Influence of aortic valve phenotype, morphology and sex on ascending aorta dilation

Bicuspid aortic valve (BAV) is an important risk factor for the development of aortic valve stenosis (AS) and is often associated with a concomitant aorthopathy. However, few studies have evaluated the effect of aortic valve (AV) phenotype on the rate of dilation of the aorta. The aim of this study was to compare the progression rate of aorta dimensions according to AV phenotype (i.e. BAV vs tricuspid aortic valve [TAV]), leaflet fusion type, and sex in patients with AS. Three-hundred twenty AS patients (231 TAV and 89 BAV; mean age: 64±14 years, 72% men) recruited in the PROGRESSA study (NCT01679431) were included in this analysis. Annual Doppler-echocardiography were performed to assess AS hemodynamic severity and measure aorta dimensions including the aortic root (AR) at the sinus level and the ascending aorta (AA) sections. Baseline and last follow-up visit measurements were used to assess the annualized change of echocardiographic parameters (median follow-up time: 4.01 [2.26 to 5.00] years). Baseline AR diameters were similar between valve phenotypes and AA diameters were larger in BAV vs. TAV (34±5 vs. 34±4, p=0.43; 38±6 vs. 34±4, p< 0.001, respectively). Median change in AR root diameter was similar in BAV vs. TAV (0.15 [-0.07 to 0.44] cm/year vs. 0.13 [-0.07 to 0.41] cm/year, p=0.69), whereas AA annualized change was larger in BAV (0.26 [0.02 to 0.52] cm/year vs. 0.14 [-0.06 to 0.40] cm/year, p=0.02). After multivariable adjustment, BAV phenotype was not a significant predictor of faster progression rate of AR or AA dilation (β: -0.003, p=0.98 and -0.095, p=0.25). BAV morphology (i.e. leaflet fusion type) was not associated of AA or AR dilatation rate (p=0.14 and p=0.8, respectively). In a separate analysis according to sex, the median changes in AR and AA were similar between women and men (p=0.53 and p=0.18). Predictors of AA progression rate in men were baseline AA diameter and AS severity (i.e. baseline peak aortic jet velocity; all p≤0.03). In women, only higher low-density lipoprotein (LDL) levels were significantly associated with faster AA progression (p=0.02). There were no significant predictors of AR annualized dilation in both women and men (all p≥0.07). This study suggests that AV phenotype, leaflet fusion type and sex are not associated with faster dilation of the AR or AA in patients with BAV AS. LDL levels were associated with faster progression of AA in women but not in men.