Background: A bicuspid aortic valve (BAV) is the most common congenital cardiac malformation and is associated with ascending aortic dilation in 60%-80% of patients. In this study, we aimed to... Show moreBackground: A bicuspid aortic valve (BAV) is the most common congenital cardiac malformation and is associated with ascending aortic dilation in 60%-80% of patients. In this study, we aimed to address the role of hemodynamic influences on the development of aortopathy in BAV patients.Patient and methods: BAV (n=36) and tricuspid aortic valve (TAV) patients (n=17) undergoing aortic valve replacement underwent preoperative flow magnetic resonance imaging (MRI) assessment to detect the area of maximal flow-induced stress in the proximal aorta. Based on these MRI data, paired ascending aortic wall samples [i.e., area of maximal jet impact (jet sample) and the opposite aortic wall (nonjet sample)] were collected during surgery. To study and describe the effects of jet stream on the complete vascular wall, a pathology score was developed based on the recently published aortic consensus paper statement on surgical pathology of the aorta using routine histologic stainings (resorcin fuchsin, hematoxylin-eosin, and Movat) and immunohistochemistry (alpha smooth muscle actin, smooth muscle 22 alpha, platelet endothelial cell adhesion molecule).Results: Comparing the jet and nonjet samples in both BAV and TAV, regions of maximal jet impact did not show any difference in the pathology score in the adventitia and the middle and outer media. In the jet samples, the inner media however showed loss of actin expression in both BAV (P<.0001) and the TAV (P=.0074), and the intimal thickness was significantly enlarged in both patient groups (BAV P=.0005, TAV P=.0041), which was not accompanied by loss of elastic lamellae or vascular smooth muscle cell nuclei.Conclusions: In our study population, we could not demonstrate a potential distinct role for hemodynamics in the development of aortopathy in BAV patients even if corrected for aortic diameter, raphe position, or whether the valve is stenotic or regurgitant. The intimal layer and inner media however showed alterations in all jet specimens. (C) 2019 The Authors. Published by Elsevier Inc. Show less
Background. The risk factors for the development of mitral annular calcification (MAC) in degenerative mitral valve disease and the effect it may have on patient-and valve-related outcomes require... Show moreBackground. The risk factors for the development of mitral annular calcification (MAC) in degenerative mitral valve disease and the effect it may have on patient-and valve-related outcomes require further evaluation.Methods. Between January 2002 and December 2015, 627 patients underwent mitral valve operations for degenerative disease. MAC was seen in 75 patients (12%); 73 (97%) underwent valve repair (6 without annuloplasty ring implantation) and 2 (3%) underwent valve replacement after an unsuccessful repair attempt.Results. MAC was linked to patient age, female sex, and degenerative disease subtype. Early mortality was comparable between patients with and without MAC (3 of 75 [4%] vs 10 of 552 [2%], p = 0.20]. In patients with MAC, one-third of the deaths were directly related to annular decalcification and reconstruction. Early repair failure was more common in patients with MAC (8 of 75 [11%] vs 17 of 552 [3%], p = 0.006). During follow-up, no differences in overall survival or freedom from late reintervention were observed. However, at 8 years after the operation, freedom from recurrent mitral regurgitation was worse in patients with MAC. In these patients, repair failure was linked to nonuse of ring annuloplasty. For patients with MAC in whom annular decalcification and annuloplasty were performed, repair durability was comparable to patients without MAC.Conclusions. Mitral valve surgery in degenerative disease accompanied by MAC is safe. Optimal surgical strategy includes annular decalcification (when this would prevent implantation of an annuloplasty ring) and ring annuloplasty and will lead to results similar to patients without MAC. However, repair performance is hampered when the annulus is not addressed. For these patients, alternative repair techniques should be explored in the future. (C) 2019 by The Society of Thoracic Surgeons Show less
AIMS: Restrictive mitral annuloplasty (RMA) can provide a durable solution for functional mitral regurgitation (MR), but might result in obstruction to antegrade mitral flow. Aim of this study was... Show moreAIMS: Restrictive mitral annuloplasty (RMA) can provide a durable solution for functional mitral regurgitation (MR), but might result in obstruction to antegrade mitral flow. Aim of this study was to assess the magnitude of change in mitral valve area (MVA) during exercise after RMA, to relate the change in MVA to left ventricular (LV) geometry and function, and to assess its haemodynamic and clinical impact.METHODS AND RESULTS: Bicycle exercise echocardiography was performed in 32 patients after RMA. Echocardiographic data at rest and during exercise were compared with preoperative echocardiographic data. Clinical endpoints were collected following the study visit. MVA increased during exercise in 25 patients (1.6 ± 0.4 cm2 to 2.0 ± 0.6 cm2, P < 0.001), whereas MVA decreased in 7 patients (1.8 ± 0.5 cm2 to 1.5 ± 0.4 cm2, P = 0.020). Patients with an increased MVA showed a significant reduction in LV volumes at rest compared to preoperatively, and an increase in stroke volume and cardiac output (CO) during exercise. In patients with decreased MVA, LV reverse remodelling was absent and myocardial flow reserve limited. Patients with decreased exercise MVA had a higher increase in mean pulmonary artery pressure (PAP) with respect to CO and worse survival 36 months after the study visit (69±19% vs. 92±5%, P = 0.005).CONCLUSIONS: Both increased and decreased MVA were observed during exercise echocardiography after RMA for functional MR. Change in MVA was related to the extent of LV geometrical and functional changes. A decreased MVA during exercise was associated with a higher increase in mean PAP with respect to CO, and worse survival. Show less
Kortekaas, K.A.; Vries, D.K. de; Roest, M.; Reinders, M.E.J.; Veer, E.P. van der; Klautz, R.J.M.; ... ; Lindeman, J.H. 2018
