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Original Articles: Cardiovascular

Thoracic Aortic Arteriosclerosis in Patients With Degenerative Aortic Stenosis With and Without Coexisting Coronary Artery Disease

^a Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
^b Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
^c Department of Cardiology, Kaplan Medical Center, Israel

Accepted for publication August 13, 2007.

^_* Address correspondence to Dr Siegel, Division of Cardiology, Room 5623, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048 (Email: siegel{at}cshs.org).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background: The association between the severity of arteriosclerosis in the thoracic aorta in patients with isolated aortic stenosis (AS) and with concomitant coronary artery disease (CAD) has been not evaluated. Therefore, the aim of our study was to compare the thoracic aortic atheroma extent and severity in patients with severe AS alone and with concomitant CAD by intraoperative transesophageal echocardiography.

Methods: We retrospectively evaluated echocardiograms of 105 consecutive patients with severe degenerative AS who underwent aortic valve replacement. Sixty patients had concomitant CAD (AS/CAD) on coronary angiography and 45 had no CAD (AS alone). These patients were compared with 54 sex- and age-matched patients without AS or CAD. Aortic atheroma (localized intimal thickening of >3 mm) prevalence and morphology in three segments of aorta were assessed with echocardiography.

Results: There were 62 men, mean age 75.3 ± 9.4 years. No difference was observed in age, sex, and risk factors for arteriosclerosis other than hypercholesterolemia among AS/CAD, AS alone, and control groups (88%, 67%, 41%, respectively; p < 0.0001). The AS/CAD group had a significantly higher rate of aortic root calcification (68%, 36%, 26%, respectively; p < 0.0001) and aortic atheroma (ascending aorta [26%, 20%, 14%, respectively; p = 0.03]; aortic arch [78%, 36%, 30%, respectively; p < 0.0001]; descending aorta [72%, 42%, 29%, respectively; p < 0.0001]) than AS alone or control subjects. Patients with AS/CAD also had more complex atheromas in the aortic arch (48%, 20%, 7%, respectively; p < 0.0001). Significant differences in extension of aortic arteriosclerosis (presence of plaques in two or three segments) were observed among the groups (70%, 31%, 18%, respectively; p < 0.0001).

Conclusions: Patients with severe AS and coexisting CAD have more extensive arteriosclerotic changes in the thoracic aorta compared with those with AS alone and control subjects. Preoperative evaluation of the thoracic aorta and more aggressive lipid therapy should be considered in these patients.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Degenerative aortic stenosis (AS) is one of the most common valvular heart diseases, resulting in valve replacement [1, 2]. Recent studies have reported an association between aortic valve calcification and arterial arteriosclerosis, suggesting that the degenerative changes of the aortic valve leading to AS may be part of a similar arteriosclerotic process [3, 4]. Transesophageal echocardiography (TEE) allows accurate assessment of the degree of arteriosclerosis in the thoracic aorta [5–10]. The severity and extent of arteriosclerosis in the thoracic aorta are strong risk factors for ischemic stroke and for overall vascular risk [11–13]. The severity of aortic arteriosclerosis has been shown to correlate with coronary artery disease (CAD). More recent studies have been demonstrated a link between arteriosclerotic changes in ascending aorta and AS. However, they did not look at the subset of patients with AS alone and those with coexisting CAD [14, 15]. It is still not clear whether CAD in patients with degenerative AS is associated with more extensive and severe arteriosclerosis of the thoracic aorta than patients with AS alone or patents without both these conditions. Therefore, we compared the presence and extent of thoracic aortic atheroma by intraoperative TEE in patients with severe degenerative AS with and without coexisting CAD, and matched control subjects having neither AS nor CAD.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
We retrospectively evaluated TEEs of 105 consecutive patients with severe degenerative AS (tricuspid aortic valve area <1 cm²) who underwent aortic valve replacement surgery (AVR). This study was approved by the Institutional Review Board at Cedars-Sinai Medical Center with a waiver to obtain consent based on the retrospective study nature and hiding of identification of patient data. All patients are prospectively entered into an Institutional Review Board–certified quality assurance database. Among all patients, 60 had concomitant CAD (AS/CAD) on coronary angiography (>50% coronary artery narrowing), and 45 had no CAD (AS/no CAD). All patients with AS and each group according to presence of CAD were compared with 54 sex-and age-matched patients without AS (on echocardiography) or CAD (on coronary angiography or no evidence of inducible ischemia on nuclear imaging). We defined diabetes mellitus as hyperglycemia requiring pharmacologic therapy; hypertension as either a systolic or diastolic increase in blood pressure (>140/90 mm Hg) or use of antihypertensive therapy; hypercholesterolemia as a total cholesterol level of greater than 200 mg/dL or use of lipid-lowering agents; and cigarette smoking as being an active smoker or having a history of smoking at least 10 pack-years within the last 20 years. An HDI-5000 ultrasound system with a 5-MHz TEE multiplane probe was used (Philips Medical System, Bothell, WA). Images were digitized, and off-line measurements were performed with the VERICIS Echo Review application (Camtronics Medical Systems Inc, Hartland, WI). Transesophageal echocardiography was performed in 105 patients as part of a routine intraoperative TEE before and after AVR. Fifty-five patients who make up the control group were referred for TEE by their cardiologists as a part of the clinical work-up for different reasons such as suspected endocarditis or atrial fibrillation, or evaluation of valvular lesions other than AS. Transesophageal echocardiography images were obtained using transgastric, midesophageal, and basal views. All segments of the thoracic aorta, including both the ascending and descending aorta and the aortic arch, were evaluated for the presence of plaques between angles of 0 and 90 degrees. Plaque thickness was defined as the thickness of the intima and media layers of the walls measured perpendicularly during systole on a frozen frame. Maximum thickness of the plaques in each region was recorded. The aortic intima was evaluated for changes in thickening, protrusion, mobile components, or ulceration. Aortic atheroma was defined as localized intimal thickening of 3 mm or greater. Complex lesions were plaques extending greater than 5 mm, or plaques that were protruding, mobile, or ulcerated. Aortic atheroma score was calculated as the sum of maximum plaque thickness of three segments and was used to assess the severity and extent of aortic arteriosclerosis. Atheroma prevalence and morphology in three segments of the aorta (ascending aorta, aortic arch, and descending aorta) were assessed. All TEEs were reviewed by one echocardiographer without knowledge of CAD status. In addition, 40 randomly selected studies were interpreted independently by the echocardiographer with excellent agreement (98%) about the presence or absence of thoracic aortic atheroma.

