Surgical Pathology of Pure Aortic Stenosis: A Study of 374 Cases

doi:10.1016/S0025-6196(12)62057-6

Mayo Clinic Proceedings

Volume 59, Issue 10, October 1984, Pages 683-690

https://doi.org/10.1016/S0025-6196(12)62057-6 Get rights and content

The gross surgical pathologic features of the aortic valve were reviewed in 374 patients who had had clinically pure aortic stenosis and aortic valve replacement at our institution during the years 1965,1970,1975, and 1980. The most common cause of aortic stenosis, accounting for 46% of our cases, was calcification of a congenitally bicuspid valve. In the remainder, stenosis was produced by postinflammatory fibrocalcific disease (including rheumatic disease) in 35%, by degenerative calcification of an aging valve in 10%, and by calcification of a congenitally unicommissural valve in 6%. The cause of aortic stenosis was indeterminate in 4%. Valvular lesions included various degrees of dystrophic calcification, commissural fusion, and cuspid fibrosis. Calcification tended to occur more extensively and at a younger age in men than in women. Furthermore, it tended to produce stenosis and to necessitate valve replacement earliest in patients with unicommissural valves (mean age, 48 years), later in those with bicuspid or postinflammatory valves (mean age, 59 and 60 years, respectively), and latest in those with degenerative stenosis (mean age, 72 years). In our study, the relative incidence of postinflammatory aortic stenosis remained unchanged from 1965 to 1980, despite the steadily decreasing incidence of acute rheumatic fever reported in western countries. Our data suggest that (1) the incidence of chronic rheumatic heart disease has not yet begun to decrease appreciably, (2) many episodes of acute rheumatic fever may be subclinical, or (3) some forms of nonrheumatic aortic valve disease may produce gross alterations indistinguishable from those of classic chronic rheumatic valvulitis.

Section snippets

METHODS

From the Tissue Registry at our institution, we (R.S. and W.D.E.) reviewed 374 surgically excised aortic valves from patients with clinically pure aortic stenosis who had undergone aortic valve replacement during the 4 years of 1965, 1970, 1975, and 1980. By pure aortic stenosis, we mean that the stenotic aortic valve was not regurgitant or was only mildly regurgitant, as evaluated clinically and at operation. Furthermore, patients in this study may have had coexistent mitral or right-sided

Morphologic Classification.

During each of the 4 years studied, the most common causes of pure aortic stenosis were calcification of a congenitally bicuspid aortic valve and postinflammatory aortic stenosis (Table 1). Of the 374 specimens, 73 (20%) had been excised in one piece, 173 (46%) in two pieces, 75 (20%) in three pieces, and only 53 (14%) in four or more pieces. The fact that 86% of the aortic valves had been excised in three or fewer pieces greatly facilitated our ability to evaluate the commissures for acquired

DISCUSSION

Numerous autopsy studies have shown that aortic stenosis usually results from postinflammatory fibrocalcific disease (including rheumatic disease) or from calcification of bicuspid, unicommissural, or aging aortic valves.1, 2, 3, 4, 5, 10, 11 The same processes were identified in surgical specimens of valves affected by aortic stenosis in a study by Davies¹⁰ and in the current study. Accordingly, both autopsy and surgical cases of valvular aortic stenosis may be classified morphologically. One

