aortic stenosis (AS). The aim of the present study was to determine the progression rate of AS in young adults, and to identify predictors of stenosis progression and outcome. METHODS Retrospective study of all patients seen at a single centre diagnosed with congenital AS (> or = 2.5 m/s) between 1992 and 2005, excluding patients with severe aortic regurgitation. The slope of the regression of the aortic jet velocity on the time elapsed since the baseline study was used to define the rate of progression of stenosis. RESULTS A total of 84 adults (mean age, 23.5+/-7.9 years) were studied who had at least two echocardiograms > 1 year (5.6+/-2.6 years) apart. The annual progression of aortic jet velocity was 0.09+/-0.15 m/s per year. Multivariable linear regression analysis identified older age (p<0.001) as an independent predictor of faster haemodynamic progression. During the follow-up period of 7.7+/-2.7 years, no patient died and 35 patients (42%) underwent aortic valve intervention. By multivariable Cox regression analysis, severe AS (> or = 4.0 m/s) and rapid progression of aortic jet velocity (> or = 0.2 m/s/year) were independent predictors of intervention. Cumulative intervention-free survival for patients with severe AS was 78+/-8% at 3 years and 48+/-10% at 5 years versus respectively 98+/-2% and 96+/-3% for patients with mild-to-moderate AS (log-rank: p<0.001). CONCLUSIONS Progression of congenital AS was relatively low in young adults compared to elderly with degenerative AS. Older age was associated with more rapid progression.
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Affiliation(s)
- Sing-Chien Yap
- Department of Cardiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, The Netherlands.
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Makkar A, Siddiqui TS, Stoddard MF, Lewis RK, Dawn B. Impact of Valvular Calcification on the Diagnostic Accuracy of Transesophageal Echocardiography for the Detection of Congenital Aortic Valve Malformation. Echocardiography 2007; 24:745-9. [PMID: 17651104 DOI: 10.1111/j.1540-8175.2007.00459.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Degeneration of congenital bicuspid or unicuspid aortic valves can progress more rapidly than that of tricuspid valves, and an early diagnosis significantly impacts decision making and outcome. We hypothesized that the extent of valvular calcification would negatively influence the diagnostic accuracy of multiplane transesophageal echocardiography (TEE) for the diagnosis of congenital aortic valve disease. METHODS TEE was performed in 57 patients undergoing aortic valve replacement surgery for aortic stenosis (n = 46), pure regurgitation (n = 9), or significant regurgitation with less than severe aortic stenosis (n = 2). The degree of aortic valve calcification and the number of valve cusps were determined at surgery. RESULTS Surgical inspection confirmed 14 bicuspid and 43 tricuspid aortic valves. Sensitivity and specificity of TEE for the diagnosis of congenital aortic valve malformation was 93% (13/14) and 91% (39/43) (P = 0.0001), respectively. In patients with no or mild aortic valve calcification (n = 13), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 100% (5/5) and 100% (8/8) (P = 0.001), respectively. In patients with moderate or marked aortic valve calcification (n = 44), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 89% (8/9) and 89% (31/35) (P<0.0001), respectively. In this subgroup of 44 patients, there were four false-positive and one false-negative diagnoses due to valvular calcification. CONCLUSIONS Although TEE is highly sensitive and specific for the detection of congenital aortic valve malformations, presence of moderate or marked calcification of the aortic valve may result in false positive and false negative diagnoses.
