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Journal of Cardiothoracic Surgery
Published in: Journal of Cardiothoracic Surgery 1/2006

Open Access 01-12-2006 | Review

Post-stenotic aortic dilatation

Authors: Emma Wilton, Marjan Jahangiri

Published in: Journal of Cardiothoracic Surgery | Issue 1/2006

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Abstract

Aortic stenosis is the most common valvular heart disease affecting up to 4% of the elderly population. It can be associated with dilatation of the ascending aorta and subsequent dissection. Post-stenotic dilatation is seen in patients with AS and/or aortic regurgitation, patients with a haemodynamically normal bicuspid aortic valve and following aortic valve replacement. Controversy exists as to whether to replace the aortic root and ascending aorta at the time of aortic valve replacement, an operation that potentially carries a higher morbidity and mortality.
The aetiology of post-stenotic aortic dilatation remains controversial. It may be due to haemodynamic factors caused by a stenotic valve, involving high velocity and turbulent flow downstream of the stenosis, or due to intrinsic pathology of the aortic wall. This may involve an abnormality in the process of extracellular matrix remodelling in the aortic wall including inadequate synthesis, degradation and transport of extracellular matrix proteins.
This article reviews the aetiology, pathology and management of patients with post-stenotic aortic dilatation.
Literature
1.
Stewart BF, Siscovick D, Lind BK, Gardin JM, Gottdiener JS, Smith VE, Kitzman DW, Otto CM: Clinical factors associated with calcific aortic valve disease: Cardiovascular Health Study. J Am Coll Cardiol. 1997, 29 (3): 630-634. 10.1016/S0735-1097(96)00563-3.CrossRefPubMed
2.
Lindroos M, Kupari M, Heikkila J, Tilvis R: Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993, 21 (5): 1220-1225.CrossRefPubMed
3.
Crawford MH, Roldan CA: Prevalence of aortic root dilatation and small aortic roots in valvular aortic stenosis. Am J Cardiol. 2001, 87 (11): 1311-1313. 10.1016/S0002-9149(01)01530-2.CrossRefPubMed
4.
Yasuda H, Nakatani S, Stugaard M, Tsujita-Kuroda Y, Bando K, Kobayashi J, Yamagishi M, Kitakaze M, Kitamura S, Miyatake K: Failure to Prevent Progressive Dilation of Ascending Aorta by Aortic Valve Replacement in Patients With Bicuspid Aortic Valve: Comparison With Tricuspid Aortic Valve. Circulation. 2003, 108: 291-294. 10.1161/01.cir.0000087449.03964.fb.CrossRef
5.
Fedak PWM, Verma S, David TE, Leask RL, Weisel RD, Butany J: Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation. 2002, 106: 900-904. 10.1161/01.CIR.0000027905.26586.E8.CrossRefPubMed
6.
Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, Tornos P, Vanoverschelde J-L, Vermeer F, Boersma E, Ravaud P, Vahanian A: A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J. 2003, 24: 1231-1243. 10.1016/S0195-668X(03)00201-X.CrossRefPubMed
7.
Mohler ER, Sheridan MJ, Nichols R, Harvey WP, Waller BF: Development and progression of aortic valve stenosis: atherosclerosis risk factors – a causal relationship? A clinical morphologic study. Clin Cardiol. 1991, 14 (12): 995-999.CrossRefPubMed
8.
Cowell SJ, Newby DE, Prescott RJ, Bloomfield , Reid J, Northridge DB, Boon NA: A randomised trial of lipid-lowering therapy in calcific aortic stenosis. New Eng J Med. 2005, 352 (23): 2389-2397. 10.1056/NEJMoa043876.CrossRefPubMed
9.
Roberts WC: The congenitally bicuspid aortic valve: a study of 85 autopsy studies. Am J Cardiol. 1970, 26: 72-83. 10.1016/0002-9149(70)90761-7.CrossRefPubMed
10.
11.
12.
Roberts WC, Ko JM: Frequency by Decades of Unicuspid, Bicuspid, and Tricuspid Aortic Valves in Adults Having Isolated Aortic Valve Replacement for Aortic Stenosis, With or Without Associated Aortic Regurgitation. Circulation. 2005, 111 (7): 920-925. 10.1161/01.CIR.0000155623.48408.C5.CrossRefPubMed
13.
Sans-Coma V, Fernandez B, Duran AC, Thiene G, Arque JM, Munoz-Chapuli R, Cardo M: Fusion of valve cushions as a key factor in the formation of congenital bicuspid aortic valves in Syrian hamsters. Anat Rec. 1996, 244 (4): 490-498. 10.1002/(SICI)1097-0185(199604)244:4<490::AID-AR7>3.0.CO;2-Z.CrossRefPubMed
14.