Data are presented as mean ± standard deviation. Statistical analysis was performed using a commercially available statistical package (SPSS 12 statistical software; SPSS Inc, Chicago, IL, or SAS version 9.1; SAS Institute, Cary, NC). Comparisons across several different groups were made by analysis of variance for continuous data and ² tests (with Fisher’s exact test when appropriate) for categorical data. The significant baseline predictor variables were entered into a stepwise multivariable logistic regression model to predict aortic atheroma. A probability value of less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Clinical Characteristics and Risk Factors
A total of 105 patients with severe AS who underwent AVR (62 men, 59%; mean age, 75.3 ± 9.4 years; aortic valve area, 0.71± 0.24 cm²) and 54 age- and sex-matched patients without AS and CAD constituted this study. Patients with AS had a somewhat higher incidence of diabetes mellitus than those without AS (31% versus 18%; p = 0.08). There was a significant difference in smoking (54% versus 33%; p = 0.008), hyperlipidemia (83% versus 42%; p < 0.0001), and the use of cholesterol-lowering agents (77% versus 35%; p < 0.0001) in patients with AS/CAD compared with AS alone. No difference was found in age, sex, and risk factors for arteriosclerosis other than hyperlipidemia among AS/CAD, AS alone, and control groups (Table 1). A higher incidence of hyperlipidemia was found in patients with AS/CAD (88%, 67%, 41%, respectively; p < 0.0001) than in those with AS alone or the control subjects, and subsequently more patients in the combined group were treated for hyperlipidemia (88%, 62%, 34%, respectively; p < 0.0001).

View larger version (48K): [in this window] [in a new window]   Fig 1. (A) Comparison of prevalence of aortic atheroma in any segment of the thoracic aorta, aortic root calcification and ascending aorta among three groups: patients with degenerative aortic stenosis (AS) with and without coronary artery disease (CAD) and the control group. (B) Comparison of aortic atheroma prevalence and morphology in the aortic arch among three groups: patients with degenerative AS with and without CAD and the control group. (C) Comparison of aortic atheroma prevalence and morphology in the descending aorta among three groups: patients with degenerative AS with and without CAD and the control group. (D) Comparison of aortic atheroma score among three groups: patients with AS with and without CAD and the control group. Aortic atheroma score (the sum of maximum plaque thickness of three segments) has been measured in patients having atheroma (83% in AS/CAD group, 62% in AS/no CAD group, and 44% in the control group patients). Probability values are for comparisons among the three groups. (Ao = aorta; Ao root Ca = aortic root calcification; Asc Ao = ascending aorta.)

View larger version (84K): [in this window] [in a new window]   Fig 2. Various types of atheroma in the thoracic aorta evaluated by intraoperative transesophageal echocardiography in patients with severe aortic stenosis and coexisting coronary artery disease. The left top image shows a protruding complex atheroma of the aortic arch (arrow). The left bottom image is an example of a simple atheroma in the junction of aortic arch and descending aorta (arrow). The right top image demonstrates highly mobile sessile atheroma in the aortic arch (arrow), and the right bottom image shows multiple protruding atheromas with very thick aortic wall (arrow).

