Association between Patterns of Aortic Dilatation and Aortic Pathology in Consecutive Aortic Surgery Cases in Relation to Aortic Valve Type

Evaluation of aortic regurgitation requires consideration of valve morphology, mechanism and severity of regurgitation and assessment of aortic dilatation. In asymptomatic patients with severe aortic regurgitation, follow-up of symptomatic status and LV size and function is mandatory. The strongest indication for valve surgery is the presence of symptoms and/or the documentation of LVEF <50% and/or end-systolic diameter =50 mm. In patients with dilated aorta, definition of aortic pathology and accurate measurements of aortic diameters are crucial. Surgery is recommended whenever aortic dilation is = 55 mm or = 50 mm in patients with bicuspid aortic valves and Marfan syndrome or =45 mm when additional risk factors are present. For patients who have an indication for valve surgery, an aortic diameter of ≥45 mm is considered to indicate concomitant surgery of the aorta. Aortic valve repair and valve-sparing aortic surgery instead of aortic valve replacement should be considered in selected cases in experienced centres.

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Differences in Aortopathy in Patients with a Bicuspid Aortic Valve with or without Aortic Coarctation

Journal of Clinical Medicine ◽

10.3390/jcm9020290 ◽

2020 ◽

Vol 9 (2) ◽

pp. 290

Author(s):

Anthonie Duijnhouwer ◽

Allard van den Hoven ◽

Remy Merkx ◽

Michiel Schokking ◽

Roland van Kimmenade ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Dissection ◽

Bicuspid Aortic Valve ◽

Aortic Coarctation ◽

Care Center ◽

Aortic Surgery ◽

Tertiary Care ◽

Aortic Diameter ◽

Aortic Dilatation ◽

Significant Difference

Objective: The combination of aortic coarctation (CoA) and bicuspid aortic valve (BAV) is assumed to be associated with a higher risk of ascending aortic dilatation and type A dissection, and current European Society of Cardiology (ESC) guidelines advise therefore to operate at a lower threshold in the presence of CoA. The aim of our study is to evaluate whether the coexistence of CoA in BAV patients is indeed associated with a higher risk of ascending aortic events (AAE). Methods: In a retrospective study, all adult BAV patients visiting the outpatient clinic of our tertiary care center between February 2003 and February 2019 were included. The primary end point was an ascending aortic event (AAE) defined as ascending aortic dissection/rupture or preventive surgery. The secondary end points were aortic dilatation and aortic growth. Results: In total, 499 BAV patients (43.7% female, age 40.3 ± 15.7 years) were included, of which 121 (24%) had a history of CoA (cBAV). An aortic event occurred in 38 (7.6%) patients at a mean age of 49.0 ± 13.6 years. In the isolated BAV group (iBAV), significantly more AAE occurred, but this was mainly driven by aortic valve dysfunction as indication for aortic surgery. There was no significant difference in the occurrence of dissection or severely dilated ascending aorta (>50 mm) between the iBAV and cBAV patients (p = 0.56). The aortic diameter was significantly smaller in the cBAV group (30.3 ± 6.9 mm versus 35.7 ± 7.6 mm; p < 0.001). The median aortic diameter increase was 0.23 (interquartile range (IQR): 0.0–0.67) mm/year and was not significantly different between both groups (p = 0.74). Conclusion: Coexistence of CoA in BAV patients was not associated with a higher risk of aortic dissection, preventive aortic surgery, aortic dilatation, or more rapid aorta growth. This study suggests that CoA is not a risk factor in BAV patients, and the advice to operate at lower diameter should be reevaluated.

