Association between bicuspid aortic valve morphotype and regional dilatation of the aortic root and trunk
- 311 Downloads
Thoracic aortic disease, including thoracic aortic aneurysm (TAA), is frequently seen in patients with bicuspid aortic valve (BAV). We hypothesized that BAV morphotype would be associated with aortic aneurysm phenotypes but that other patient variables would significantly modify this relationship. 829 patients between 18 and 90 years with BAV and available raw imaging of the aortic valve and the ascending aorta to its mid-portion prior to aortic valve and aortic surgery were examined. The sinuses of Valsalva and proximal ascending aorta were measured from 2-dimensional co-planar echocardiographic images. We observed strong associations between patient habitus and raw and normalized dimensions of the aortic root and ascending aorta. Patients with R–L morphotype presented at an older age with larger aortic root but similar ascending aortic dimensions. After accounting for patient morphometric characteristics and severity of aortic valve disease, patients with R–L valve morphotype were marginally more likely to have an aortic root aneurysm (86% vs. 78%; P = 0.043), defined as aortic root dimension Z score ≥3. We observed only small differences in aortic dimensions between BAV morphotypes, that are eclipsed by variation in patient habitus. We interpret these findings to mean that BAV patients will not likely benefit from therapies based on aortic valve morphotype. Rather, we propose that all BAV patients should undergo longitudinal follow-up, independent of valve morphotype. Guidelines for aortic surgery based upon dimensions alone may be improved by considering patient characteristics such as age, body size and other characteristics.
KeywordsAortic valve/*abnormalities/surgery Bicuspid aortic valve Ascending aorta Aortic aneurysm Prognosis
Bicuspid aortic valve
Tricuspid aortic valve
This work was funded by NIH Grants R01HL114823 (SCB) and R01HL118266 (JDM).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Institutional Review Board determined that individual patient consent was not required.
- 1.Michelena HI, Prakash SK, Della Corte A, Bissell MM, Anavekar N, Mathieu P, Bosse Y, Limongelli G, Bossone E, Benson DW, Lancellotti P, Isselbacher EM, Enriquez-Sarano M, Sundt TM 3rd, Pibarot P, Evangelista A, Milewicz DM, Body SC, Investigators BA (2014) Bicuspid aortic valve: identifying knowledge gaps and rising to the challenge from the International bicuspid aortic valve consortium (BAVCon). Circulation 129(25):2691–2704. doi: 10.1161/CIRCULATIONAHA.113.007851 CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Della Corte A, Bancone C, Dialetto G, Covino FE, Manduca S, D’Oria V, Petrone G, De Feo M, Nappi G (2014) Towards an individualized approach to bicuspid aortopathy: different valve types have unique determinants of aortic dilatation. Eur J Cardiothorac Surg 45(4):e118–124, (discussion e124). doi: 10.1093/ejcts/ezt601 CrossRefPubMedGoogle Scholar
- 4.Prakash SK, Bosse Y, Muehlschlegel JD, Michelena HI, Limongelli G, Della Corte A, Pluchinotta FR, Russo MG, Evangelista A, Benson DW, Body SC, Milewicz DM, Investigators B (2014) A roadmap to investigate the genetic basis of bicuspid aortic valve and its complications: insights from the International BAVCon (Bicuspid Aortic Valve Consortium). J Am Coll Cardiol 64(8):832–839. doi: 10.1016/j.jacc.2014.04.073 CrossRefPubMedPubMedCentralGoogle Scholar
- 6.Conti CA, Della Corte A, Votta E, Del Viscovo L, Bancone C, De Santo LS, Redaelli A (2010) Biomechanical implications of the congenital bicuspid aortic valve: a finite element study of aortic root function from in vivo data. J Thorac Cardiovasc Surg 140(4):890–896. doi: 10.1016/j.jtcvs.2010.01.016 CrossRefPubMedGoogle Scholar
- 7.Bissell MM, Hess AT, Biasiolli L, Glaze SJ, Loudon M, Pitcher A, Davis A, Prendergast B, Markl M, Barker AJ, Neubauer S, Myerson SG (2014) Response to letter regarding article, “Aortic dilation in bicuspid aortic valve disease: flow pattern is a major contributor and differs with valve fusion type”. Circ Cardiovasc Imaging 7(1):214. doi: 10.1161/CIRCIMAGING.113.001497 CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Bissell MM, Hess AT, Biasiolli L, Glaze SJ, Loudon M, Pitcher A, Davis A, Prendergast B, Markl M, Barker AJ, Neubauer S, Myerson SG (2013) Aortic dilation in bicuspid aortic valve disease: flow pattern is a major contributor and differs with valve fusion type. Circ Cardiovasc Imaging 6(4):499–507. doi: 10.1161/CIRCIMAGING.113.000528 CrossRefPubMedGoogle Scholar
- 9.Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quinones M, American Society of E, European Association of E (2009) Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 22(1):1–23, (quiz 101–102). doi: 10.1016/j.echo.2008.11.029 CrossRefPubMedGoogle Scholar