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From January 2020 to February 2021, surgically excised rheumatic stenotic MV from 54 Tanzanian patients were studied. These were examined using hematoxylin-eosin, von Kossa staining, and immunohistochemistry.
The median (range) age of patients was 39 (14–57) years with 34 (63%) females. Secondary prophylaxis was given to 7 (13%) patients and 2 (3.7%) had evidence of rheumatic fever (RF). With hematoxylin-eosin, 37 (68.5%) specimens showed fibrinoid degeneration (FD), 44 (81.5%) leucocytic infiltrates, 6 (11.1%) Aschoff nodules, 30 (55.6%) calcification, and 39 (72.2%) fibrosis. Thirty-five (64.8%) specimens were positive to von Kossa. The proportion of specimens positive for CD3, CD20, CD68, and CD8 were 46 (85.2%), 35 (64.8%), 39 (72.2%), and 8 (14.8%) respectively. Valvular calcium was high among older patients, males and with a higher trans-MV gradient. The degree of inflammatory cellular infiltration was associated with valvular calcification, FD with ARF, leucocytic infiltrates with disease duration of <10 years, and fibrosis with the absence of atrial fibrillation. C-reactive protein and anti-streptolysin titres were high in CD20 and CD8 staining cells.
This study confirms that high MV calcium are found in patients who are old, male, and with severe mitral stenosis. The association between clinical parameters with histopathological-immunohistochemical studies observed in our study provides new insight to disease presentation. We found a low rate of secondary prophylaxis and two patients with ARF. Our findings are comparable with those from other countries suggesting similar pathogenesis and thus intervention modalities. This is the first study on mitral valve histopathology to be reported from Africa.
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La válvula aórtica bicúspide (VAB) es la malformación cardíaca congénita más frecuente. Se asocia a un mayor riesgo de complicaciones cardiovasculares, entre las que se incluye la endocarditis infecciosa (EI).
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De un total de 328 casos con EI, 118 (35,67%) fueron sobre válvula aórtica. Tenían VAB 18 (16,22%). Los casos con VAB eran más jóvenes que los portadores de VAT (51 ± 19,06 vs. 60,83 ± 15,73 años, p = 0,021) y tenían menos comorbilidad (índice de Charlson 0,67 ± 0,77 vs. 1,44 ± 1,64, p = 0,03). En el grupo con VAB observamos tendencia a EI causada por Staphylococcus spp. (38,9 vs. 21,5%, p = 0,137). Con diferencia estadística, hubo más complicaciones perivalvulares entre los casos con VAB (55,6% vs. 16,1%, p = 0,001) predominando los abscesos (38,9 vs. 16,1%, p = 0,047). Ser portador de VAB fue el único factor predictor de las mismas (OR 7,87, IC del 95%, 2,38-26,64, p = 0,001). Los pacientes con VAB se operaron más (83,3 vs. 44,1%, p = 0,004) y la mortalidad durante el ingreso hospitalario fue menor, aunque no alcanzó significación estadística (5,6 vs. 25,8%, p = 0,069). La supervivencia a un año fue significativamente superior en el grupo de VAB (93,8 vs 69,3%, p = 0,048).
Los pacientes con EI sobre VAB son jóvenes, con poca comorbilidad asociada. Tienen frecuentemente complicaciones perivalvulares por lo que requieren cirugía precoz. La mortalidad intrahospitalaria comparada con EI sobre VAT es menor y la supervivencia a un año es significativamente mayor.
Bicuspid aortic valve (BAV) is the most frequent congenital cardiac disease. It is associated to a higher risk of cardiovascular complications, including infective endocarditis (IE).
Retrospective, observational and single centre study that included all patients with IE diagnosed between 1996 and 2014. An analysis was made of the epidemiological, clinical, microbiological and echocardiographic data, complications during hospital admission, need for surgery, in-hospital mortality, and 1-year follow-up. Cases with endocarditis on prosthetic valves or other locations were excluded, as well as those for which the aortic valve morphology had not been accurately defined. A comparative statistical analysis was performed between BAV and tricuspid (TAV).
Of a total of 328 cases with IE, 118 (35.67%) were on aortic valve, with 18 (16.22%) of them being BAV. The BAV cases were younger than TAV (51 ± 19.06 vs. 60.83 ± 15.73 years, P=.021) and they had less comorbidity (Charlson 0.67 ± 0.77 vs. 1.44 ± 1.64, P=.03).). There was a higher tendency of Staphylococcal origin (38.9 vs. 21.5%, P=.137), and 55.6% showed peri-valvular complications (TAV 16.1%, P=.001), in particular, abscesses (38.9 vs.16.1%, P=.047). BAV was the only predictive factor of peri-valvular complications (OR 7.87, 95% CI; 2.38–26.64, P=.001). Patients with BAV had more surgery during their admission (83.3 vs. 44.1%, P=.004), had less in-hospital mortality, with no statistical significance (5.6 vs. 25.8%, P=.069), and 1-year survival was significantly superior (93.8 vs 69.3%, P=.048).
