Jackson et al
Acquired Cardiovascular Disease
Ascending aortic dilatation is rarely associated with coronary artery disease regardless of aortic valve morphology Veronica Jackson, MD, PhD,a Maria J. Eriksson, MD, PhD,b Kenneth Caidahl, MD, PhD,b Per Eriksson, PhD,c and Anders Franco-Cereceda, MD, PhDa Objective: Differences in clinical presentation between patients with tricuspid aortic valves (TAVs) or bicuspid aortic valves (BAVs) and aortic valve disease are evident. Whether these differences can be attributed to differences in cardiovascular risks remains uncertain. Methods: Patient characteristics, echocardiographic findings, medical history, medication, and laboratory findings were evaluated in 702 patients with aortic valve and/or ascending aortic pathology; 202 also had concomitant coronary artery disease. Results: A BAV was commonly found in patients with isolated valve disease (BAV 47%, TAV 53%) and frequently associated with ascending aortic dilatation (BAV 80%, TAV 20%). In patients with coronary artery disease, a TAV was commonly found (TAV 84%, BAV 16%). The combination of ascending aortic dilatation and coronary artery disease was markedly rare regardless of valve morphology (TAV, 7 out of 38; BAV, 6 out of 127). The distribution of valve pathology and clinical parameters was similar in patients with TAV and BAV with coronary artery disease (P .12). Without coronary artery disease, parameters associated with cardiovascular risks were more often seen in patients with TAV than in patients with BAV (P .0001).
Supplemental material is available online.
A bicuspid aortic valve (BAV) is the most common cardiac malformation, with an estimated prevalence of 0.5% to 2%1 and a male to female ratio of 3:1.2 It is believed to be autosomal dominantly inherited with reduced penetrance3 and is associated with other congenital cardiovascular lesions.4 Typically a BAV fails earlier in life and BAV patients are approximately 10 years younger than patients with tricuspid From the Cardiothoracic Surgery Unita and Clinical Physiology Unit,b Department of Molecular Medicine and Surgery, and Atherosclerosis Research Unit at the Center for Molecular Medicine,c Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. Supported by the Tornspiran Foundation, the Mats Kleberg Foundation, the Leducq Foundation, and a donation from Fredrik Lundberg. Disclosures: Authors have nothing to disclose with regard to commercial support. Read at The American Association for Thoracic Surgery Aortic Symposium 2014, New York, New York, April 24-25, 2014. Received for publication April 17, 2014; revisions received Aug 8, 2014; accepted for publication Aug 13, 2014. Address for reprints: Veronica Jackson, MD, PhD, Cardiothoracic Surgery Unit, N3:03, Karolinska University Hospital, 171 76 Stockholm, Sweden (E-mail: [email protected]). 0022-5223/$36.00 Copyright Ó 2014 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.08.023
ACD
Conclusions: Coronary artery disease is uncommon in surgical patients with BAV, but it is associated with TAV, advanced age, and male gender. Coronary artery disease and ascending aortic dilatation rarely coexist, regardless of valve phenotype. Differences in the prevalence of coronary artery disease or ascending aortic dilatation between patients with TAV and BAV are not explained by differences in cardiovascular risks or the distribution of valve pathology. (J Thorac Cardiovasc Surg 2014;-:1-8)
aortic valves (TAV), when the surgical correction of aortic valve pathology is indicated.5,6 In addition, the BAV population is reported to have a calculated age-adjusted relative risk of aneurysm formation of 86.2 and aortic dissection of 8.4 compared with the general population.7 The disproportion of aortic aneurysms and aortic dissection rates may indicate that factors other than aorta size contribute to the incidence of aortic dissection in patients with BAV.7 The underlying pathologic mechanisms of aneurysm formation in patients with TAV and BAVare still not known. There are reports of a genetic predisposition for a weakened aortic wall in patients with BAV8-11 but also of hemodynamic influences on the aortic wall caused by the malformed valve possibly leading to aortic dilatation.12,13 Moreover, aneurysm formation in patients with TAV, but not BAV, is associated with an immune response and inflammation of the intima/media region of the aortic wall.14 It is well known that atherosclerosis and inflammation play important roles in the pathogenesis of coronary artery disease15 as well as in the formation of aortic valve stenosis.16 Differences in clinical presentation between patients with BAVor TAVand aortic valve disease are evident.2,17 Whether these differences can be attributed to differences in cardiovascular risks remains uncertain. We evaluated
