Valve-Related Hemodynamics Mediate Human Bicuspid Aortopathy: Insights From Wall Shear Stress Mapping

David G. Guzzardi, Alex J. Barker, Pim Van Ooij, S. Chris Malaisrie, Jyothy J. Puthumana, Darrell D. Belke, Holly E.M. Mewhort, Daniyil A. Svystonyuk, Sean Kang, Subodh Verma, Jeremy Collins, James Carr, Robert O. Bonow, Michael Markl, James D. Thomas, Patrick M. Mccarthy, Paul W.M. Fedak*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

307 Scopus citations


Background Suspected genetic causes for extracellular matrix (ECM) dysregulation in the ascending aorta in patients with bicuspid aortic valves (BAV) have influenced strategies and thresholds for surgical resection of BAV aortopathy. Using 4-dimensional (4D) flow cardiac magnetic resonance imaging (CMR), we have documented increased regional wall shear stress (WSS) in the ascending aorta of BAV patients. Objectives This study assessed the relationship between WSS and regional aortic tissue remodeling in BAV patients to determine the influence of regional WSS on the expression of ECM dysregulation. Methods BAV patients (n = 20) undergoing ascending aortic resection underwent pre-operative 4D flow CMR to regionally map WSS. Paired aortic wall samples (i.e., within-patient samples obtained from regions of elevated and normal WSS) were collected and compared for medial elastin degeneration by histology and ECM regulation by protein expression. Results Regions of increased WSS showed greater medial elastin degradation compared to adjacent areas with normal WSS: decreased total elastin (p = 0.01) with thinner fibers (p = 0.00007) that were farther apart (p = 0.001). Multiplex protein analyses of ECM regulatory molecules revealed an increase in transforming growth factor β-1 (p = 0.04), matrix metalloproteinase (MMP)-1 (p = 0.03), MMP-2 (p = 0.06), MMP-3 (p = 0.02), and tissue inhibitor of metalloproteinase-1 (p = 0.04) in elevated WSS regions, indicating ECM dysregulation in regions of high WSS. Conclusions Regions of increased WSS correspond with ECM dysregulation and elastic fiber degeneration in the ascending aorta of BAV patients, implicating valve-related hemodynamics as a contributing factor in the development of aortopathy. Further study to validate the use of 4D flow CMR as a noninvasive biomarker of disease progression and its ability to individualize resection strategies is warranted.

Original languageEnglish (US)
Article number21525
Pages (from-to)892-900
Number of pages9
JournalJournal of the American College of Cardiology
Issue number8
StatePublished - Aug 25 2015


  • aneurysm
  • imaging
  • remodeling

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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