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This was a retrospective survey at Second Affiliated Hospital of Zhejiang University, which included all consecutive patients between 2010 and 2015.
In all, 139,496 patients were enrolled. Among severe valve diseases, MR was the most frequent (n = 946, 0.68%) followed by MS (n = 524, 0.38%), AS (n = 392, 0.28%), and AR (n = 371, 0.27%). Severe MR and AS prevalence rates increased strikingly with age. Rheumatic heart disease had an prevalence of 1.56% (n = 2179), and remained one of the most common causes of severe VHD in patients younger than 65 years old (99.5% of MS with rheumatic; 27.6% of MR with rheumatic; 25.7% of AS with rheumatic; 31.6% of AR with rheumatic). Aortic valve calcification was the predominant AS etiology, and its prevalence greatly increased with age. In severe AR, rheumatic fever was the most common etiology in patients below 65; in those above 65, etiology was mostly degenerative. In severe primary MR, mitral valve prolapse was the most common cause. Prevalence of secondary MR increased with age, from 16.4% in 18–44 years old to 51.7% in individuals ≥ 75.
Severe valvular diseases are very common; rheumatic fever and degenerative valvular changes remain predominant causes in patients below 65 and older ones, respectively. Young adults present mainly with primary MR, while secondary MR is more common in elderly ones.
Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: A single center experience
2014, Indian Heart Journal
Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo).
Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort.
In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS + MR > MS + AR > MR + AR > AS + AR > MR + AS > MS + AS. Overall, 9.7% of cases had organic tricuspid valve disease.
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Surgical pathology of native valve endocarditis in 310 specimens from 287 patients (1985-2004)
2013, Cardiovascular Pathology
Citation Excerpt :
This is based on the observation that preexisting calcification of the infected valve was absent in 182 (59%) valves, mild or moderate in 114 (37%), and severe in 14 (5%). Prior studies from our institution support this hypothesis [28–31]. Further investigation of this topic will be the subject of a future study.
Few large studies have documented the clinical and pathologic features of native valve endocarditis (NVE) independently from prosthetic valve endocarditis (PVE).
A retrospective study of medical records of all patients undergoing operation for NVE at Mayo Clinic in Rochester, MN (1985–2004), was performed. Medical records were reviewed from 287 patients for demographics, infecting organism, and comorbidities. Microscopic slides from 310 valves were reviewed for features of infection.
The study cohort included 287 patients, with age ranging from 9 to 87 years (mean, 54), yielding 310 valves. Most (73%) were from men, and 84% were regurgitant. Risk factors included bicuspid aortic valve (23%), dental manipulation (20%), mitral valve prolapse (18%), diabetes mellitus (16%), and others (< 5% each); in 15%, no risk factor was identified. The four most commonly identified organisms were viridans group streptococci (28%), Staphylococcus aureus (18%), enterococci (9%), and coagulase-negative staphylococci (8%). NVE was histologically active in 58% and healed in 42%, and affected left-sided valves in 94%. It was associated with embolization in 29%, acute heart failure in 29%, and annular abscess in 18%. Men accounted for a higher percentage of aortic NVE than mitral NVE (82% versus 63%, respectively; P=.001). Among 126 valves with active endocarditis, 25% had no microorganisms identified histologically.
NVE affected men nearly three times as frequently as women. Diabetes mellitus emerged as a prevalent (and previously underrecognized) risk factor for NVE. The most common infecting organisms were streptococci and staphylococci. Microorganisms were identified histologically in the majority of active endocarditis cases.

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^*: Mayo Graduate School of Medicine, Rochester, Minnesota. Present address: Loyola University Medical Center, Maywood, Illinois.

^†: Mayo Graduate School of Medicine, Rochester, Minnesota.

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Surgical Pathology of Pure Aortic Stenosis: A Study of 374 Cases

Section snippets

METHODS

Morphologic Classification.

DISCUSSION

Semin Roentgenol

Am Heart J

Am Heart J

Am J Med

Am J Cardiol

Hum Pathol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Med

Am Heart J

Am Heart J

Am Heart J