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
1
Acquired Cardiovascular Disease
Abbreviations and Acronyms ASAP ¼ Advanced Study of Aortic Pathology BAV ¼ bicuspid aortic valve TAV ¼ tricuspid aortic valve
patient characteristics, echocardiographic findings, medical history, medication, and laboratory findings in patients undergoing aortic valve surgery with or without concurrent replacement of the ascending aorta and/or concurrent coronary artery bypass grafting. METHODS
ACD
The study population consisted of a total of 702 patients undergoing cardiac surgery between February 2007 and February 2012. A total of 500 consecutive patients who underwent surgery because of aortic valve and/or ascending aortic pathology within the setting of the Advanced Study of Aortic Pathology (ASAP), a prospective single center study,5 were included. Patients with coronary artery disease, defined as significant stenosis on coronary angiogram, were not included in the ASAP study. Patients were stratified according to valve morphology (TAV/BAV) and ascending aortic morphology (nondilatated or dilatated ascending aorta) based on intraoperative transesophageal echocardiography examination and valve inspection by the surgeon. The definitions of valve pathology and ascending aortic pathology, as well as how the echocardiographic measurements were obtained, have been described in detail previously.5 In addition, 202 patients, who were not included in the ASAP study but who had undergone aortic valve surgery during the same time period as patients of the ASAP study, with or without concurrent replacement of the aortic root and/or ascending aorta, who had undergone coronary artery bypass grafting, were included; all medical records were reviewed retrospectively. Patients were stratified according to valve morphology (based on the surgeon’s inspection of the valve) and ascending aortic morphology (based on whether the aortic root and/or the ascending aorta was surgically replaced). Measurements of the aortic root and ascending aorta were obtained from preoperative computed tomography examinations. If not available, measurements from the preoperative aortogram or from the preoperative transthoracic echocardiography examination were used. Information on current and previous cardiovascular disease in patients and close relatives, as well as ongoing medication and laboratory findings at the time of surgery were prospectively registered (n ¼ 500) and retrospectively reviewed (n ¼ 202). For a complete list of variables and parameters analyzed refer to Table E1. The study was approved by the regional human research ethics committee and informed consent was obtained from all patients. Patients with unicuspid aortic valves (n ¼ 15), and those who underwent isolated ascending aortic replacement (n ¼ 40), were not included in the between-group comparisons. Fifteen patients did not undergo preoperative transthoracic echocardiography within the setting of the study due to logistic reasons. In addition, 17 patients who did not meet the criteria of aortic valve stenosis or regurgitation according to the definitions of the study protocol were excluded from the analyses regarding valve pathology.
Statistical Analyses Categorical data were summarized using frequency counts and percentages. Continuous data were presented as means standard deviation or as median and interquartile range (P25-P75). The MannWhitney U test and the t test for independent samples were used to compare different subgroups for continuous variables; the c2 test and Fisher exact test were used for categorical variables. To analyze the effect of isolated
2
Jackson et al
valve pathology/combined valve and aortic pathology when controlling for valve stenosis/valve regurgitation, 2-way factorial analysis of variance was used for continuous variables and logistic regression analysis was used for dichotomous variables. In the case of a significant interaction, simple main effects tests were examined; that is, effects of 1 factor holding the other factor fixed. The distribution of some variables was positively skewed; therefore, before the formal parametric analyses, the variables were log-transformed. Analysis of covariance and logistic regression analysis were used to adjust for age. Software used were Statistica (version 10.0, StatSoft, Inc. Tulsa Okla) and SAS (system 9.1, SAS Institute Inc, Cary, NC).
