SOURCES FOR MORPHOLOGIC STUDIES
Before 1960, the only source for studying the heart was the autopsy. The early years of cardiac valve replacement provided a rich source of necropsy "material" until valve techniques and artificial heart valves became more refined. In the 1950s and 1960s, most physicians attributed valvular heart disease in adults to rheumatic heart disease. During the 1960s and 1970s, many thousands of patients with rheumatic heart disease underwent replacement of one or more cardiac valves. By the 1980s, most of this rheumatic heart disease pool of patients had undergone operation; in addition, the frequency of rheumatic fever and subsequently rheumatic ...
<25, 25-30, and><25% above normal (55). Among patients with MVP associated with severe MR, this annular circumference generally increases>
<1%)
7. M R + AR 28 (1%)
8. AS + MR 27 (1%)
9. Tricuspid stenosis + MS + AS 0
Totals1872 (100%) ([double dagger])
* Excludes patients with mitral regurgitation secondary to coronary
heart disease (papillary muscle dysfunction), carcinoid heart disease,
hypertrophic cardiomyopathy, and those with infective endocarditis
limited to one or both right-sided cardiac valves. Tricuspid valve
regurgitation was present in many patients in most of the nine
functional groups.
([dagger]) In many patients, the aortic valve cusps were
normal or nearly normal and the regurgitation was the result of
disease of the aorta (the Marfan and Marfan-like syndrome, syphilis;
systemic hypertension, healed aortic dissection).
([double dagger]) The operatively excised valves in the 1872 patients
were examined and classified by WCR.
Table 3. Findings at necropsy in unoperated isolated
aortic valve stenosis in men vs women (n = 192)
Variable Men (n = 139) Women (n = 53)
Age (years): range (mean)16-99 (61) 32-90 (71)
Symptomatic 103/129 (80%) 41/49 (84%)
Total cholesterol (mg/dL)206 [+ or -] 63161 [+ or -] 26
Severity of stenosis
1+ 24 (18%) 7 (13%)
2+ 22 (16%) 9 (17%)
3+ 93 (67%) 37 (70%)
Coronary narrowing
0 73 (53%) 20 (38%)
[greater than or equal to] 1 66 (47%) 33 (62%)
Mitral annular calcium
0 101 (73)% 23 (43%)
1+-3+ 38 (27%) 30 (57%)
Heart weight (g) 610 [+ or -] 135 486 [+ or -] 111
Aortic valve
Unicuspid 16 (12%)} 59% 1 (2%)} 45%
Bicuspid 66 (47%)} 23(43%)}
Tricuspid 57 (41%) 29 (55%)
Left ventricular
Fibrosis 57 (41%) 13 (25%)
Necrosis 13 (9%)5 (9%)
Table 4. Underlying structure of the aortic valve in unoperated
patients studied at necropsy with isolated aortic valve stenosis
with or without associated aortic regurgitation (n = 192)
Unicuspid Bicuspid Tricuspid
(n =17) (n = 89) (n = 86)
Variable [9%] [46%] [45%]
Age (years): range (mean) 25-73 (46) 16-87 (62)36-99 (64)
Males16 (94%) 66 (74%) 57 (66%)
Symptomatic 15 (88%)73/84 (87%) 57/78 (73%)
Total cholesterol (mg/dL) 216 203 173
Mode of death
Sudden (outside hospital) 1 (6%) 15 (17%) 11 (13%)
Sudden (inside hospital)1 (6%) 13 (15%) 6 (7%)
Nonsudden (cardiac)14 (82%) 47 (53%) 45 (52%)
Vascular 0 2 (2%)4 (5%)
Noncardiovascular 1 (6%) 12 (14%) 20 (23%)
Severity of stenosis
1+ 1 (6%) 11 (12%) 19 (22%)
2+0 14 (16%) 17 (20%)
3+ 16 (94%) 64 (72%) 50 (58%)
Coronary narrowing
0 15 (88%) 57 (64%) 41 (48%)
[greater than or equal to] 12 (12%) 32 (36%) 45 (52%)
Mitral annular calcium
0 12 (71%) 72 (81%) 40 (47%)
1+-3+ 5 (29%) 17 (19%) 46 (53%)
Heart weight (g) (mean)617 578 573
Left ventricular
Fibrosis 8/15 (53%) 34/88 (39%) 28/85 (33%)
Necrosis 1/16 (6%) 8/87 (9%)9/85 (11%)
Table 5. Data in patients having isolated aortic valve
replacement for aortic stenosis ([+ or -] aortic regurgitation)
at three different medical centers
Variable NIH (1963-1989)
Valve structure
Unicuspid
Men 84/342 (25%)
Women 14/110 (13%)
Bicuspid
Men 158/342 (46%)
Women 53/110 (48%)
Tricuspid
Men 47/342 (14%)
Women 28/110 (25%)
Indeterminate
Men 53/342 (15%)
Women 15/110 (14%)
Age (years): range (mean [+ or -] SD)
Men21-82 (54 [+ or -] 12)
Men [greater than or
equal to] 65 62/331 (19%)
Women 33-86 (57 [+ or -] 11)
Women
[great than or equal to] 65 27/104 (26%)
Gender
Men 342/452 (76%)
Women 110/452 (24%)
Aortic valve weight (g): range (mean [+ or -] SD)
Men 0.70-10.2
(4.05 [+ or -] 1.91)
Women 0.55-5.50
(2.80 [+ or -] 1.26)
