Direction of aortic jet flow is important in predicting aortic dilatation in patients with bicuspid aortic valve

Cengiz Ozturk1, Ahmet Ozturk2, Sevket Balta1, Mustafa Aparci3, Sait Demirkol1, Murat Unlu1, Zekeriya Arslan4, Turgay Celik1

1Department of Cardiology, Gulhane Medical Faculty, Ankara, Turkey
2Department of Geriatric Medicine, Gulhane Medical Faculty, Ankara, Turkey
3Department of Cardiology, Gulhane Medical Faculty, Haydarpasa, Istanbul, Turkey
4Department of Cardiology, Mevki Military Hospital, Ankara, Turkey

Address for correspondence:
Cengiz Ozturk, MD, Department of Cardiology, Gulhane Medical Faculty, Ankara, Turkey, tel: +90 312 3044264, fax: +90 312 3044250,
e-mail: drcengizozturk@yahoo.com.tr

We read the article “Bicuspid aortic valve morphology and its association with aortic diameter: an echocardiographic study” written by Miśkowiec et al. [1] with great interest. In the article they aimed to investigate the impact of bicuspid aortic valve (BAV) cusp fusion morphology on the diameters of the aorta in their study. They found that type I BAV cusp fusion morphology is more commonly associated with dilatation of the aorta at the level of the sinus of Valsalva and the ascending aorta than type II. These results are very important in researching the effects of BAV on aortic structure in patients during our daily practice. We would like to thank the authors for this detailed and useful research. However, there are some comments that need to be discussed.

First of all, the echocardiographic measurements were taken from the database and the last one was selected for the analyses. Besides the assessment techniques and aortic size thresholds, these measurements are related with the analysis of intra-observer and inter-observer differences. The measurement of distances must be very sensitive, so the measurements should be done by at least two sonographers. This comment should be noted in present study.

There are some reports about the relation between aortic dilatation and some occupations, due to the nature of some professions, especially military, security, weight lifting, athletics, heavy work, etc. The long-term Valsalva and anti-G manoeuvres may have some effect on aortic and cardiac morphology, especially in BAV patients [2–5]. It is concluded that strenuous activities in these individuals might be important for the prevention of future cases of aortic aneurysm and dissection. But what about the professions of the study population in the present study?

As the authors reported, haemodynamic theory is important and helps to explain why the aortic dilatation occurred. The increased regional wall shear stress, abnormal transvalvular-flow patterns, and helical jet flow directed toward the aortic wall may be responsible. The left ventricular mass, end systolic and diastolic volume, interventricular septal thickness, degree of stenosis, and transvalvular pressure gradients may also effect all the measurements [6–11]. But what about blood pressure measurements of the patients? Are there any relations between these parameters and aortic dilatation or BAV morphology? It would be useful to give them in the present study.

Conflict of interest: none declared

References

1. 1. Miśkowiec DŁ, Lipiec P, Kasprzak JD. Bicuspid aortic valve morphology and its association with aortic diameter: an echocardiographic study. Kardiol Pol, 2016; 74: 151–158. doi: 10.5603/KP.a2015.0134.
2. 2. Aparci M, Erdal M, Isilak Z et al. Enlargement of the aorta: an occupational disease? Exp Clin Cardiol, 2013; 18: 93–97.
3. 3. Ozturk C, Ilbasmıs MS, Akin A.Cardiac responses to long duration and high magnitude +Gz exposure in pilots: an observational study. Anadolu Kardiyol Derg, 2012; 12: 668–674. doi: 10.5152/akd.2012.219.
4. 4. Ozturk C, Cakmak T, Metin S et al. Acceleration forces can effect cardiovascular structure. J Physiol Sci, 2014; 64: 157–158. doi: 10.1007/s12576-013-0299-y.
5. 5. Ozturk C, Ozturk A, Cakmak T et al. Bicuspid aortic valve may affect aortic dimensions in aviators. Aviat Space Environ Med, 2014; 85: 867. doi: 10.3357/ASEM.4031.2014.
6. 6. Rydzek J, Gąsior Z. [Recurrent syncope in a male patient with bicuspid aortic valve.] Kardiol Pol, 2011; 69: 475–477.
7. 7. Ruzmetov M, Shah JJ, Fortuna RS, Welke KF. The association between aortic valve leaflet morphology and patterns of aortic dilation in patients with bicuspid aortic valves. Ann Thorac Surg, 2015; 99: 2101–2107. doi: 10.1016/j.athoracsur.2015.02.036.
8. 8. Jackson V, Petrini J, Eriksson MJ et al. Aortic dimensions in relation to bicuspid and tricuspid aortic valve pathology. J Heart Valve Dis, 2014; 23: 463–472.
9. 9. Pagé M, Mongeon FP, Stevens LM et al. Aortic dilation rates in patients with biscuspid aortic valve: correlations with cusp fusion phenotype. J Heart Valve Dis, 2014; 23: 450–457.
10. 10. Kim JS, Ko SM, Chee HK et al. Relationship between bicuspid aortic valve phenotype, valvular function, and ascending aortic dimensions. J Heart Valve Dis, 2014; 23: 406–413.
11. 11. Sievers HH, Stierle U, Hachmann RM, Charitos EI. New insights in the association between bicuspid aortic valve phenotype, aortic configuration and valve haemodynamics. Eur J Cardiothorac Surg, 2016; 49: 439–446. doi: 10.1093/ejcts/ezv087.