Toward individualized management of the ascending aorta in bicuspid aortic valve surgery: The role of valve phenotype in 1362 patients

Sievers, Hans‐Hinrich; Stierle, Ulrich; Mohamed, Salah A.; Hanke, Thomas; Richardt, Doreen; Schmidtke, Claudia; Charitos, Efstratios I.

doi:10.1016/j.jtcvs.2014.04.007

Cited by 58 publications

(40 citation statements)

References 38 publications

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“…Pathology studies also found worse elastic fiber loss in aortic wall tissue of BAV-AI patients, 31, 32 which is in accordance with clinical observations that BAV-AI patients, especially those with predominantly sinus dilatation (so-called “root phenotype”), suffered from faster ascending aorta dilatation and higher risk for adverse aortic events even after aortic valve replacement. 13–15, 33–35 In advent of above evidences, an aggressive policy of preventive aortic intervention might be appreciated in BAV-AI patients who exhibit a uniform WSS elevation around the lumen of the ascending aorta, and who are also known to present at a younger age and with the “root phenotype”. Meanwhile, BAV-AS patients who exhibit exaggerated flow eccentricity and elevation of regional WSS could benefit from less aggressive treatment strategies including reduction aortoplasty guided by WSS mapping.…”

Section: Discussionmentioning

confidence: 99%

Aortic shear stress in patients with bicuspid aortic valve with stenosis and insufficiency

Shan

Wang

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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Objectives Bicuspid aortic valve (BAV), characterized by valve malformation and risk for aortopathy, displays profound alteration in systolic aortic outflow and wall shear stress (WSS) distribution. The present study performed 4-dimenstional flow MRI in BAV patients with right-left (R-L) cusp fusion, focusing on the impact of valve function upon hemodynamic status within ascending aorta. Methods Four-dimensional flow MRI was performed in 50 R-L BAV subjects and 15 age- and aortic size-matched controls with tricuspid aortic valve. BAV patients were categorized into 3 groups according to their aortic valve function as follows: BAV with no more than mild aortic valve dysfunction (BAV-CTL, n=20), BAV with severe aortic insufficiency (BAV-AI, n=15), and BAV with severe aortic stenosis (BAV-AS, n=15). Results All R-L BAV patients exhibited peak WSS at the right-anterior position of the ascending aorta (BAV vs. TAV at right-anterior position: 0.91±0.23 N/m2 vs. 0.43±0.12 N/m2, p<0.001) with no distinct alteration between BAV-AI and BAV-AS. The predominance of dilatation involving the tubular ascending aorta (82%, type 2 aortopathy) persisted, with or without valve dysfunction. Compared to BAV-CTL subjects, the BAV-AI group displayed universally elevated WSS (0.75±0.12 N/m2 vs. 0.57±0.09 N/m2, p<0.01) in the ascending aorta, which was associated with elevated cardiac stroke volume (p<0.05). The BAV-AS group showed elevated flow eccentricity in the form of significantly increased standard deviation of circumferential WSS, which correlated with markedly increased peak aortic valve velocity (p<0.01). Conclusions The location of peak aortic WSS and type of aortopathy remained homogeneous among R-L BAV patients irrespective of valve dysfunction. Severe aortic insufficiency or stenosis resulted in further elevated aortic WSS and exaggerated flow eccentricity.

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Section: Discussionmentioning

confidence: 99%

Aortic shear stress in patients with bicuspid aortic valve with stenosis and insufficiency

Shan

Wang

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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“…The frequency of BAV morphotypes is consistent with previous work from our laboratory 8 and others. 7,9 …”

Section: Methodsmentioning

confidence: 99%

Elevated oxidative stress in the aortic media of patients with bicuspid aortic valve

Billaud

Phillippi

Kotlarczyk

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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Objective Congenital bicuspid aortic valve (BAV) is distinctly associated with the development of ascending aortopathy in adulthood, portending risk of both ascending aortic aneurysm and dissection. Our previous work implicated deficiency in oxidative stress response as a mediator of the BAV-associated aortopathy. We hypothesize that reactive oxygen species generation invokes elevated local oxidative tissue damage in ascending aorta of patients with BAV. Methods Ascending aortic specimens were obtained from patients undergoing elective aortic replacement and/or aortic valve replacement and during heart transplant operations. Levels of superoxide anion were measured via high-pressure liquid chromatography–based detection of 2-hydroxyethidium in aortic specimens. Lipid peroxidation and enzymatic activity of superoxide dismutase and peroxidase were quantified in aortic specimens. Results Superoxide anion production was elevated in aortic specimens from patients with nonaneurysmal BAV (n = 59) compared with specimens from patients with the morphologically normal tricuspid aortic valve (TAV, n = 38). Total superoxide dismutase activity was similar among aortic specimens from patients with TAV versus BAV (n = 27 and 26, respectively), whereas peroxidase activity was increased in aortic specimens from patients with BAV compared with specimens from patients with TAV (n = 14 for both groups). Lipid peroxidation was elevated in aortic specimens from BAV patients compared with TAV patients (n = 14 and 11, respectively). Conclusions Superoxide anion accumulation and increased lipid peroxidation demonstrate that, despite increased peroxidase activity, the ascending aortopathy of patients with BAV involves oxidative stress. In addition, the absence of increased superoxide dismutase activity in BAV specimens indicates a deficiency in antioxidant defense. This suggests that the characteristic smooth muscle cell loss observed in BAV aortopathy may be a consequence of superoxidemediated cell damage.

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“…The decision for AAR concomitant to the valve surgery was based on a multifactorial policy presented in detail elsewhere. 9 In brief, the following factors were included: diameter of the AA around 45 mm, BSA, sex, age-more progressive decision in young age-fragility of the wall of the AA, progressive increase of AA diameter (0.5 cm per year), family history of aortic disease, BAV type 1 with insufficiency and BAV type 2/unicuspid, phenotype III and IV of AA according to Fazel and colleagues. 16 Age, especially young age, was of special concern for decision making, because age is the most powerful determinant of growth and young age shows faster growth of AA diameters.…”

Section: Surgerymentioning

confidence: 99%

Longer-term results, z scores, and decision nomograms for treatment of the ascending aorta in 1693 bicuspid aortic valve operations

Sievers¹,

Stock²,

Stierle³

et al. 2018

The Journal of Thoracic and Cardiovascular Surgery

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In our study, ascending aorta intervention could be performed with low hospital mortality and obviously did not add to the overall mortality compared with no intervention. Ascending aorta replacement was the most definite intervention. The multifactorial decision for ascending aorta intervention including the z score of the ascending aorta was more liberal in younger patients compared to the simple aortic size guidelines and provided excellent results. However, generalizability needs further data.

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Toward individualized management of the ascending aorta in bicuspid aortic valve surgery: The role of valve phenotype in 1362 patients

Cited by 58 publications

References 38 publications

Aortic shear stress in patients with bicuspid aortic valve with stenosis and insufficiency

Aortic shear stress in patients with bicuspid aortic valve with stenosis and insufficiency

Elevated oxidative stress in the aortic media of patients with bicuspid aortic valve

Longer-term results, z scores, and decision nomograms for treatment of the ascending aorta in 1693 bicuspid aortic valve operations

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