Left ventricular to aortic peak systolic gradient (mm Hg):
range (mean [+ or -] SD)
Men10-145 (69 [+ or -] 30)
Women 10-165 (76 [+ or -] 34)
Aortic valve area ([cm.sup.2]): range (mean [+ or -] SD)
Men 0.20-1.90
(0.66 [+ or -0] 0.32)
Women 0.23-1.10
(0.53 [+ or -] 0.21)
Cardiac index (L/min/[m.sup.2]): range (mean [+ or -] SD)
Men 1.10-5.00
(2.58 [+ or -0] 0.72)
Women 1.60-4.50
(2.68 [+ or -0] 0.69)
Simultaneous coronary bypass
Men 21/238 (9%)
Women 6/74 (8%)
Variable GUMC (1969-1992)
Valve structure
Unicuspid
Men 56/255 (22%)
Women 24/145 (17%)
Bicuspid
Men 129/255 (50%)
Women 68/145 (47%)
Tricuspid
Men 63/255 (25%)
Women 48/145 (33%)
Indeterminate
Men 7/255(3%)
Women 5/145(3%)
Age (years): range (mean [+ or -] SD)
Men24-88 (64 [+ or -] 11)
Men [greater than or
equal to] 65 124/251 (49%)
Women 22-89 (67 [+ or -] 12)
Women
[great than or equal to] 65 94/142 (66%)
Gender
Men 255/400 (64%)
Women 145/400 (36%)
Aortic valve weight (g): range (mean [+ or -] SD)
Men 1.20-11.0
(4.36 [+ or -] 1.83)
Women 0.40-6.70
(3.02 [+ or -] 1.26)
Left ventricular to aortic peak systolic gradient (mm Hg):
range (mean [+ or -] SD)
Men10-160 (69 [+ or -] 25)
Women 30-170 (81 [+ or -] 32)
Aortic valve area ([cm.sup.2]): range (mean [+ or -] SD)
Men 0.27-1.97
(0.75 [+ or -] 0.31)
Women 0.20-1.30
(0.57 [+ or -] 0.21)
Cardiac index (L/min/[m.sup.2]): range (mean [+ or -] SD)
Men 1.00-7.30
(2.87 [+ or -] 0.93)
Women 1.60-6.20
(2.79 [+ or -] 0.81)
Simultaneous coronary bypass
Men 77/198 (39%)
Women 29/118 (25%)
Variable BUMC (1993-2004)
Valve structure
Unicuspid
Men36/601 (6%)
Women 12/356 (4%)
Bicuspid
Men 316/601 (53%)
Women 153/356 (43%)
Tricuspid
Men 242/601 (40%)
Women 186/356 (52%)
Indeterminate
Men7/601 (1%)
Women 5/356 (1%)
Age (years): range (mean [+ or -] SD)
Men25-91 (69 [+ or -] 12)
Men [greater than or
equal to] 65 424/601 (71%)
Women 27-91 (70 [+ or -] 11)
Women
[great than or equal to] 65 273/356 (77%)
Gender
Men 601/957 (63%)
Women 356/957 (37%)
Aortic valve weight (g): range (mean [+ or -] SD)
Men 0.89-11.30
(3.11 [+ or -] 1.51)
Women 0.45-4.97
(1.89 [+ or -] 0.87)
Left ventricular to aortic peak systolic gradient (mm Hg):
range (mean [+ or -] SD)
Men10-141 (52 [+ or -] 23)
Women 10-133 (54 [+ or -] 28)
Aortic valve area ([cm.sup.2]): range (mean [+ or -] SD)
Men 0.20-1.90
(0.78 [+ or -] 0.26)
Women 0.18-1.49
(0.67 [+ or -] 0.22)
Cardiac index (L/min/[m.sup.2]): range (mean [+ or -] SD)
Men --
Women--
Simultaneous coronary bypass
Men 332/601 (55%)
Women 167/356 (47%)
Reproduced with permission from Roberts WC et al, 2005 (22).
BUMC indicates Baylor University Medical Center; GUMC, Georgetown
University Medical Center; NIH, National Institutes of Health.
Table 6. Age, body mass index, concomitant coronary artery bypass,
left ventricular to aortic peak systolic gradients, and aortic valve
areas in seven aortic valve weight groups in men and in women
AV Age (years):
weight No. ofrange
(g)patients (average)
Men
[less than or equal to] 1 0 --><40-100 44/46
Lucas, 1982 (57) 102 69 [+ or -} 12 62/40
([paragraph])
Lucas, 1982 (57)69 ** -- --
Dollar, 1991 (58) 56 **16-70 33/23
(mean 48)
No. of mitral
MVPleaflets
First author, cause prolapsed
year (reference) of death 1/2 MR
Pomerance,4 12/23 8
1969
Davies, 1978 (61) 6 69/2123
Lucas, 1982 (57) 4 34/6818
Lucas, 1982 (57) -- -- --
Dollar, 1991 (58) 29 50/632
First author,
year (reference) RCT IE SD
Pomerance, 2 ([dagger]) 2 1
1969
Davies, 1978 (61) -- 9 13
Lucas, 1982 (57) 7 ([dagger]) 7 0
Lucas, 1982 (57) 19 ([double 7 16
dagger])
Dollar, 1991 (58)18 ([double 0 15
dagger])
First author,
year (reference) MS ASD *MAC
Pomerance,01 9
1969
Davies, 1978 (61) 00 3
Lucas, 1982 (57) 13 --
Lucas, 1982 (57) 20 9 --
Dollar, 1991 (58) 24 12
First author,HW
year (reference) increased DMA
Pomerance,13 --
1969
Davies, 1978 (61) 8 ([parallel]) 6
Lucas, 1982 (57) -- --
Lucas, 1982 (57) -- --
Dollar, 1991 (58)30 ([dagger] 40
[dagger])
* Secundum type atrial septal defect.
([dagger]) Thirty cases from a single hospital (1 % of autopsies).
([double dagger]) Unassociated with infective endocarditis.
([section]) Cases acquired from four different hospitals (4.5% of
autopsies).
([parallel]) Heart weight>