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Affiliation(s)
- Akash Makkar
- Division of Cardiology, Department of Medicine, University of Louisville, Louisville, KY 40292, USA
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Ahmed S, Honos GN, Walling AD, Michel CM, Sebag IA, Rudski LG, Therrien J. Clinical outcome and echocardiographic predictors of aortic valve replacement in patients with bicuspid aortic valve. J Am Soc Echocardiogr 2007; 20:998-1003. [PMID: 17555932 DOI: 10.1016/j.echo.2007.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical outcomes and echocardiographic parameters associated with aortic valve replacement (AVR) for bicuspid aortic valve are scarce. METHODS We conducted retrospective analysis of 208 adults with bicuspid aortic valve referred for transthoracic echocardiograms. RESULTS The Kaplan-Meier survival free of death or need for cardiac surgery was 72% at 5 years. Cardiac surgery was performed in 19%, the majority (68%) for symptomatic aortic stenosis. Peak gradient 80 mm Hg or greater (hazard ratio 11.8, 95% confidence interval 3.7-37.8, P < .0001) and aortic valve area less than or equal to 0.75 cm(2) (hazard ratio 2.9, 95% confidence interval 1.0-8.5, P = .05) predicted the need for AVR. Patients with a large (54%) versus normal left ventricular outflow tract dimension underwent AVR for symptomatic aortic stenosis at a larger calculated aortic valve area (1.07 +/- 0.21 vs 0.75 +/- 0.18 cm(2), P < .0001) but at a similar peak gradient and velocity ratio (76 +/- 19 vs 76 +/- 22 mm Hg, P = not significant; 0.23 +/- 0.06 vs 0.26 +/- 0.12, P = not significant, respectively). CONCLUSIONS Clinical events are common among patients with bicuspid aortic valve. Peak gradient 80 mm Hg or more and aortic valve area less than or equal to 0.75 cm(2) predicts the need for AVR. Gradients and velocity ratio better reflect the hemodynamic burden of aortic stenosis in patients with a large left ventricular outflow tract.
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Affiliation(s)
- Shaheeda Ahmed
- Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Ciotti GR, Vlahos AP, Silverman NH. Morphology and function of the bicuspid aortic valve with and without coarctation of the aorta in the young. Am J Cardiol 2006; 98:1096-102. [PMID: 17027579 DOI: 10.1016/j.amjcard.2006.05.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Revised: 05/11/2006] [Accepted: 05/11/2006] [Indexed: 10/24/2022]
Abstract
This study sought to determine the morphology and function of bicuspid aortic valves (BAVs) with and without coarctation of the aorta (CoA) in a young population. The transthoracic echocardiograms of 117 patients with BAVs and 62 patients with CoA were retrospectively reviewed and compared with normal transthoracic echocardiographic results. In each patient, the area subtended by the aortic cusps and valve and the diameters of the aortic root at different levels were measured, and additionally in each BAV, the type of cusp fusion and the presence and degree of aortic stenosis and/or regurgitation were evaluated. The median age of patients with BAVs was 4 years (range 0 days to 34 years), and the median age of patients with CoA was 1.9 years (range 0 days to 16.5 years). BAVs with right and left coronary cusp fusion were significantly associated with CoA (p <0.0001) and cardiac anomalies (p <0.0001), whereas BAVs with noncoronary and right coronary cusp fusion were affected by valvar dysfunction (p <0.001). Compared with normal tricuspid aortic valves, BAVs had aortic root dilation, even in patients with no hemodynamic disturbance, particularly at the level of the ascending aorta (p <0.0001); the difference was still significant comparing BAVs and CoA with tricuspid aortic valves and CoA (p <0.0001). In conclusion, different morphologies of BAVs are associated with different cardiac abnormalities, valvar function, and aortic root dilation. Although detectable early in life, valvar dysfunction and aortic root dilation progress with age.
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Affiliation(s)
- Giovanna R Ciotti
- Pediatric Cardiology Department, Royal Manchester Children's Hospital, Manchester, United Kingdom.
