Abstract
We investigated association between hemodynamic characteristics and aortic dilatation in patients with severe aortic stenosis (AS). Eighty patients with severe AS (mean age, 67.2 ± 12.5 years) who underwent multi-detector computed tomography and phase-contrast magnetic resonance imaging at the ascending aorta were retrospectively analyzed. Patients with an ascending aorta diameter >4 cm had a significantly higher forward flow rate at systole (28.5 ± 6.0 vs. 36.2 ± 8.6 L min, P < 0.001), and retrograde flow rate at systole (11.3 ± 4.2 vs. 18.8 ± 5.8 L min, P < 0.001), fractional reverse ratio (a ratio of retrograde flow rate to forward flow rate; 34.1 ± 11.9% vs. 43.5 ± 18.0%, P = 0.014), flow skewness Rskewness (a ratio of sum of forward and retrograde systole flow to net systole flow rate; 2.4 ± 0.7 vs. 3.2 ± 1.0, P < 0.001). The presence of bicuspid aortic valve (BAV; odds ratio [OR] 72.01, 95% confidence interval [CI] 10.57–490.46, P < 0.001), Left ventricular mass index (LVMI; OR 1.02 /g/m2; CI 1.00–1.04, P = 0.043) and Rskewness (OR 5.6 per 1, 95% CI 1.8–17.1, P = 0.001) were associated with aortic dilatation. BAV, LVMI, and increased Rskewness in the ascending aorta are associated with aortic dilatation in patients with AS.
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References
Ward C (2000) Clinical significance of the bicuspid aortic valve. Heart 83(1):81–85
Basso C, Boschello M, Perrone C, Mecenero A, Cera A, Bicego D, Thiene G, De Dominicis E (2004) An echocardiographic survey of primary school children for bicuspid aortic valve. Am J Cardiol 93(5):661–663
Nistri S, Basso C, Marzari C, Mormino P, Thiene G (2005) Frequency of bicuspid aortic valve in young male conscripts by echocardiogram. Am J Cardiol 96(5):718–721
Roberts WC, Ko JM (2005) 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 111(7):920–925
Nistri S, Sorbo M, Marin M, Palisi M, Scognamiglio R, Thiene G (1999) Aortic root dilatation in young men with normally functioning bicuspid aortic valves. Heart 82(1):19–22
Hahn RT, Roman MJ, Mogtadek AH, Devereux RB (1992) Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol 19(2):283–288
Sabet HY, Edwards WD, Tazelaar HD, Daly RC (1999) Congenitally bicuspid aortic valves: a surgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 additional cases. Mayo Clin Proc 1:14–26
Fernandes SM, Sanders SP, Khairy P, Jenkins KJ, Gauvreau K, Lang P, Simonds H, Colan SD (2004) Morphology of bicuspid aortic valve in children and adolescents. J Am Coll Cardiol 44(8):1648–1651
Sievers H-H, Sievers HL (2011) Aortopathy in bicuspid aortic valve disease—genes or hemodynamics? or Scylla and Charybdis? Eur J Cardiothorac Surg 39(6):803–804
Loscalzo ML, Goh DL, Loeys B, Kent KC, Spevak PJ, Dietz HC (2007) Familial thoracic aortic dilation and bicommissural aortic valve: a prospective analysis of natural history and inheritance. Am J Med Genet Part A 143(17):1960–1967
Cripe L, Andelfinger G, Martin LJ, Shooner K, Benson DW (2004) Bicuspid aortic valve is heritable. J Am Coll Cardiol 44(1):138–143
Fedak PW, Verma S, David TE, Leask RL, Weisel RD, Butany J (2002) Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation 106(8):900–904
Yasuda H, Nakatani S, Stugaard M, Tsujita-Kuroda Y, Bando K, Kobayashi J, Yamagishi M, Kitakaze M, Kitamura S, Miyatake K (2003) Failure to prevent progressive dilation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve: comparison with tricuspid aortic valve. Circulation 108(10 suppl 1):II-291–II-294