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Prospects of development in aortic surgery: literature review

Perm Medical Journal ◽

10.17816/pmj37543-51 ◽

2021 ◽

Vol 37 (5) ◽

pp. 43-51

Author(s):

B. K. Kadyraliev ◽

V. B. Arutyunyan ◽

M. N. Askadinov ◽

S. V. Kucherenko

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Malignant Tumors ◽

Chronic Renal Disease ◽

Aortic Surgery ◽

Aortic Ring ◽

Good Alternative ◽

Aortic Dilatation ◽

Repeated Surgery

Foreign sources of literature regarding the issue of aortic surgery are analyzed. Special attention is paid to aortic valve replacement using the Ozaki technique. The first replacement of aortic valve cusps with synthetic material was implemented by H. Th. Bahnson in 1959; he implanted the neocusp from Teflon. Nowadays, so as to replace the aortic valve, mechanical, biological valves, homotransplants, autotransplants and valves imitated endovascularly are actively applied. All the above mentioned types of the valves have both merits and demerits, therefore each patient should have an individual approach. When choosing the prosthesis and type of surgical intervention, cardiosurgeons take into account the following factors: patients age, availability of concomitant diseases (atrial fibrillation, chronic renal disease, malignant tumors), presence of small aortic ring, aortic dilatation, availability of other valve diseases, infectious endocarditis, first or repeated surgery on the valve as well as pregnancy or planning of pregnancy. In 2007, Shigeyuki Ozaki proposed the technique for replacement of all aortic valve cusps from autopericardium treated with 0.6 % glutaraldehyde solution. This surgery permits to form the aortic valve with excellent hemodynamic characteristics and low rate of reoperation in the early and remote periods. Aortic valve replacement using Ozaki technique is a perspective technique and good alternative for surgical treatment of aortic valve along with prostheses.

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Fluid Structural Interaction of a Patient Specific Congenital Bicuspid Aortic Valve

ASME 2012 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2012-80196 ◽

2012 ◽

Author(s):

V. Govindarajan ◽

H. S. Udaykumar ◽

S. Vigmostad ◽

M. M. Levack ◽

J. H. Gorman ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Root ◽

Aortic Aneurysms ◽

Patient Specific ◽

Aortic Dilatation ◽

Structural Interaction ◽

Aortic Pathology ◽

Specific Geometry ◽

Opening Phase

Congenital Bicuspid Aortic Valve (BAV) is a valvular anomaly where a patient is born with a valve with two leaflets instead of a normal tri-leaflet valve. It has also been reported that BAVs are prone to progressive calcification and also other complications such as ascending aortic dilatation, dissection and rupture [1]. The geometrical variations with the BAV may be a factor in altering the deformation and stresses on the leaflets resulting in calcification of the leaflets earlier than with normal tri-leaflet aortic valves. Altered flow patterns past BAV into the ascending aorta can also be anticipated. Analysis of flow dynamics during the opening phase, and the resultant fluid forces on the aortic root could improve our understanding of aortic aneurysms and dissections observed in patients with BAV [2]. In this study, the valvular deformation and the flow across a patient-specific BAV and root are simulated using the method of fluid structural interaction analysis. The patient-specific geometry is obtained employing 3D ultrasound images segmented as point cloud data and surfaces are constructed with commercial software GAMBIT using NURBS based connectivity. The opening phase of the valve is simulated under flow with physiological Reynolds number and with realistic material properties for the leaflets and the aortic root. Such an analysis on the dynamics of BAV with patient-specific geometry may be a useful tool in stratifying BAV patients that may be at risk in developing valvular and ascending aortic pathology.

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Abstract 2069: Aortic Valve Replacement In Patients With Bicuspid Aortic Valve Disease Is Not Followed By Progressive Aortic Dilatation: A 15-year Study

Circulation ◽

10.1161/circ.116.suppl_16.ii_448-b ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Ayyaz Ali ◽

Amit Patel ◽

Darren Freed ◽

Yasir Abu-Omar ◽

Ahmad Y Sheikh ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Valve Disease ◽