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Zeppilli P, Bianco M, Bria S, Palmieri V. Bicuspid aortic valve: an innocent finding or a potentially life-threatening anomaly whose complications may be elicited by sports activity? J Cardiovasc Med (Hagerstown) 2006; 7:282-7. [PMID: 16645403 DOI: 10.2459/01.jcm.0000219322.04881.9e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The bicuspid aortic valve is the most frequent congenital anomaly of the heart in adults. Since the 1970s, with the advent of two-dimensional echocardiography, the in-vivo diagnosis of bicuspid aortic valve has become easier and greater attention has been paid to this anomaly in normal young people, particularly in sportsmen because, from a theoretical point of view, physical exercise may stress the abnormal aortic valve, favouring an early deterioration of the valve itself, as well as a dilation of the ascending aorta. Although the bicuspid aortic valve may remain without clinical consequences for a lifetime, it may be responsible for severe complications such as aortic stenosis, aortic insufficiency, endocarditis and aortic dilation/dissection, sometimes requiring surgery. Moreover, the bicuspid aortic valve may be associated with other cardiovascular anomalies, mainly aortic coarctation. At present there are no prospective studies dealing with effect of physical training and competitive sports on the natural course of the bicuspid aortic valve. However, in order to take any decision about sports eligibility, sports physicians should perform an initial accurate staging of the bicuspid aortic valve, taking into account haemodynamic factors, aortic complications and associated significant cardiovascular anomalies. A strict follow-up, with serial cardiological controls, is mandatory as well as antibiotic prophylaxis for endocarditis, particularly in subjects engaged in contact sports.
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Affiliation(s)
- Paolo Zeppilli
- Centro Studi di Medicina dello Sport--Università Cattolica del Sacro Cuore, Rome, Italy.
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Schäfers HJ. Reconstruction of bicuspid aortic valves. Surgical tool or toy? ZEITSCHRIFT FUR KARDIOLOGIE 2005; 94:431-3. [PMID: 15997342 DOI: 10.1007/s00392-005-0242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 01/21/2005] [Indexed: 05/03/2023]
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Wash 98195-6422, USA.
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Alegret JM, Vernis JM, Palazón O, Borràs X, Duran I. Factors related to aortic regurgitation in the presence of a dilated aortic root. Am J Cardiol 2005; 95:417-20. [PMID: 15670560 DOI: 10.1016/j.amjcard.2004.09.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Revised: 09/27/2004] [Accepted: 09/24/2004] [Indexed: 11/20/2022]
Abstract
The relation among aortic regurgitation (AR) and aortic root diameter, anthropometric variables, and aortic valve morphology was assessed in 142 patients with dilated aortic roots. The diameter of the aortic root indexed for body surface area and aortic valve sclerosis were related to the presence and severity of AR.
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Affiliation(s)
- Josep M Alegret
- Secció de Cardiologia, Department de Medicina Interna, Hospital Universitari de Sant Joan, Universitat Rovira i Virgili, Reus, Spain.
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Fernandes SM, Sanders SP, Khairy P, Jenkins KJ, Gauvreau K, Lang P, Simonds H, Colan SD. Morphology of bicuspid aortic valve in children and adolescents. J Am Coll Cardiol 2004; 44:1648-51. [PMID: 15489098 DOI: 10.1016/j.jacc.2004.05.063] [Citation(s) in RCA: 158] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Revised: 04/16/2004] [Accepted: 05/18/2004] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The aim of this study was to determine the relationship between aortic valve morphology and valve dysfunction. BACKGROUND The morphology of the bicuspid or bicommissural aortic valve (BAV) may predict the severity of valve dysfunction. Therefore, we assessed the relationship between BAV, aortic coarctation, and the degree of valve pathology in children. METHODS A retrospective review of 1,135 patients with BAV who were identified between 1986 and 1999 was performed. Patients younger than 18 years of age with BAV that was identifiable via echocardiography were included. The most recent or last study of each patient before intervention or endocarditis was reviewed. Mild stenosis was defined as a valve gradient > or =2 m/s, moderate or greater aortic stenosis as > or =3.5 m/s. Aortic regurgitation was quantified using standard criteria. RESULTS Median age was 3 years (range, 1 day to 17.9 years), and 67% of the patients were male. Right-coronary and left-coronary leaflet fusion were the most common types of BAV (70%). Aortic stenosis that was moderate or greater was observed most often in patients with right-coronary and non-coronary leaflet fusion (odds ratio 2.4, 95% confidence interval 1.6 to 3.6; p < or = 0.001). Similarly, right-coronary and non-coronary leaflet fusion was more often associated with moderate aortic regurgitation or greater (odds ratio 2.4, 95% confidence interval 1.2 to 4.7; p = 0.01). The majority of patients with aortic coarctation had fusion of the right-coronary and left-coronary leaflets (89%), and aortic coarctation was associated with lesser degrees of valve stenosis or regurgitation. CONCLUSIONS Analysis of BAV morphology is of clinical and prognostic relevance. Fusion of the right-coronary and non-coronary leaflets was associated with more significant valve pathology, whereas fusion of the right-coronary and left-coronary leaflets was associated overwhelmingly with aortic coarctation and less aortic valve pathology.