Fernandez MC, Duran AC, Real R, Lopez D, Fernandez B, de Andres AV, Arque JM, Gellego A, Sans-Coma V: Coronary artery anomalies and aortic valve morphology in the Syrian Hamster. Lab Anim. 2000, 34 (2): 145-154.CrossRefPubMed
15.
Becker AE, Becker MJ, Edwards JE: Anomalies associated with coarctation of the aorta – Particular reference to infancy. Circulation. 1970, 41: 1067-1075.CrossRefPubMed
16.
Stewart AB, Ahmed R, Travill CM, Newman CG: Coarctation of the aorta, life and health 20–44 years after surgical repair. Br Heart J. 1993, 69: 65-70.CrossRefPubMedPubMedCentral
17.
Huntington K, Hunter AGW, Chan K-L: A prospective study to assess the frequency of familial clustering of congenital bicuspid aortic valve. J Am Coll Cardiol. 1997, 30: 1809-1812. 10.1016/S0735-1097(97)00372-0.CrossRefPubMed
18.
Hahn RT, Roman MJ, Mogtader AH, Devereux RB: Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cadiol. 1992, 19: 283-8.CrossRef
19.
Kappetein AP, Gittenberger-de Groot AC, Zwinderman AH, Rohmer J, Poelmann RE, Huysmans HA: The neural crest as a possible pathogenic factor in coarctation of the aorta and bicuspid aortic valve. J Thorac Cardiovasc Surg. 1991, 102 (6): 830-836.PubMed
20.
Schievink WI, Mokri B: Familial aorto-cervicocephalic arterial dissections and congenitally bicuspid aortic valve. Stroke. 1995, 26: 1935-1940.CrossRefPubMed
21.
Lee TC, Zhao YD, Courtman DW, Stewart DJ: Abnormal aortic valve development in mice lacking endothelial nitric oxide synthase. Circulation. 2000, 101: 2345-2348.CrossRefPubMed
22.
Eagleton MJ, Peterson DA, Sullivan VV, Roelofs KJ, Ford JA, Stanley JC, Upchurch GR: Nitric oxide inhibition increases aortic wall matrix metalloproteinase-9 expression. J Surg Res. 2002, 104 (1): 15-21. 10.1006/jsre.2002.6396.CrossRefPubMed
23.
Gurvitz M, Chang R-K, Drant S, Allada V: Frequency of aortic root dilation in children with a bicuspid aortic valve. Am J Cardiol. 2004, 94 (10): 1337-1340. 10.1016/j.amjcard.2004.07.130.CrossRefPubMed
24.
Okamoto RJ, Xu H, Kouchoukos NT, Moon MR, Sundt TM: The influence of mechanical properties on the wall stress and distensibility of the dilated ascending aorta. J Thorac Cardiovasc Surg. 2003, 126 (3): 842-850. 10.1016/S0022-5223(03)00728-1.CrossRefPubMed
25.
Nkomo VT, Enriquez-Sarano M, Ammash NM, Melton LJ, Bailey KR, Desjardins V, Horn RA, Tajik AJ: Bicuspid aortic valve associated with aortic dilatation: A community-based study. Arterioscler Thromb Vasc Biol. 2003, 23: 351-356. 10.1161/01.ATV.0000055441.28842.0A.CrossRefPubMed
26.
Nistri S, Sorbo MD, Marin M, Palisi M, Scognamiglio R, Thiene G: Aortic root dilatation in young men with normally functioning bicuspid aortic valves. Heart. 1999, 82 (1): 19-22.CrossRefPubMedPubMedCentral
27.
Cecconi M, Manfrin M, Moraca A, Zanoli R, Colonna PL, Bettuzzi MG, S Moretti, D Gabrielli, Perna GP: Aortic dimensions in patients with bicuspid aortic valve without significant valve dysfunction. Am J Cardiol. 2005, 95 (2): 292-294. 10.1016/j.amjcard.2004.08.098.CrossRefPubMed
28.
Morgan-Hughes GJ, Roobottom CA, Owens PE, Marshall AJ: Dilatation of the aorta in pure, severe, bicuspid aortic valve stenosis. Am Heart J. 2004, 147 (4): 736-740. 10.1016/j.ahj.2003.10.044.CrossRefPubMed
29.