Valve Disease ◽

Aortic Diameter ◽

Implantation Technique ◽

Aortic Dilatation ◽

Aortic Pathology ◽

Ascending Aortic Diameter

Objectives A bicuspid aortic valve may be associated with an aortopathy, this may lead to progressive aortic dilatation over time. It is uncertain whether the ascending aorta should be replaced prophylactically during AVR in these patients. We analyzed change in ascending aortic diameter following AVR, to determine whether a clinically important aortic pathology exists in patients with bicuspid aortic valve disease. Methods Demographic, operative and clinical data were obtained retrospectively through casenote review. AVR was performed using a homograft or porcine stentless valve using the subcoronary implantation technique. Patients were grouped according to whether their native aortic valve was identified as tricuspid (TC) or bicuspid (BC) at operation. Serial transthoracic echocardiograms were analyzed to measure pre-operative and post-operative ascending aortic diameter. Results 217 patients underwent AVR between 1 st January 1991 and 1 st January 2001. Ninety patients had a bicuspid aortic valve, in the remaining 127 the valve was tricuspid. The bicuspid group was younger ( BC 62yr +/− 15, TC 71yr +/− 12 yrs; p < 0.001). Follow-up echocardiography was performed 6.0 +/− 4.3 years post-operatively. Pre-operative ascending aortic diameter was similar (BC 3.2 +/− 0.5, TC 3.2 +/− 0.5 cm; p = 0.56) There was no difference in the increase in ascending aortic diameter over follow-up (BC 0.1 +/− 0.5, TC 0.0 +/− 0.5 cm; p = 0.34) Conclusion The clinical importance of “bicuspid aortopathy” in an older age group appears to be minimal. Additional aortic procedures designed to protect against progressive aortic aneurysmal disease in this setting are not justified.

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Bicuspid Aortic Valve: Role of Multiple Gene Variants in Influencing the Clinical Phenotype

BioMed Research International ◽

10.1155/2018/8386123 ◽

2018 ◽

Vol 2018 ◽

pp. 1-9 ◽

Cited By ~ 1

Author(s):

Elena Sticchi ◽

Rosina De Cario ◽

Alberto Magi ◽

Sabrina Giglio ◽

Aldesia Provenzano ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Root ◽

Rare Variants ◽

Aortic Surgery ◽

Genetic Diagnosis ◽

Clinical Manifestations ◽

Aortic Dilatation ◽

Reduced Penetrance ◽

Next Generation Sequencing Ngs

Background. Bicuspid aortic valve (BAV) is a common congenital heart defect with increased prevalence of aortic dilatation and dissection. BAV has an autosomal dominant pattern of inheritance with reduced penetrance and variable expressivity. BAV has been described as an isolated trait or associated with other clinical manifestations in syndromic conditions. Identification of a syndromic condition in a BAV patient is clinically relevant in order to personalize indication to aortic surgery. We aimed to point out how genetic diagnosis by next-generation sequencing (NGS) can improve management of a patient with complex BAV clinical picture. Methods and Results. We describe a 45-year-old Caucasian male with BAV, thoracic aortic root and ascending aorta dilatation, and connective features evocative but inconclusive for clinical diagnosis of Marfan syndrome (MFS). Targeted (91 genes) NGS was used. Proband genetic variants were investigated in first-degree relatives. Proband carried 5 rare variants in 4 genes: FBN1(p.Asn542Ser and p.Lys2460Arg), NOTCH1(p.Val1739Met), LTBP1(p.Arg1330Gln), and TGFBR3(p.Arg423Trp). The two FBN1 variants were inherited in cis by the mother, showing systemic features evocative of MFS, but with a milder phenotype than that observed in the proband. Careful clinical observation along with the presence of the FBN1 variants allowed diagnosis of MFS in the proband and in his mother. NOTCH1 variant was found in mother and brother, not exhibiting BAV, thus not definitely supporting/excluding association with BAV. Interestingly, the proband, his brother and father, all showing root dilatation, and his sister, with upper range aortic root dimension, were carriers of a TGFBR3 variant. LTBP1 might also modulate the vascular phenotype. Conclusions. Our results underline the usefulness of NGS together with family evaluation in diagnosis of patients with monogenic traits and overlapping clinical manifestations due to contribution of the same genes and/or presence of comorbidities determined by different genes.

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Variability in surveillance practice for patients with diagnosis of bicuspid aortic valve syndrome

10.22541/au.163369397.71813285/v1 ◽

2021 ◽

Author(s):