Tadros TM, Klein MD, Shapira OM (2009) Ascending aortic dilatation associated with bicuspid aortic valve pathophysiology, molecular biology, and clinical implications. Circulation 119(6):880–890
Bissell MM, Hess AT, Biasiolli L, Glaze SJ, Loudon M, Pitcher A, Davis A, Prendergast B, Markl M, Barker AJ (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
Barker AJ, Markl M, Bürk J, Lorenz R, Bock J, Bauer S, Schulz-Menger J, von Knobelsdorff-Brenkenhoff F (2012) Bicuspid aortic valve is associated with altered wall shear stress in the ascending aorta. Circ Cardiovasc Imaging 5(4):457–466
Meierhofer C, Schneider EP, Lyko C, Hutter A, Martinoff S, Markl M, Hager A, Hess J, Stern H, Fratz S (2013) Wall shear stress and flow patterns in the ascending aorta in patients with bicuspid aortic valves differ significantly from tricuspid aortic valves: a prospective study. Eur Heart J Cardiovasc Imaging 14(8):797–804
Guzzardi DG, Barker AJ, van Ooij P, Malaisrie SC, Puthumana JJ, Belke DD, Mewhort HE, Svystonyuk DA, Kang S, Verma S (2015) Valve-related hemodynamics mediate human bicuspid aortopathy: insights from wall shear stress mapping. J Am Coll Cardiol 66(8):892–900
Raghav V, Barker AJ, Mangiameli D, Mirabella L, Markl M, Yoganathan AP (2017) Valve mediated hemodynamics and their association with distal ascending aortic diameter in bicuspid aortic valve subjects. J Magn Reson Imaging. doi: 10.1002/jmri.25719
Lehoux S, Tedgui A (2003) Cellular mechanics and gene expression in blood vessels. J Biomech 36(5):631–643
Piatti F, Pirola S, Bissell M, Nesteruk I, Sturla F, Della Corte A, Redaelli A, Votta E (2017) Towards the improved quantification of in vivo abnormal wall shear stresses in BAV-affected patients from 4D-flow imaging: benchmarking and application to real data. J Biomech 50:93–101
Saikrishnan N, Mirabella L, Yoganathan AP (2015) Bicuspid aortic valves are associated with increased wall and turbulence shear stress levels compared to trileaflet aortic valves. Biomech Model Mechanobiol 14(3):577–588
Shan Y, Li J, Wang Y, Wu B, Barker AJ, Markl M, Wang C, Wang X, Shu X (2017) Aortic shear stress in patients with bicuspid aortic valve with stenosis and insufficiency. J Thorac Cardiovasc Surg 156(6):1263–1272
Kimura N, Nakamura M, Komiya K, Nishi S, Yamaguchi A, Tanaka O, Misawa Y, Adachi H, Kawahito K (2017) Patient-specific assessment of hemodynamics by computational fluid dynamics in patients with bicuspid aortopathy. J Thorac Cardiovasc Surg 153(4):S52–S62 [e53]
Youssefi P, Sharma R, Figueroa CA, Jahangiri M (2016) Functional assessment of thoracic aortic aneurysms–the future of risk prediction? Br Med Bull 121(1):61–71
Barker AJ, Lanning C, Shandas R (2010) Quantification of hemodynamic wall shear stress in patients with bicuspid aortic valve using phase-contrast MRI. Ann Biomed Eng 38(3):788–800
Mirabella L, Barker AJ, Saikrishnan N, Coco ER, Mangiameli DJ, Markl M, Yoganathan AP (2015) MRI-based protocol to characterize the relationship between bicuspid aortic valve morphology and hemodynamics. Ann Biomed Eng 43(8):1815–1827
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin III JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt III TM, Thomas JD, American College of Cardiology/American Heart Association, Task Force on Practice G (2014) 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 63 (22):e57–e185. doi:10.1016/j.jacc.2014.02.536
Achenbach S, Delgado V, Hausleiter J, Schoenhagen P, Min JK, Leipsic JA (2012) SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr 6(6):366–380. doi:10.1016/j.jcct.2012.11.002
