Comparison of the Structure of the Aortic Valve and Ascending Aorta in Adults Having Aortic Valve Replacement for Aortic Stenosis Versus for Pure Aortic Regurgitation and Resection of the Ascending Aorta for Aneurysm

Abstract

Background-There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction-either aortic stenosis (AS) or pure aortic regurgitation (AR)-something not previously undertaken. Methods and Results-Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4ϩ) was zero or 1ϩ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2ϩ to 4ϩ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13). Conclusions-These data strongly suggest that the type of aortic valve dysfunction-AS versus pure AR-is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease. (Circulation. 2011;123:896-903.)

Echocardiographic versus Histologic Findings in Marfan Syndrome

“…22 Furthermore, dilation of the aortic root and the ascending aorta can alter aortic leaflet stress and thereby affect coaptation of an otherwise normal aortic valve, 23 resulting in significant aortic regurgitation as revealed by echocardiography. This is consistent with the observations of Roberts and colleagues, 24,25 who reported, in the histologic specimens of patients with Marfan syndrome, severe loss of medial elastic fibers in the sinuses of Valsalva and in the ascending aorta. In addition, the findings of myxomatous involvement of the aortic valve suggest that surgical decisions regarding the aortic valve in patients with Marfan syndrome should not arise only from the echocardiographic appearance of the valve.…”

Aortic Valve Stenosis Alters Expression of Regional Aortic Wall Shear Stress: New Insights From a 4‐Dimensional Flow Magnetic Resonance Imaging Study of 571 Subjects

“…Aortic regurgitation is an additional risk factor for aortopathy1; however, it is difficult to quantify diastolic WSS attributed to low signal‐to‐noise ratio with 4D flow MRI and the need for a time resolved segmentation to capture aortic root motion. Given the results from previous studies showing the greatest flow differences between patient groups occur at systole,29 we chose to focus on systolic WSS.…”

Bicuspid aortic valve syndrome and fibrillinopathies: potential impact on clinical approach

“…Recently, Benedik and colleagues evaluated the histological and mechanical characteristics of the aortic wall in patients who underwent aortic stenosis or regurgitation surgery and showed that the latter group had a worse quality and a superior thickness of the ascending aorta than the former 35 . Roberts and colleagues observed, in histological sections of ascending aortas, only a minimal loss of medial elastic fibers in the aortic media of patients with aortic stenosis compared to severe elastic fibers damage reported in patients with aortic regurgitation 36 .…”

“…Interestingly, 8 out of our 10 patients displayed this phenotype, in association with a certain degree of systemic features typical of connective tissue disorders 11 . Finally, the 2 patients bearing FBN1 mutations had significant aortic regurgitation, which is a powerful predictor of loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease 35,36 . These findings call for greater focus on the BAV-related cardiovascular abnormalities rather than on the MFS-like systemic features, which may well coexist and warrant investigation in BAV patients in general, but are not associated with the FBN1 mutations identified in the present study.…”