RESULTS Of 500 patients without coronary artery disease, 42% had a TAV and 55% had a BAV (3% had a unicuspid aortic valve); 60% had isolated aortic valve pathology and 32% had concomitant ascending aortic dilatation (8% had isolated aortic dilatation); and 80% of patients with dilatated aortas had a BAV. The distribution of aortic valve pathology (stenosis/regurgitation) did not differ between TAV and BAV patients with nondilatated aortas (P ¼ .89). With concomitant ascending aortic pathology, valve regurgitation was the most frequent valve pathology in patients with TAV, whereas valve stenosis was more common in patients with BAV (P
Acquired Cardiovascular Disease
Ascending aortic dilatation is rarely associated with coronary artery disease regardless of aortic valve morphology Veronica Jackson, MD, PhD,a Maria J. Eriksson, MD, PhD,b Kenneth Caidahl, MD, PhD,b Per Eriksson, PhD,c and Anders Franco-Cereceda, MD, PhDa Objective: Differences in clinical presentation between patients with tricuspid aortic valves (TAVs) or bicuspid aortic valves (BAVs) and aortic valve disease are evident. Whether these differences can be attributed to differences in cardiovascular risks remains uncertain. Methods: Patient characteristics, echocardiographic findings, medical history, medication, and laboratory findings were evaluated in 702 patients with aortic valve and/or ascending aortic pathology; 202 also had concomitant coronary artery disease. Results: A BAV was commonly found in patients with isolated valve disease (BAV 47%, TAV 53%) and frequently associated with ascending aortic dilatation (BAV 80%, TAV 20%). In patients with coronary artery disease, a TAV was commonly found (TAV 84%, BAV 16%). The combination of ascending aortic dilatation and coronary artery disease was markedly rare regardless of valve morphology (TAV, 7 out of 38; BAV, 6 out of 127). The distribution of valve pathology and clinical parameters was similar in patients with TAV and BAV with coronary artery disease (P .12). Without coronary artery disease, parameters associated with cardiovascular risks were more often seen in patients with TAV than in patients with BAV (P .0001).
Supplemental material is available online.
A bicuspid aortic valve (BAV) is the most common cardiac malformation, with an estimated prevalence of 0.5% to 2%1 and a male to female ratio of 3:1.2 It is believed to be autosomal dominantly inherited with reduced penetrance3 and is associated with other congenital cardiovascular lesions.4 Typically a BAV fails earlier in life and BAV patients are approximately 10 years younger than patients with tricuspid From the Cardiothoracic Surgery Unita and Clinical Physiology Unit,b Department of Molecular Medicine and Surgery, and Atherosclerosis Research Unit at the Center for Molecular Medicine,c Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. Supported by the Tornspiran Foundation, the Mats Kleberg Foundation, the Leducq Foundation, and a donation from Fredrik Lundberg. Disclosures: Authors have nothing to disclose with regard to commercial support. Read at The American Association for Thoracic Surgery Aortic Symposium 2014, New York, New York, April 24-25, 2014. Received for publication April 17, 2014; revisions received Aug 8, 2014; accepted for publication Aug 13, 2014. Address for reprints: Veronica Jackson, MD, PhD, Cardiothoracic Surgery Unit, N3:03, Karolinska University Hospital, 171 76 Stockholm, Sweden (E-mail: [email protected]). 0022-5223/$36.00 Copyright Ó 2014 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.08.023
ACD
Conclusions: Coronary artery disease is uncommon in surgical patients with BAV, but it is associated with TAV, advanced age, and male gender. Coronary artery disease and ascending aortic dilatation rarely coexist, regardless of valve phenotype. Differences in the prevalence of coronary artery disease or ascending aortic dilatation between patients with TAV and BAV are not explained by differences in cardiovascular risks or the distribution of valve pathology. (J Thorac Cardiovasc Surg 2014;-:1-8)
aortic valves (TAV), when the surgical correction of aortic valve pathology is indicated.5,6 In addition, the BAV population is reported to have a calculated age-adjusted relative risk of aneurysm formation of 86.2 and aortic dissection of 8.4 compared with the general population.7 The disproportion of aortic aneurysms and aortic dissection rates may indicate that factors other than aorta size contribute to the incidence of aortic dissection in patients with BAV.7 The underlying pathologic mechanisms of aneurysm formation in patients with TAV and BAVare still not known. There are reports of a genetic predisposition for a weakened aortic wall in patients with BAV8-11 but also of hemodynamic influences on the aortic wall caused by the malformed valve possibly leading to aortic dilatation.12,13 Moreover, aneurysm formation in patients with TAV, but not BAV, is associated with an immune response and inflammation of the intima/media region of the aortic wall.14 It is well known that atherosclerosis and inflammation play important roles in the pathogenesis of coronary artery disease15 as well as in the formation of aortic valve stenosis.16 Differences in clinical presentation between patients with BAVor TAVand aortic valve disease are evident.2,17 Whether these differences can be attributed to differences in cardiovascular risks remains uncertain. We evaluated
