Small aortic root in aortic stenosis: a bystander of atherosclerotic burden?

Abstract

In patients with aortic stenosis (AS) requiring aortic valve intervention, the accurate assessment of aortic annulus and aortic root size and geometry is of high clinical interest.1 The presence of small aortic root (SAR), may complicate aortic valve procedure. Furthermore, earlier in the natural history of patients with AS, SAR per se , may make the AS severity assessment more complex, due to increase pressure recovery phenomenon. Indeed, SAR may be source of discordant findings between AS severity parameters such as aortic valve area and mean pressure gradient.2 Altogether, these points underline the challenge particularities of patients with AS and SAR in clinical practice. However, although the determinants of SAR are well known, data regarding the potential prognostic value of SAR per se for risk stratification in patients with AS are lacking. Beforehand, the exact definition of SAR and the appropriate method of assessment still remain undetermined. In this issue of the ‘Journal’, Bahlmann et al. 3 report a sub-analysis of the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. They measured, in the study core-lab, the end-diastolic inner diameters and anterior wall thicknesses of the ascending aorta at the sinus of Valsalva and sino-tubular junction levels in 1560 patients who underwent echocardiography in 173 centres. They defined SAR as aortic sino-tubular junction diameter indexed for body height < 14 mm/m in women and <15 mm/m in men. Their results may be summarized as follow: 1. SAR is frequent (17%) in patients with asymptomatic moderate AS, 2. female gender, larger aortic root wall thickness at the sino-tubular junction, higher pressure recovery, lower systemic arterial compliance …