- 10.Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ, American Society of E (2003) Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 16(7):777–802. doi: 10.1016/S0894-7317(03)00335-3 CrossRefPubMedGoogle Scholar
- 12.Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ, Chamber Quantification Writing G, American Society of Echocardiography’s G, Standards C, European Association of E (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18(12):1440–1463. doi: 10.1016/j.echo.2005.10.005 CrossRefPubMedGoogle Scholar
- 13.Campens L, Demulier L, De Groote K, Vandekerckhove K, De Wolf D, Roman MJ, Devereux RB, De Paepe A, De Backer J (2014) Reference values for echocardiographic assessment of the diameter of the aortic root and ascending aorta spanning all age categories. Am J Cardiol 114 (6):914–920. doi: 10.1016/j.amjcard.2014.06.024 CrossRefPubMedGoogle Scholar
- 15.Della Corte A, Bancone C, Dialetto G, Covino FE, Manduca S, Montibello MV, De Feo M, Buonocore M, Nappi G (2014) The ascending aorta with bicuspid aortic valve: a phenotypic classification with potential prognostic significance. Eur J Cardiothorac Surg 46(2):240–247, (discussion 247). doi: 10.1093/ejcts/ezt621 CrossRefPubMedGoogle Scholar
- 19.Kang JW, Song HG, Yang DH, Baek S, Kim DH, Song JM, Kang DH, Lim TH, Song JK (2013) Association between bicuspid aortic valve phenotype and patterns of valvular dysfunction and bicuspid aortopathy: comprehensive evaluation using MDCT and echocardiography. JACC Cardiovasc Imaging 6(2):150–161. doi: 10.1016/j.jcmg.2012.11.007 CrossRefPubMedGoogle Scholar
- 21.Jassal DS, Bhagirath KM, Tam JW, Sochowski RA, Dumesnil JG, Giannoccaro PJ, Jue J, Pandey AS, Joyner CD, Teo KK, Chan KL (2010) Association of Bicuspid aortic valve morphology and aortic root dimensions: a substudy of the aortic stenosis progression observation measuring effects of rosuvastatin (ASTRONOMER) study. Echocardiography 27(2):174–179. doi: 10.1111/j.1540-8175.2009.00993.x CrossRefPubMedGoogle Scholar
- 23.Ruzmetov M, Shah JJ, Fortuna RS, Welke KF (2015) The association between aortic valve leaflet morphology and patterns of aortic dilation in patients with bicuspid aortic valves. Ann Thorac Surg 99(6):2101–2107, (discussion 2107–2108). doi: 10.1016/j.athoracsur.2015.02.036 CrossRefPubMedGoogle Scholar
- 24.Prakash SK, Bosse Y, Muehlschlegel JD, Michelena HI, Limongelli G, Della Corte A, Pluchinotta FR, Russo MG, Evangelista A, Benson DW, Body SC, Milewicz DM, Investigators BA (2014) A roadmap to investigate the genetic basis of bicuspid aortic valve and its complications: insights from the International BAVCon (Bicuspid Aortic Valve Consortium). J Am Coll Cardiol 64(8):832–839. doi: 10.1016/j.jacc.2014.04.073 CrossRefPubMedPubMedCentralGoogle Scholar
- 25.Buchner S, Hulsmann M, Poschenrieder F, Hamer OW, Fellner C, Kobuch R, Feuerbach S, Riegger GA, Djavidani B, Luchner A, Debl K (2010) Variable phenotypes of bicuspid aortic valve disease: classification by cardiovascular magnetic resonance. Heart 96(15):1233–1240. doi: 10.1136/hrt.2009.186254 CrossRefPubMedGoogle Scholar
- 26.Thanassoulis G, Yip JW, Filion K, Jamorski M, Webb G, Siu SC, Therrien J (2008) Retrospective study to identify predictors of the presence and rapid progression of aortic dilatation in patients with bicuspid aortic valves. Nat Clini Pract Cardiovasc Med 5(12):821–828. doi: 10.1038/ncpcardio1369 CrossRefGoogle Scholar
- 27.Detaint D, Michelena HI, Nkomo VT, Vahanian A, Jondeau G, Sarano ME (2014) Aortic dilatation patterns and rates in adults with bicuspid aortic valves: a comparative study with Marfan syndrome and degenerative aortopathy. Heart 100(2):126–134. doi: 10.1136/heartjnl-2013-304920 CrossRefPubMedGoogle Scholar
- 30.Fazel SS, Mallidi HR, Lee RS, Sheehan MP, Liang D, Fleischman D, Herfkens R, Mitchell RS, Miller DC (2008) The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. J Thorac Cardiovasc Surg 135(4):901–907. doi: 10.1016/j.jtcvs.2008.01.022 CrossRefPubMedGoogle Scholar
- 33.Accf/Aha/Aats/Acr/Asa/Sca/Scai/Sir/Sts/Svm Guidelines For The Diagnosis Management Of Patients With Thoracic Aortic Disease Representative M, Hiratzka LF, Creager MA, Isselbacher EM, Svensson LG, Members* AAGftMoPWVHDR, Nishimura RA, Bonow RO, Guyton RA, Sundt TM 3rd, ACC/AHA Task Force M, Halperin JL, Levine GN, Anderson JL, Albert NM, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis J, Joglar J, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Wijeysundera DN (2016) Surgery for aortic dilatation in patients with bicuspid aortic valves: a statement of clarification from the American college of cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 133(7):680–686. doi: 10.1161/CIR.0000000000000331 CrossRefGoogle Scholar