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
1
Acquired Cardiovascular Disease
Abbreviations and Acronyms ASAP ¼ Advanced Study of Aortic Pathology BAV ¼ bicuspid aortic valve TAV ¼ tricuspid aortic valve
patient characteristics, echocardiographic findings, medical history, medication, and laboratory findings in patients undergoing aortic valve surgery with or without concurrent replacement of the ascending aorta and/or concurrent coronary artery bypass grafting. METHODS
ACD
The study population consisted of a total of 702 patients undergoing cardiac surgery between February 2007 and February 2012. A total of 500 consecutive patients who underwent surgery because of aortic valve and/or ascending aortic pathology within the setting of the Advanced Study of Aortic Pathology (ASAP), a prospective single center study,5 were included. Patients with coronary artery disease, defined as significant stenosis on coronary angiogram, were not included in the ASAP study. Patients were stratified according to valve morphology (TAV/BAV) and ascending aortic morphology (nondilatated or dilatated ascending aorta) based on intraoperative transesophageal echocardiography examination and valve inspection by the surgeon. The definitions of valve pathology and ascending aortic pathology, as well as how the echocardiographic measurements were obtained, have been described in detail previously.5 In addition, 202 patients, who were not included in the ASAP study but who had undergone aortic valve surgery during the same time period as patients of the ASAP study, with or without concurrent replacement of the aortic root and/or ascending aorta, who had undergone coronary artery bypass grafting, were included; all medical records were reviewed retrospectively. Patients were stratified according to valve morphology (based on the surgeon’s inspection of the valve) and ascending aortic morphology (based on whether the aortic root and/or the ascending aorta was surgically replaced). Measurements of the aortic root and ascending aorta were obtained from preoperative computed tomography examinations. If not available, measurements from the preoperative aortogram or from the preoperative transthoracic echocardiography examination were used. Information on current and previous cardiovascular disease in patients and close relatives, as well as ongoing medication and laboratory findings at the time of surgery were prospectively registered (n ¼ 500) and retrospectively reviewed (n ¼ 202). For a complete list of variables and parameters analyzed refer to Table E1. The study was approved by the regional human research ethics committee and informed consent was obtained from all patients. Patients with unicuspid aortic valves (n ¼ 15), and those who underwent isolated ascending aortic replacement (n ¼ 40), were not included in the between-group comparisons. Fifteen patients did not undergo preoperative transthoracic echocardiography within the setting of the study due to logistic reasons. In addition, 17 patients who did not meet the criteria of aortic valve stenosis or regurgitation according to the definitions of the study protocol were excluded from the analyses regarding valve pathology.
Statistical Analyses Categorical data were summarized using frequency counts and percentages. Continuous data were presented as means standard deviation or as median and interquartile range (P25-P75). The MannWhitney U test and the t test for independent samples were used to compare different subgroups for continuous variables; the c2 test and Fisher exact test were used for categorical variables. To analyze the effect of isolated
2
Jackson et al
valve pathology/combined valve and aortic pathology when controlling for valve stenosis/valve regurgitation, 2-way factorial analysis of variance was used for continuous variables and logistic regression analysis was used for dichotomous variables. In the case of a significant interaction, simple main effects tests were examined; that is, effects of 1 factor holding the other factor fixed. The distribution of some variables was positively skewed; therefore, before the formal parametric analyses, the variables were log-transformed. Analysis of covariance and logistic regression analysis were used to adjust for age. Software used were Statistica (version 10.0, StatSoft, Inc. Tulsa Okla) and SAS (system 9.1, SAS Institute Inc, Cary, NC).
RESULTS Of 500 patients without coronary artery disease, 42% had a TAV and 55% had a BAV (3% had a unicuspid aortic valve); 60% had isolated aortic valve pathology and 32% had concomitant ascending aortic dilatation (8% had isolated aortic dilatation); and 80% of patients with dilatated aortas had a BAV. The distribution of aortic valve pathology (stenosis/regurgitation) did not differ between TAV and BAV patients with nondilatated aortas (P ¼ .89). With concomitant ascending aortic pathology, valve regurgitation was the most frequent valve pathology in patients with TAV, whereas valve stenosis was more common in patients with BAV (P