Keane MG, Wiegers SE, Plappert T, Pochettino A, Bavaria JE, John Sutton MG: Bicuspid Aortic Valves Are Associated With Aortic Dilatation Out of Proportion to Coexistent Valvular Lesions. Circulation. 2000, 102: 35-39.CrossRef
30.
Segura AM, Luna RE, Horiba K, Stetler-Stevenson WG, McAllister HA, Willerson JT, Ferrans VJ: Immunohistochemistry of matrix metalloproteinases and their inhibitors in thoracic aortic aneurysms and aortic valves of patients with Marfan's syndrome. Circulation Suppl. 1998, 98: II-331-II-338.
31.
Fedak PWM, de Sa MPL, Verma S, Nili N, Kazemian P, Butany J, Strauss BH, Weisel RD, David TE: Vascular matrix remodeling in patients with bicuspid aortic valve malformations: implications for aortic dilatation. J Thorac Cardiovasc Surg. 2003, 126 (3): 797-805. 10.1016/S0022-5223(03)00398-2.CrossRefPubMed
32.
Cotrufo M, Della Corte A, De Santo LS, Quarto C, De Feo M, Romano G, Amarelli C, Scardone M, Di Meglio F, Guerra G, Scarano M, Vitale S, Castaldo C, Montagnani S: Different patterns of extracellular matrix protein expression in the convexity and the concavity of the dilated aorta with bicuspid aortic valve: Preliminary results. J Thorac Cardiovasc Surg. 2005, 130 (2): 504-511. 10.1016/j.jtcvs.2005.01.016.CrossRefPubMed
33.
Robicsek F, Thubrikar MJ, Cook JW, Fowler B: The congenitally bicuspid aortic valve: how does it function? Why does it fail?. Ann Thorac Surg. 2004, 77: 177-185. 10.1016/S0003-4975(03)01249-9.CrossRefPubMed
34.
Richards KE, Deserranno D, Donal E, Greenberg NL, Thomas JD, Garcia MJ: Influence of structural geometry on the severity of bicuspid aortic stenosis. Am J Physiol Heart Circ Physiol. 2004, 287: H1410-H1416. 10.1152/ajpheart.00264.2003.CrossRefPubMed
35.
Dollery CM, McEwan JR, Henney AM: Matrix Metalloproteinases and cardiovascular disease. Circ Res. 1995, 77: 863-868.CrossRefPubMed
36.
Visse R, Nagase H: Matrix metalloproteinases and tissue inhibitors of metalloproteinases: structure, function, and biochemistry. Circ Res. 2003, 92: 827-839. 10.1161/01.RES.0000070112.80711.3D.CrossRefPubMed
37.
Nagase H, Woessner JF: Matrix metalloproteinases. J Biol Chem. 1999, 274: 21491-21494. 10.1074/jbc.274.31.21491.CrossRefPubMed
38.
Tamarina NA, McMillan WD, Shively VP, Pearce WH: Expression of matrix metalloproteinases and their inhibitors in aneurysms and normal aorta. Surg. 1997, 122 (2): 264-271. 10.1016/S0039-6060(97)90017-9.CrossRef
39.
LeMaire SA, Wang X, Wilks JA, Carter SA, Wen S, Won T, Leonardelli D, Anand G, Conklin LD, Wang XL, Thompson RW, Coselli JS: Matrix metalloproteinases in ascending aortic aneurysms: Bicuspid versus trileaflet aortic valves. J Surg Res. 2005, 123 (1): 40-48. 10.1016/j.jss.2004.06.007.CrossRefPubMed
40.
Boyum J, Fellinger EK, Schmoker JD, Trombley L, McPartland K, Ittleman FP, Howard AB: Matrix metalloproteinase activity in thoracic aortic aneurysms associated with bicuspid and tricuspid aortic valves. J Thorac Cardiovasc Surg. 2004, 127 (3): 686-691. 10.1016/j.jtcvs.2003.11.049.CrossRefPubMed
41.
Ikonomidis JS, Gibson WC, Butler JE, McClister DM, Sweterlitsch SE, Thompson RP, Mukherjee R, Spinale FG: Effects of Deletion of the Tissue Inhibitor of Matrix Metalloproteinases-1 Gene on the Progression of Murine Thoracic Aortic Aneurysms. Circulation Suppl. 2004, 110: II-268-273. 10.1161/01.CIR.0000138384.68947.20.
42.
Kaden JJ, Dempfle C-E, Grobholz R, Fischer CS, Vocke DC, Kilic R, Sarikoc A, Pinol R, Hagl S, Lang S, Brueckmann M, Borggrefe M: Inflammatory regulation of extracellular matrix remodeling in calcific aortic valve stenosis. Cardiovasc Pathol. 2005, 14 (2): 80-87. 10.1016/j.carpath.2005.01.002.CrossRefPubMed
43.
