What is the management approach for patients with a dilated aortic root and ascending aorta?

From the Guidelines

Surgical intervention is indicated for patients with a dilated aortic root and ascending aorta when the maximum diameter reaches ≥5.5 cm, or ≥5.0 cm in patients with additional risk factors, such as a bicuspid aortic valve or Marfan syndrome, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. The management approach for patients with a dilated aortic root and ascending aorta involves both medical therapy and surgical intervention based on the degree of dilation and associated risk factors.

• Medical therapy includes beta-blockers, such as metoprolol or atenolol, to reduce aortic wall stress by decreasing heart rate and blood pressure.
• Angiotensin receptor blockers (ARBs) like losartan may be particularly beneficial in patients with Marfan syndrome.
• Blood pressure should be maintained below 130/80 mmHg.
• Lifestyle modifications are essential, including strict avoidance of isometric exercise, competitive sports, and activities with sudden acceleration/deceleration.
• Regular imaging surveillance is necessary, with echocardiography, CT, or MRI recommended every 6-12 months for moderate dilation (4.0-4.5 cm) and more frequently for larger dimensions. Surgical intervention thresholds are as follows:
• ≥5.5 cm in most patients
• ≥5.0 cm in patients with a bicuspid aortic valve or Marfan syndrome
• ≥4.5 cm in patients with additional risk factors, such as family history of dissection or rapid growth rate (>0.5 cm/year) These thresholds exist because the risk of catastrophic complications like dissection or rupture increases exponentially as the aorta enlarges beyond these dimensions, as supported by the 2022 ACC/AHA guideline 1 and other studies 1.

From the Research

Management Approach for Dilated Aortic Root and Ascending Aorta

The management approach for patients with a dilated aortic root and ascending aorta involves surgical intervention, with the goal of preventing complications such as dissection, rupture, and death. The decision to operate is based on the diameter of the aortic root and ascending aorta, as well as the presence of other risk factors.

Operating Cut-Offs

The operating cut-offs for dilated aortic root and ascending aorta are as follows:

• Aortic root dilatation: 5.0 cm 2
• Mid-ascending aortic dilatation: 5.25 cm 2
• Ascending aortic aneurysm: 5.5 cm 3, 4
• Ascending aortic aneurysm in patients with low surgical risk or known connective tissue disorders: 5.0 cm 4

Surgical Techniques

The surgical techniques used to manage dilated aortic root and ascending aorta include:

• Replacement of the aortic root and ascending aorta with a composite graft 5, 4
• Valve-sparing root reconstructive options 4
• Reduction aortoplasty 4
• Interposition graft replacement 4
• Bentall operation, which comprises root replacement with an aortic tube graft and mechanical valve 6
• Valve-sparing operations, which aim to preserve the aortic valve 6

Risk Factors

The risk factors that influence the decision to operate include:

• Presence of connective tissue disorders, such as Marfan syndrome 2, 4
• Presence of bicuspid aortic valve or coarctation of the aorta 6
• Presence of complex congenital heart disease 6
• Short stature 2
• Significant comorbidity 5