Among 105 patients, 5 patients (4.7%) experienced a perioperative stroke, and in 4 of them complex atheromas (3 of them protruding and mobile) in the aortic arch were present on TEE. In all patients, brain computed tomography was obtained that verified cerebral infarction. Three patients experienced unilateral hemiparesis during the first 48 hours after surgery. In 1 patient a focal deficit (hemiplegia and aphasia) occurred immediately after he awoke from anesthesia. One patient experienced acute confusion state early after surgery with evidence of infarction on computed tomography. Among 38 patients who had complex aortic arch atheroma on TEE, the incidence of postoperative stroke was 16%. The operative mortality was 0.9%.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
This study evaluated the association between coexisting CAD and AS and the severity of atheromatous changes in the aorta. Comparing two groups of patients with AS (with and without CAD) and the age- and sex-matched control group, we were able to determine the impact of each of these conditions on severity and extension of arteriosclerotic changes in the thoracic aorta. Similar to a prior report, we found that patients with severe AS had a higher prevalence of arteriosclerotic changes in all portions of the thoracic aorta compared with the age- and sex- matched control group with neither AS nor CAD [15]. However, using the aortic atheroma scores, patients with AS/CAD had significantly higher rates of aortic atheroma in all segments and more extensive arteriosclerotic changes compared with those with AS/no CAD and control subjects. In addition, patients with combined AS/CAD had significantly higher prevalence of both simple and complex atheromas in the aortic arch, compared with those with AS/no CAD and control subjects. Although no significant difference was found between patients with AS/no CAD and the control group, CAD appears to be strongly associated with thoracic aortic arteriosclerosis. Using a stepwise multivariable logistic regression model, CAD was found to be the only significant predictor of the presence of aortic atheroma in patients with severe AS.

It has been demonstrated that aortic plaques are related to the presence and severity of CAD [16] and of the intimal thickening in the carotid artery [17]. In addition, a recent study found a strong association between the presence of AS and severity of aortic atheromas, suggesting that AS might be a manifestation of the arteriosclerotic process [15]. Although a large number of patients in this study had concomitant coronary artery bypass grafting, this study did not look at patients with isolated AS separately. The difference in aortic arteriosclerosis between patients with degenerative AS and bicuspid AS has been described, suggesting that the pathogenesis of these two diseases might be different [18]. Transesophageal echocardiography is an accurate method to assess arteriosclerotic plaques in the thoracic aorta and is considered to be the current noninvasive clinical "gold standard." Magnetic resonance imaging findings in terms of aortic plaque composition, extent, and size closely correlate with TEE [19].

A high incidence of perioperative stroke (25%) in patients with protruding atheromas has been reported compared with those with less severe aortic arch atheromas (2%) [20]. In that study the intraoperative diagnosis changed the surgical approach in 8%, including changing of the site of cannulation or debridement of atheroma during circulatory arrest. The presence of complex aortic arch atheromas has been shown to increase the stroke rate by sixfold after heart surgery [21]. In our study, 16% of patients with complex aortic arch experienced perioperative stroke. The overall incidence of perioperative stroke in our study is 4.7% and was similar to previously published data [15]. Of note, 4 of 5 of our patients with perioperative stroke had complex aortic arch atheromas. Perioperative stroke has been mostly attributed to manipulations of the ascending aorta during graft anastomosis, cross-clamping, or cannulation with the "sandblasting effect" from the high-flow jet [22]. Therefore, patients with severe aortic arch arteriosclerosis represent a high risk for heart surgery with cannulation of the aortic arch. The detection of complex aortic atheromas and choice of the surgical approach can reduce the incidence of this debilitating complication. Intraoperative palpation of the aorta has been found to be insensitive for detecting and assessing the severity of the lesions [23]. Transesophageal echocardiography has been demonstrated to be much more sensitive than palpation to detect ascending aorta atheromas [20]. During surgery epiaortic ultrasound has also been shown to predict stroke [22]. However, this technique is used only intraoperatively, whereas TEE is a safe and sensitive tool for preoperative assessment of thoracic aortic arteriosclerosis, identifying high-risk patients for stroke and helping in the decision making and planning of different surgical approaches in this patient population. Moreover, it has been shown that TEE-guided cannulation reduces mortality and stroke [24]. Unlike patients with severe arteriosclerosis of the aorta who undergo coronary artery bypass grafting, in whom off-pump techniques can be used without any manipulation of the aorta, in those who require AVR either aortic clamping or hypothermic circulatory arrest is currently needed. In patients with a milder degree of aortic arch arteriosclerosis the uses of a short aortic cannula or a soft-flow cannula have been introduced with no perioperative stroke [25]. Several reports on a small number of patients described different techniques for managing aortic valve disease in patients with severe aortic arch arteriosclerosis including a "no-touch" technique in which an alternative site for arterial cannulation is chosen and AVR is performed under hypothermic circulatory arrest [26, 27]. However, the duration of hypothermic circulatory arrest was long; therefore, an alternative strategy such as aortic endarterectomy in patients with aortic arteriosclerosis has been introduced. This technique, however, has been not shown to prevent embolization [21]. Another method using balloon occlusion of the ascending aorta after performing an aortotomy with the use of hypothermic circulatory arrest for a brief time has been suggested, but demonstrated an increased risk for embolizations [28]. In a recent study of 62 patients with severely arteriosclerotic ascending aortas who underwent AVR, five different strategies were used to manage the ascending aorta [29]. These techniques included AVR with the use of hypothermic circulatory arrest (39%), ascending aortic endarterectomy (26%), ascending aortic replacement (19%), aortic inspection and cross-clamping during hypothermic circulatory arrest (10%), and balloon occlusion of the ascending aorta (6%). The postoperative death was 14%, and 10 % experienced stroke. Although strokes were limited to those with AVR with hypothermic circulatory arrest and aortic endarterectomy, the choice of the operative technique did not influence the risk of stroke. Complete AVR during hypothermic circulatory arrest (the "no-touch" technique) had required a prolonged period of circulatory arrest. In this study authors concluded that ascending aortic replacement is a preferred technique, as it required a short period of hypothermic circulatory arrest and showed comparable mortality with a low risk of stroke.