Edep ME, Shirani J, Wolf P, Brown DL: Matrix metalloproteinase expression in nonrheumatic aortic stenosis. Cardiovasc Pathol. 2000, 9 (5): 281-286. 10.1016/S1054-8807(00)00043-0.CrossRefPubMed
44.
Koullias GJ, Korkolis DP, Ravichandran P, Psyrri A, Hatzaras I, Elefteriades JA: Tissue microarray detection of matrix metalloproteinases, in diseased tricuspid and bicuspid aortic valves with or without pathology of the ascending aorta. Eur J Cardiothorac Surg. 2004, 26 (6): 1098-1103. 10.1016/j.ejcts.2004.07.050.CrossRefPubMed
45.
Soini Y, Satta J, Maatta M, Autio-Harmainen H: Expression of MMP2, MMP9, MT1-MMP, TIMP1 and TIMP2 mRNA in valvular lesions of the heart. J Pathol. 2001, 194 (2): 225-231. 10.1002/path.850.CrossRefPubMed
46.
de Sa M, Moshkovitz Y, Butany J, David TE: Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the Ross procedure. J Thorac Cardiovasc Surg. 1999, 118 (4): 588-596. 10.1016/S0022-5223(99)70002-4.CrossRefPubMed
47.
Andrus BW, O'Rourke DJ, Dacey LJ, Palac RT: Stability of Ascending Aortic Dilatation Following Aortic Valve Replacement. Circulation Suppl. 2003, 108: II-295-II-229.
48.
Matsuyama KA, Akita T, Yoshikawa M, Murayama M, Yano T, Takenaka H, Katou W, Toyama M, Okada M, Sawaki M, Ueda Y: Natural History of a Dilated Ascending Aorta After Aortic Valve Replacement. Circ J. 2005, 69: 392-396. 10.1253/circj.69.392.CrossRefPubMed
49.
Shapira OM, Aldea GS, Cutter SM, Fitzgerald CA, Lazar HL, Shemin RJ: Improved clinical outcomes after operation of the proximal aorta: a 10-year experience. Ann Thorac Surg. 1999, 67: 1030-1037. 10.1016/S0003-4975(99)00066-1.CrossRefPubMed
50.
Elefteriades JA: Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002, 74: S1877-S1880. 10.1016/S0003-4975(02)04147-4.CrossRefPubMed
51.
Borger MA, Preston M, Ivanov J, Fedak PWM, Davierwala P, Armstrong S, David TE: Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?. J Thorac Cardiovasc Surg. 2004, 128 (5): 677-683. 10.1016/j.jtcvs.2004.07.009.CrossRefPubMed
52.
Urbanski PP, Wagner M, Zacher M, Hacker RW: Aortic root replacement versus aortic valve replacement: a case-match study. Ann Thorac Surg. 2001, 72 (1): 28-32. 10.1016/S0003-4975(01)02643-1.CrossRefPubMed
53.
Sundt TM, Mora BN, Moon MR, Bailey MS, Pasque MK, Gay WA: Options for repair of a bicuspid aortic valve and ascending aortic aneurysm. Ann Thorac Surg. 2000, 69: 1333-1337. 10.1016/S0003-4975(00)01220-0.CrossRefPubMed
54.
Robicsek F, Thubrikar MJ: Conservative operation in the management of annular dilatation and ascending aortic aneurysm. Ann Thorac Surg. 1994, 57: 1672-1674.CrossRefPubMed
55.
Kuralay E, Demirkilic U, özal E, Savas öz B, Cingöz F, Günay C, Ceylan S, Arslan M, Tatar H: Surgical approach to ascending aorta in bicuspid aortic valve. J Card Surg. 2003, 18: 173-180. 10.1046/j.1540-8191.2003.02025.x.CrossRefPubMed
56.
Golesworthy T, Lampérth M, Mohiaddin R, Pepper J, Thornton W, Treasure T: The tailor of Gloucester: a jacket for the Marfan's aorta. Lancet. 2004, 364: 1582-. 10.1016/S0140-6736(04)17308-X.CrossRefPubMed
57.
David TE, Omran A, Ivanov J, Armstrong S, de Sa MP, Sonnenberg B, Webb G: Dilatation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg. 2000, 119 (2): 210-220. 10.1016/S0022-5223(00)70175-9.CrossRefPubMed
58.