Arianna Kahler-Quesada ◽

Ishani Vallabhajosyula ◽

Sameh Yousef ◽

Makoto Mori ◽

Roland Assi ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Care Center ◽

Aortic Surgery ◽

Tertiary Care ◽

Tertiary Care Center ◽

Aortic Pathology ◽

Increased Risk ◽

Surveillance Practice

Background/Aim: In patients with bicuspid aortic valves, guidelines call for regular follow-up to monitor disease progression and guide timely intervention. We aimed to evaluate how closely these recommendations are followed at a tertiary care center. Methods: This was retrospective cohort study at a tertiary care center. Among 48,504 patients who received echocardiograms between 2013-2018, 245 patients were identified to have bicuspid aortic valve. Bivariate analyses compared patient and echocardiographic characteristics between patients who did and did not receive follow-up by a cardiovascular specialist. Results: The mean age of the cohort was 55.2  15.6 years and 30.2% were female. During a median follow-up of 3.5  2.2 years, 72.7% of patients had at least one visit with a cardiovascular specialist after diagnosis of bicuspid aortic valve by echocardiogram. Patients followed by specialists had a higher proportion of follow-up surveillance by echocardiogram (78.7% vs. 34.3%, p< .0001), or by CT or MRI (41.0% vs. 3.0%, p < .0001), and were more likely to undergo valve or aortic surgery compared with patients not followed by specialists. Patients with moderate to severe valvular or aortic pathology (aortic stenosis/regurgitation, dilated ascending aorta) were not more likely to be followed by a cardiovascular specialist or receive follow-up echocardiograms. Conclusions: Follow-up care for patients with bicuspid aortic valve was highly variable, and surveillance imaging was performed sparsely despite guidelines. There is an urgent need for surveillance and clinical follow-up mechanisms to monitor this patient population with increased risk of progressive valvulopathy and aortopathy.

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Bicuspid aortic valve and aortopathy: novel prognostic predictors for the identification of high-risk patients

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa250 ◽

2020 ◽

Author(s):

Luca Longobardo ◽

Scipione Carerj ◽

Alessandra Bitto ◽

Maurizio Cusmà-Piccione ◽

Maria Ludovica Carerj ◽

...

Keyword(s):

Regression Analysis ◽

Surgical Treatment ◽

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Primary Endpoint ◽

Cox Regression ◽

Aortic Surgery ◽

Aortic Aneurysms ◽

Aortic Dilatation ◽

Cox Regression Analysis

Abstract Aims Bicuspid aortic valve (BAV) may be complicated by aortic aneurysms and dissection. This study aimed to evaluate the prognostic efficacy of markers from cardiac imaging, as well as genetic and new biomarkers, to early predict aortic complications. Methods and results We re-evaluated after a mean time of 48 ± 11 months 47 BAV patients who had undergone previous echocardiography for evaluation of aortic stiffness and 2D aortic longitudinal strain (LS) (by speckle-tracking analysis), and who had given a blood sample for the assessment of a single-nucleotide polymorphism of elastin gene (ELN rs2 071307) and quantification of elastin soluble fragments (ESF). Surgical treatment of aortic aneurysm/dissection was the primary endpoint, and an aortic dimension increase (of one or more aortic segments) ≥1 mm/year was the secondary endpoint. Nine patients underwent surgical treatment of ascending aorta (AA) aneurysms. Out of the 38 patients who did not need surgical intervention, 16 showed an increase of aortic root and/or AA dimension ≥1 mm/year. At multivariate Cox regression analysis, an impaired AA LS was an independent predictor of aortic surgery [P = 0.04; hazard ratio (HR) 0.961; 95% confidence interval (CI) 0.924–0.984] and aortic dilatation (P = 0.007; HR 0.960; 95% CI 0.932–0.989). An increased quantity of ESF was correlated (P = 0.015) with the primary endpoint at univariate Cox regression analysis but it did not keep statistical significance at multivariate analysis. Conclusion In BAV patients, impairment of elastic properties of the AA, as assessed by 2D LS, is an effective predictor of aortic complications.

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

Netherlands Heart Journal ◽

10.1007/s12471-021-01594-3 ◽

2021 ◽

Author(s):

J. R Olsthoorn ◽

K. Y. Lam ◽

F. Akca ◽

N. M. A. J. Timmermans ◽

M. E. S. H. Tan

Keyword(s):

Aortic Valve ◽

Aortic Surgery ◽

Composite Graft ◽

Ascending Aorta ◽

Alternative Strategy ◽

Aortic Dilatation ◽

Valve Prosthesis ◽

Aortic Replacement ◽

Ascending Aortic Replacement ◽

Valve Pathology

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

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