From the Guidelines
Monitoring and treatment of aortic root dilation should be guided by the most recent and highest quality evidence, which recommends regular imaging surveillance and medical management based on the degree of dilation and underlying cause, with surgical intervention generally recommended when the aortic root diameter reaches 5.0 cm in most patients, or at smaller diameters for those with high-risk conditions, as stated in the 2022 aortic disease guideline-at-a-glance 1.
Key Recommendations
- Patients with aortic root dilation should undergo regular imaging surveillance, including echocardiography every 6-12 months for mild dilation, and more frequently for moderate to severe dilation, as well as CT or MRI imaging annually for more precise measurements 1.
- Medical management typically includes beta-blockers, such as metoprolol or atenolol, to reduce hemodynamic stress on the aortic wall, and angiotensin receptor blockers, such as losartan, which are particularly beneficial in Marfan syndrome 1.
- Blood pressure should be maintained below 130/80 mmHg, and lifestyle modifications include avoiding strenuous isometric exercise, competitive sports, and activities with sudden acceleration/deceleration 1.
- Surgical intervention is generally recommended when the aortic root diameter reaches 5.0 cm in most patients, or at smaller diameters for those with high-risk conditions, such as Marfan syndrome, bicuspid aortic valve, family history of dissection, or rapid growth rate (>0.5 cm/year) 1.
High-Risk Conditions
- Marfan syndrome: surgical intervention recommended at smaller diameters (4.5-5.0 cm) due to increased risk of dissection 1.
- Bicuspid aortic valve: surgical intervention recommended at smaller diameters (4.5-5.0 cm) due to increased risk of dissection 1.
- Family history of dissection: surgical intervention recommended at smaller diameters (4.5-5.0 cm) due to increased risk of dissection 1.
- Rapid growth rate (>0.5 cm/year): surgical intervention recommended at smaller diameters (4.5-5.0 cm) due to increased risk of dissection 1.
From the Research
Monitoring Guidelines for Aortic Root Dilation
- The dilated aortic root is often asymptomatic and found incidentally on routine imaging studies such as chest radiograph, echocardiography, chest computed tomography, or magnetic resonance imaging 2
- Serial imaging studies are necessary to observe the dilated aortic root carefully over time 2
- Screening of relatives is important, especially in cases of hereditary aortopathies such as Marfan syndrome and bicuspid aortic valve disease 2, 3, 4
Treatment Guidelines for Aortic Root Dilation
- Angiotensin receptor blockers (ARBs) have been shown to slow down the progression of aortic dilatation in patients with Marfan syndrome 3
- Beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers can slow the progression of aortic dilation in Marfan syndrome, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers possibly having more effect than beta-blockers 4
- Medical prophylaxis with losartan or atenolol can reduce proximal aortic growth rates in young patients with bicuspid aortopathy 5
- Surgical repair strategies are available for patients with aortic root aneurysms, including valve sparing aortic root replacement and placement of a composite valved graft 6
- The choice of surgical procedure depends on the individual patient's condition, including the presence of normal aortic leaflet tissue and minimal regurgitation 6
Surgical Options for Aortic Root Aneurysm Disease
- Valve sparing aortic root replacement may have a lower rate of bleeding and thrombotic complications during long-term follow-up with excellent long-term survival and low rates of aortic valve reintervention 6
- Composite valve graft conduits are commonly used and have good outcomes 6
- Patients with aortic root aneurysms who are symptomatic or reach the recommended size criteria should undergo surgical repair 6