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
Ha H, Choi W, Park H, Lee SJ (2014) Advantageous swirling flow in 45° end-to-side anastomosis. Exp Fluids 55(12):1–13
von Knobelsdorff-Brenkenhoff F, Karunaharamoorthy A, Trauzeddel RF, Barker AJ, Blaszczyk E, Markl M, Schulz-Menger J (2016) Evaluation of aortic blood flow and wall shear stress in aortic stenosis and its association with left ventricular remodeling. Circ Cardiovasc Imaging 9(3):e004038
Girdauskas E, Rouman M, Disha K, Fey B, Dubslaff G, Theis B, Petersen I, Gutberlet M, Borger MA, Kuntze T (2016) Functional aortic root parameters and expression of aortopathy in bicuspid versus tricuspid aortic valve stenosis. J Am Coll Cardiol 67(15):1786–1796
Burris NS, Sigovan M, Knauer HA, Tseng EE, Saloner D, Hope MD (2014) Systolic flow displacement correlates with future ascending aortic growth in patients with bicuspid aortic valves undergoing magnetic resonance surveillance. Invest Radiol 49(10):635–639
Stalder A, Russe M, Frydrychowicz A, Bock J, Hennig J, Markl M (2008) Quantitative 2D and 3D phase contrast MRI: optimized analysis of blood flow and vessel wall parameters. Magn Reson Med 60(5):1218–1231
Sigovan M, Hope MD, Dyverfeldt P, Saloner D (2011) Comparison of four-dimensional flow parameters for quantification of flow eccentricity in the ascending aorta. J Magn Reson Imaging 34(5):1226–1230
Sherwin S, Blackburn HM (2005) Three-dimensional instabilities and transition of steady and pulsatile axisymmetric stenotic flows. J Fluid Mech 533:297–327
Varghese SS, Frankel SH, Fischer PF (2007) Direct numerical simulation of stenotic flows. Part 1. Steady flow. J Fluid Mech 582:253–280
Dyverfeldt P, Hope MD, Tseng EE, Saloner D (2013) Magnetic resonance measurement of turbulent kinetic energy for the estimation of irreversible pressure loss in aortic stenosis. JACC Cardiovasc Imaging 6(1):64–71
Ha H, Kim GB, Kweon J, Huh HK, Lee SJ, Koo HJ, Kang J-W, Lim T-H, Kim D-H, Kim Y-H (2016) Turbulent kinetic energy measurement using phase contrast MRI for estimating the post-stenotic pressure drop: in vitro validation and clinical application. PloS ONE 11(3):e0151540
Casas B, Lantz J, Dyverfeldt P, Ebbers T (2015) 4D flow MRI-Based pressure loss estimation in stenotic flows: evaluation using numerical simulations. Magn Reson Med 75(4):1808–1821
Petersson S, Dyverfeldt P, Ebbers T (2012) Assessment of the accuracy of MRI wall shear stress estimation using numerical simulations. J Magn Reson Imaging 36(1):128–138
Fratz S, Chung T, Greil GF, Samyn MM, Taylor AM, Buechel ERV, Yoo S-J, Powell AJ (2013) Guidelines and protocols for cardiovascular magnetic resonance in children and adults with congenital heart disease: SCMR expert consensus group on congenital heart disease. J Cardiovasc Magn Reson 15(1):51
Acknowledgements
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (NRF-2016R1A1A1A05921207, 2015R1A2A2A04003034) and a grant (2017-7208) from the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea. The study protocol was approved by the hospital institutional review board.
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Ha, H., Koo, H.J., Lee, J.G. et al. Association between flow skewness and aortic dilatation in patients with aortic stenosis. Int J Cardiovasc Imaging 33, 1969–1978 (2017). https://doi.org/10.1007/s10554-017-1196-x
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DOI: https://doi.org/10.1007/s10554-017-1196-x