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Affiliation(s)
- Susan M Fernandes
- Department of Cardiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Lewin MB, McBride KL, Pignatelli R, Fernbach S, Combes A, Menesses A, Lam W, Bezold LI, Kaplan N, Towbin JA, Belmont JW. Echocardiographic evaluation of asymptomatic parental and sibling cardiovascular anomalies associated with congenital left ventricular outflow tract lesions. Pediatrics 2004; 114:691-6. [PMID: 15342840 PMCID: PMC1361301 DOI: 10.1542/peds.2003-0782-l] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Left ventricular outflow tract obstructive (LVOTO) malformations are a leading cause of infant mortality from birth defects. Genetic mechanisms are likely, and there may be a higher rate of asymptomatic LVOTO anomalies in relatives of affected children. This study sought to define the incidence of cardiac anomalies in first-degree relatives of children with congenital aortic valve stenosis (AVS), coarctation of the aorta (CoA), and hypoplastic left heart syndrome (HLHS). METHODS A total of 113 probands with a nonsyndromic LVOTO malformation of AVS (n = 25), BAV (n = 3), CoA (n = 52), HLHS (n = 30), and aortic hypoplasia with mitral valve atresia (n = 2) were ascertained through chart review or enrolled at the time of diagnosis. Echocardiography was performed on 282 asymptomatic first-degree relatives. RESULTS Four studies had poor acoustic windows, leaving 278 studies for analysis. BAV were found in 13 (4.68%) first-degree relatives. The relative risk of BAV in the relatives was 5.05 (95% confidence interval: 2.2-11.7), and the broad sense heritability was 0.49, based on a general population frequency of 0.9%. BAV was more common in multiplex families compared with sporadic cases. An additional 32 relatives had anomalies of the aorta, aortic valve, left ventricle, or mitral valve. CONCLUSIONS The presence of an LVOTO lesion greatly increases the risk of identifying BAV in a parent or sibling, providing additional support for a complex genetic cause. The parents and siblings of affected patients should be screened by echocardiography as the presence of an asymptomatic BAV may carry a significant long-term health risk.
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Affiliation(s)
- Mark B Lewin
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
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Ferencik M, Pape LA. Changes in size of ascending aorta and aortic valve function with time in patients with congenitally bicuspid aortic valves. Am J Cardiol 2003; 92:43-6. [PMID: 12842243 DOI: 10.1016/s0002-9149(03)00462-4] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Bicuspid aortic valve (BAV) is associated with premature valve dysfunction and abnormalities of the ascending aorta. Limited data exist regarding serial changes of aortic dilation in patients with BAV. We studied paired transthoracic echocardiograms of 68 patients with BAV (mean age 44 years) and with at least 2 examinations >12 months apart (mean follow-up 47 months) to characterize the progression of aortic dilation and the natural history of valve function. We measured aortic root and ascending aortic diameters at baseline and follow-up. We measured aortic gradients and severity of aortic regurgitation (AR). During follow-up, aortic diameters increased at the sinuses of Valsalva by 1.9 mm (95% confidence interval [CI] 1.3 to 2.5), at the sinotubular junction by 1.6 mm (95% CI 0.8 to 2.3), and at the proximal ascending aorta by 2.7 mm (95% CI 1.9 to 3.6). Mean rate of diameter progression was 0.5 mm/year at the sinuses of Valsalva (95% CI 0.3 to 0.7), 0.5 mm/year at the sinotubular junction (95% CI 0.3 to 0.7), and 0.9 mm/year at the proximal ascending aorta (95% CI 0.6 to 1.2). Progression was observed regardless of hemodynamic function at baseline. Mean aortic valve gradient increased significantly from baseline to follow-up (17.6 mm Hg vs 25.7 mm Hg, p <0.001). The degree of AR increased during follow-up in 17 patients (25%). In addition, progression of aortic diameter dilation occurred irrespective of baseline valve function in adult patients with BAV. We also observed considerable progression of aortic gradients and AR over time.
