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Ann Thorac Surg 2005;80:1562
© 2005 The Society of Thoracic Surgeons
a Department of Pediatric Cardiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
b Department of Cardiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
(Email: otutarel{at}hotmail.com; westhoff-bleck.mechthild{at}mh-hannover.de).
We read with interest the study by Robicsek and colleagues [1]. They are right when stating that the debate whether the changes found in the aortic wall of patients with bicuspid aortic valves (BAV) are of genetic origin or due solely to hemodynamic stresses is still ongoing [1]. Their study could provide an argument for the proponents of the theory that hemodynamic stresses are the cause for aortic dilatation. Despite the small number of specimens examined and great individual variation in their anatomy, this study could give us a clue why we diagnose aortic dilatation even in patients with a normal functioning aortic valve, ie without stenosis or regurgitation. However, if the bicuspid aortic valve has a stenotic nature without being hemodynamically (as defined by pressure and flow) stenotic and this hemodynamic burden on the aortic wall leads to its dilatation as proposed by the authors [1], then aortic valve replacement should prevent further dilatation.
Yasuda and colleagues [2] compared the annual dilatation rate of the aortic root between patients with a BAV who had undergone aortic valve replacement (AVR), patients with a BAV without AVR, and patients with a tricuspid aortic valve (TAV) who had undergone AVR. They found that aortic dilation in BAV patients tended to be faster than that in TAV patients. The BAV patients with and without AVR showed similar progressive dilatation. In contrast, patients with a TAV did not show significant dilation at any levels of the aorta. They concluded that AVR could not prevent progressive aortic dilation in BAV [2]. In 2002, Russo and colleagues [3] reported the results of a study in which they evaluated long-term changes in the ascending aorta after aortic valve replacement in 50 patients with a BAV compared with 50 patients with a TAV. They found that 5 patients with a BAV suffered late acute aortic dissection and 7 died a sudden unexplained death, which the authors suggested could be related to aortic pathology. In contrast acute aortic dissection or unexplained sudden death was not reported in the patients with a TAV.
In view of the two later studies, one has to conclude that there is a strong case for a congenital weakness of the aortic wall in patients with bicuspid aortic valves leading to an accelerated process of vessel degeneration in the face of hemodynamic stresses. But the jury is still out on a definite answer to this question.
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  F. Robicsek Bicuspid Aortic Valves and Dilatation of the Ascending Aorta: Reply Ann. Thorac. Surg., October 1, 2005; 80(4): 1562 - 1563. [Full Text] [PDF]
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