Franco E. Covino

Towards an individualized approach to bicuspid aortopathy: different valve types have unique determinants of aortic dilatation

OBJECTIVES Bicuspid aortic valve (BAV)-related aortopathy is increasingly recognized to be a heterogeneous disease entity, although the surgical approach, from indications to techniques, is still standard rather than individualized. We aimed to define the determinants of aortic dilatation in BAV patients stratified according to the valve morphotype. METHODS A consecutive echocardiographic series of 622 BAV patients was analysed. Among demographic (age, sex), anthropometric (height, weight, body surface area, body mass index), clinical (associated diseases) and echocardiographic variables (valve function, ventricular parameters), the determinants of aortic root and ascending tract diameter were assessed by multivariate regression models, as well as the predictors of aortic dilatation (size index >2.1 cm/m(2)) both in the overall population and separately in groups of different valve morphotypes (RL, right-left fusion; RN, right-non-coronary fusion). RESULTS Independent determinants of aortic root diameter (at sinuses) were age (P < 0.001), significant aortic regurgitation (P < 0.001), sex (female protective, P < 0.001) and valve morphotype (RN protective, P < 0.001). Independent determinants of ascending aortic diameter (tubular tract) were age (P < 0.001), RN morphotype (P < 0.001), body mass index (P = 0.005) and chronic obstructive pulmonary disease (P < 0.001). In univariate analysis, the RL morphotype was associated with dilatation (ASI > 2.1 cm/m(2)) at sinuses in 41% cases vs 22% for RN (P < 0.001), and the RN morphotype was associated with dilatation at the tubular tract in 68 vs 56% for RL (P = 0.007). The presence of root dilatation was predicted by age and absence of significant stenosis in the RL morphotype subgroup, and by severe regurgitation in the RN subgroup. In the RL-type subgroup, non-regurgitant aortic valve and chronic lung disease predicted dilatation at the ascending level; and in the RN-type subgroup, age and obesity. CONCLUSIONS The two most common BAV morphotypes are associated with aortic dilatation at two different tracts (RL at the root; RN at the tubular ascending tract) independently of valve function. Moreover, the determinants of aortic dilatation were at least in part different between the two morphotypes: this may provide stratification criteria for individualized methods of follow-up and treatment.

Association of left ventricular hypertrophy and aortic dilation in patients with acute thoracic aortic dissection.

This study was designed to evaluate the impact of left ventricular mass on aortic diameters in patients who presented with acute thoracic aortic dissection where aortic dilation is common. Retrospective review of transthoracic and transesophageal echocardiograms was conducted for 63 patients treated for acute thoracic aortic dissection and for 16 normal subjects who were comparable for gender prevalence, age, heart rate, and blood pressure. The diameter of the aortic root was measured by transthoracic echocardiography. Diameters of the ascending aorta, and of the aorta at locations of 25, 30, and 35 cm from the dental arch were measured by transesophageal echocardiography. The findings indicated that all aortic diameters were significantly larger in patients with aortic dissection. Patients with aortic dissection also presented with greater left ventricular mass indices (p < 0.00001) than normal subjects. Fractional shortening and left atrial diameter measurements obtained in patients with aortic dissection were similar to those obtained in the control group. Overall, the left ventricular mass index exhibited univariate relationships with aortic root diameter (r= 0.27, p<0.02) and aortic diameters at 25 cm (r=0.51, p < 0.00001), 30 cm (r= 0.58, p < 0.00001), and 35 cm (r= 0.55, p < 0.00001) distal to the arch but not with the diameter of the ascending aorta. After adjusting for gender, body mass index, history of hyper tension and aortic dissection extent (Stanford types) by separate multivariate models, the authors found that the left ventricular mass index was independently associated with aortic diameters at 25 cm (β = 0.32, p < 0.001), 30 cm (β = 0.38, p < 0.0001), and 35 cm (β = 0.34, p < 0.0005) distal to the arch. They conclude that left ventricular mass is independently asso ciated with aortic arch and descending aorta diameters in patients with acute thoracic aortic dissection. Left ventricular hypertrophy may be considered a risk factor for aortic enlarge ment and subsequent dissection.

Aortic Dissection with Fistula to Right Atrium After Heart Transplantation: Diagnosis by Transthoracic and Transesophageal Echocardiography

Aortic dissection with rupture into the right atrium is an extremely rare and rapidly fatal condition that may occur after cardiac surgery. We report the case of a 59‐year‐old woman with a 6‐year history of heart transplantation who presented with subacute illness characterized by chest pain and severe cardiac decompensation accompanied by a continuous murmur in the precordium. The diagnosis of aortic dissection complicated by right atrial fistula was made by the combination of transthoracic and transesophageal echocardiographic examination.

Pleuro-pericardiocenthesis: an unusual procedure

By echocardiography performed from the left posterior thoracic wall, we visualized a large posterior pericardial effusion and a left pleural effusion (Figs. 1 and 2). We inserted a catheter from the left posterior axillary line into the pleural (Fig. 1) and pericardial cavity (Fig. 2). A

Cardiac Rupture Due to Mitral Valve Endocarditis

A 66-year-old lady with a history of mitral valve endocarditis and recent onset of low-output syndrome, underwent successful emergency surgery for myocardial rupture with hemopericardium. Visualization of the abscess cavity was not possible with transthoracic echocardiography and a definitive diagnosis was made by transesophageal echocardiography. Diagnostic and therapeutic aspects of mitral valve abscess are reviewed.