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Affiliation(s)
- Maros Ferencik
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
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Fedak PWM, Verma S, David TE, Leask RL, Weisel RD, Butany J. Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation 2002; 106:900-4. [PMID: 12186790 DOI: 10.1161/01.cir.0000027905.26586.e8] [Citation(s) in RCA: 509] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Paul W M Fedak
- Division of Cardiac Surgery, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
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Paladini D, Russo MG, Vassallo M, Tartaglione A, Pacileo G, Martinelli P, Calabrò R. Ultrasound evaluation of aortic valve anatomy in the fetus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:30-34. [PMID: 12100414 DOI: 10.1046/j.1469-0705.2002.00723.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To assess the feasibility of ultrasound identification of aortic valve anatomy in the fetus, with particular emphasis on the detection of bicuspid aortic valve. METHODS This study was a prospective analysis of 21 fetuses with prenatally diagnosed congenital left heart obstructive lesions and 45 normal fetuses undergoing routine ultrasound evaluated at a tertiary referral center. These fetuses underwent detailed echocardiography, including the study of the aortic valve on a targeted short-axis view of the right ventricle. Necropsies or postnatal echocardiograms were available for confirmation of the diagnosis in all cases. RESULTS Aortic cusps and commissures were satisfactorily visualized in 38/45 (84%) normal fetuses and in 18/21 (86%) fetuses with congenital heart disease. The aortic valve was correctly defined as bicuspid in one normal fetus and in six fetuses with congenital heart disease. In two fetuses with a positive family history, the bicuspid aortic valve was isolated. There was one incorrect diagnosis (a unicuspid unicommissural valve diagnosed prenatally as a bicuspid aortic valve in a fetus with severe aortic stenosis) and one false-positive diagnosis in a fetus diagnosed with a coarctation and a bicuspid aortic valve late in the third trimester of pregnancy and in which both anomalies were not confirmed at neonatal echocardiography. CONCLUSIONS This study demonstrated that aortic valve anatomy can be satisfactorily assessed in fetuses with and without left heart obstructive lesions. We believe that a detailed search for a bicuspid aortic valve should be attempted in all patients referred for a positive family history of congenital heart disease, in general, and of left ventricle outflow tract obstruction or bicuspid aortic valve, in particular. In fact, the presence of an asymptomatic bicuspid aortic valve has been demonstrated to represent an important factor predisposing to the development of bacterial endocarditis and dissecting aortic aneurysm late in adult life. Therefore, an early detection of such an anomaly may contribute to ensure a longer symptom-free lifespan of individuals with the most common cardiac anomaly at birth.
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Affiliation(s)
- D Paladini
- Fetal Cardiology Unit, Department of Gynecology and Obstetrics, University Fecerico II of Naples, Italy.
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Chan KL, Ghani M, Woodend K, Burwash IG. Case-controlled study to assess risk factors for aortic stenosis in congenitally bicuspid aortic valve. Am J Cardiol 2001; 88:690-3. [PMID: 11564401 DOI: 10.1016/s0002-9149(01)01820-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- K L Chan
- University of Ottawa Heart Institute, Ontario, Ottawa, Canada.
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Keane MG, Wiegers SE, Plappert T, Pochettino A, Bavaria JE, Sutton MGSJ. Bicuspid Aortic Valves Are Associated With Aortic Dilatation Out of Proportion to Coexistent Valvular Lesions. Circulation 2000. [DOI: 10.1161/circ.102.suppl_3.iii-35] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
—Bicuspid aortic valves (BAVs) are associated with premature valve stenosis, regurgitation, and ascending aortic aneurysms. We compared aortic size in BAV patients with aortic size in control patients with matched valvular lesions (aortic regurgitation, aortic stenosis, or mixed lesions) to determine whether intrinsic aortic abnormalities in BAVs account for aortic dilatation beyond that caused by valvular hemodynamic derangement alone.