Degenerative AS has many similarities in the arteriosclerotic plaque histology as well as many of the same predisposing risk factors. Despite the similarities in clinical risk factors such as hypercholesterolemia or hypertension, others such as sex, diabetes, and endothelial dysfunction have not been as strongly linked to AS [30]. Some of the histopathologic findings associated with degenerative aortic valve disease and arteriosclerosis are different. For example, calcific changes, which can be also seen in arteriosclerotic plaques, occur earlier and are more prominent in calcific aortic valve disease [3]. Moreover, in contrast to the gradual progression of degenerative AS, acute plaque rupture can occur in CAD. These discrepancies may help to explain the limited response to statin therapy in altering of aortic valve disease progression compared with well-established efficacy on coronary artery plaque regression and reversal of carotid intimal-medial thickening by statins [31]. At present, based on the available data there are no indications for statin therapy solely on the basis of AS alone if conventional guidelines for statin therapy are not met [32–34]. Despite the fact that both patient populations with AS and with CAD were found to have strong association with aortic arteriosclerosis, it still remains unclear why some patients with severe AS have normal coronary arteries and whether both CAD and AS are linked to aortic atheroma. The present study clearly demonstrates that coexisting CAD in patients with AS appears to have an extremely strong association with advanced thoracic aortic arteriosclerosis, whereas those without CAD had only a trend for higher prevalence of atheroma in the thoracic aorta compared with control subjects.

Clinical Implications
From our findings, several clinical implications can be drawn. The presence of complex aortic arch atheromas on TEE appears be associated with an increased risk of perioperative stroke. A preoperative and intraoperative evaluation of the thoracic aorta should be considered, especially in patients having combined aortic and coronary disease. In selected patients with severe arteriosclerosis of the ascending aorta and aortic arch, coronary artery bypass grafting can be done without cardiopulmonary bypass, and alternative surgical approaches including ascending aortic replacement or "no-touch" procedures without aortic clamping must be considered. Recently developed transapical surgical approach of implantation of a catheter-mounted valve combined with off-pump coronary artery bypass grafting is being pursued to reduce the risk of stroke in this high-risk population. Finally, it is not surprising that in patients with AS having thoracic aorta atheromas, significant higher low-density lipoprotein levels were found compared with those who had no arteriosclerotic changes. However, even in patients with atheroma the mean low-density lipoprotein level was less than 100 mg/dL, suggesting the need for more aggressive treatment in this population.

Conclusions
Among patients with severe AS, coexisting CAD is strongly associated with the presence and severity of arteriosclerotic changes in the thoracic aorta. Careful presurgical evaluation and alternative approaches in patients with combined AS and CAD, who represent a high-risk population in terms of severe arteriosclerosis and calcification of the ascending aorta, should be considered.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alfredo Trento Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goland, S. Articles by Siegel, R. J. Search for Related Content PubMed PubMed Citation Articles by Goland, S. Articles by Siegel, R. J. Related Collections Coronary disease Valve disease Related Article