Schmid F-X, Bielenberg K, Holmer S, Lehle K, Djavidani B, Prasser C, Wiesenack C, Birnbaum D: Structural and biomolecular changes in aorta and pulmonary trunk of patients with aortic aneurysm and valve disease: implications for the Ross procedure. Eur J Cardiothorac Surg. 2004, 25: 748-753. 10.1016/j.ejcts.2004.02.028.CrossRefPubMed
59.
Luciani GB, Casali G, Favero A, Prioli MA, Barozzi L, Santini F, Mazzucco A: Fate of the aortic root late after Ross operation. Circulation Suppl. 2003, 108: II-61-II-67.CrossRef
60.
Slater M, Shen I, Welke K, Komanapalli C, Ungerleider R: Modification of the Ross procedure to prevent autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005, : 181-184.
61.
Hraska V, Krajci M, Haun C, Ntalakoura K, Razek V, Lacour-Gayet F, Weil J, Reichenspurner H: Ross and Ross-Konno procedure in children and adolescents: mid-term results. Eur J Cardiothorac Surg. 2004, 25 (5): 742-747. 10.1016/j.ejcts.2004.01.009.CrossRefPubMed
62.
Bogers AJ, Kappetein A-P, Roos-Hesselink JW, Takkenberg JJM: Is a bicuspid aortic valve a risk factor for adverse outcome after an autograft procedure?. Ann Thorac Surg. 2004, 77: 1998-2003. 10.1016/j.athoracsur.2003.12.036.CrossRefPubMed
63.
Shores J, Berger KR, Murphy EA, Pyeritz RE: Progression of aortic dilatation and the benefit of long-term β-adrenergic blockade in Marfan's syndrome. New Eng J Med. 1994, 330: 1335-1341. 10.1056/NEJM199405123301902.CrossRefPubMed
64.
O'Brien KD, Shavelle DM, Caulfield MT, McDonald TO, Olin-Lewis K, Otto CM, Probstfield JL: Association of angiotensin-converting enzyme with low-density lipoprotein in aortic valvular lesions and in human plasma. Circulation. 2002, 106: 2224-2230. 10.1161/01.CIR.0000035655.45453.D2.CrossRefPubMed
65.
Rosenhek R, Rader F, Loho N, Gabriel H, Heger M, Klaar U, Schemper M, Binder T, Maurer G, Baumgartner H: Statins but not angiotensin-converting enzyme inhibitors delay progression of aortic stenosis. Circulation. 2004, 110: 1291-1295. 10.1161/01.CIR.0000140723.15274.53.CrossRefPubMed
66.
Steinmetz EF, Buckley C, Shames ML, Ennis TL, Vanvickle-Chavez SJ, Mao D, Goeddel LA, Hawkins CJ, Thompson RW: Treatment with simvastatin suppresses the development of experimental abdominal aortic aneurysms in normal and hypercholesterolaemic mice. Ann Surg. 2005, 241 (1): 92-101.PubMedPubMedCentral
67.
Rossi-Foulkes R, Roman MJ, Rosen SE, Kramer-Fox R, Ehlers KH, O'Loughlin JE, Davis JG, Devereux RB: Phenotypic features and impact of βeta blocker or calcium antagonist therapy on aortic lumen size in the Marfan syndrome. Am J Cardiol. 1999, 83 (9): 1364-1368. 10.1016/S0002-9149(99)00101-0.CrossRefPubMed
68.
Weber M, Arnold R, Rau M, Brandt R, Berkovitsch A, Mitrovic V, Hamm C: Relation of N-terminal pro-B-type natriuretic peptide to severity of valvular aortic stenosis. Am J Cardiol. 2004, 94: 740-745. 10.1016/j.amjcard.2004.05.055.CrossRefPubMed
69.
Weber M, Arnold R, Rau M, Elsaesser A, Brandt R, Mitrovic V, Hamm C: Relation of N-terminal pro B-type natriuretic peptide to progression of aortic valve disease. Eur Heart J. 2005, 26: 1023-1030. 10.1093/eurheartj/ehi236.CrossRefPubMed
70.
Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H: Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation. 2004, 109: 2302-2308. 10.1161/01.CIR.0000126825.50903.18.CrossRefPubMed
Metadata
Title
Post-stenotic aortic dilatation
Authors
Emma Wilton
Marjan Jahangiri
Publication date
01-12-2006
Publisher
BioMed Central
Published in
Journal of Cardiothoracic Surgery / Issue 1/2006
Electronic ISSN: 1749-8090
DOI
https://doi.org/10.1186/1749-8090-1-7

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