Methods and Results
—Diameters of the left ventricular outflow tract, sinus of Valsalva, sinotubular junction, and proximal aorta were measured from transthoracic echocardiograms in 118 consecutive BAV patients. Annular area was measured by planimetry, and BAV eccentricity was expressed as the ratio of the right leaflet area to the total annular area. Seventy-seven control patients with tricuspid aortic valves were matched for sex and for combined severity of regurgitation and stenosis. BAV patients (79 men and 39 women, aged 44.1±15.5 years) had varying degrees of regurgitation (84 patients [71%]) and stenosis (48 patients [41%]). Within the bicuspid group, multivariate analysis demonstrated that aortic diameters increased with worsening aortic regurgitation (
P
<0.001) and advancing age (
P
<0.05) but not with the severity of aortic stenosis. BAV patients had larger aortic diameters than did control patients at all ascending aortic levels measured (
P
<0.01), despite advanced age in the control patients.
Conclusions
—Aortic dimensions are larger in BAV patients than in control patients with comparable degrees of tricuspid aortic valve disease. Although more severe degrees of aortic regurgitation are associated with aortic dilatation in BAV patients, intrinsic pathology appears to be responsible for aortic enlargement beyond that predicted by hemodynamic factors.
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Affiliation(s)
- Martin G. Keane
- From the Cardiovascular Division (M.G.K., S.E.W., T.P., M.G.S.J.S.), Department of Medicine, and the Cardiothoracic Surgery Division (A.P., J.E.B.), Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Susan E. Wiegers
- From the Cardiovascular Division (M.G.K., S.E.W., T.P., M.G.S.J.S.), Department of Medicine, and the Cardiothoracic Surgery Division (A.P., J.E.B.), Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Ted Plappert
- From the Cardiovascular Division (M.G.K., S.E.W., T.P., M.G.S.J.S.), Department of Medicine, and the Cardiothoracic Surgery Division (A.P., J.E.B.), Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Alberto Pochettino
- From the Cardiovascular Division (M.G.K., S.E.W., T.P., M.G.S.J.S.), Department of Medicine, and the Cardiothoracic Surgery Division (A.P., J.E.B.), Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Joseph E. Bavaria
- From the Cardiovascular Division (M.G.K., S.E.W., T.P., M.G.S.J.S.), Department of Medicine, and the Cardiothoracic Surgery Division (A.P., J.E.B.), Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Martin G. St. John Sutton
- From the Cardiovascular Division (M.G.K., S.E.W., T.P., M.G.S.J.S.), Department of Medicine, and the Cardiothoracic Surgery Division (A.P., J.E.B.), Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
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Affiliation(s)
- C Ward
- North West Regional Cardiac Centre, South Manchester University NHS Trust, Southmoor Road, Manchester M23 9LT, UK
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Abstract
As the incidence of valvular disease in the elderly is increasing, understanding of its pathogenesis and natural progression as well as surgical approaches and device technologies are improving. Future studies are needed to develop medical interventions that slow or halt the degenerative valvular processes associated with aging. In addition, mechanical approaches with lower operative risks should be explored and the search should continue for a valve substitute that is durable, hemodynamically efficient, easy to implant, and does not require anticoagulation. Hopefully, future intervention trials will include quality of life assessments such as symptoms, functional capacity and perceptions of well being. At present, the degenerative valvular processes must be followed closely by the clinician, and individual management decisions for the elderly based on the type and severity of valve disease, comorbid medical conditions, and the risks and benefits of intervention, along with patient preferences, rather than on the chronologic age of the patient. It is becoming clear that both survival and quality of life outcomes can improve by consideration of surgery at the onset of indications, before further deterioration eliminates the opportunity to provide benefit for the elderly patient with valvular disease.
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Affiliation(s)
- D A Hinchman
- Department of Medicine, University of Washington, Seattle, USA
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