What is the management for a patient with significant aortic root and ascending aorta dilation (~55 mm at the level of the main pulmonary artery (PA))?

From the Guidelines

Surgical intervention is strongly recommended for a patient with significant aortic root and ascending aorta dilation of approximately 55 mm at the level of the main pulmonary artery, as this diameter exceeds the threshold for intervention. According to the most recent guidelines, surgery should be considered in patients who have isolated aortic arch aneurysm with a maximal diameter ≥55 mm 1. The standard surgical approach involves either a composite valve graft (Bentall procedure) if the aortic valve is also affected, or a valve-sparing root replacement (David procedure) if the valve is structurally normal.

While awaiting surgery, the patient should be started on beta-blockers such as metoprolol (25-100 mg twice daily) or atenolol (25-100 mg daily) to reduce hemodynamic stress on the aortic wall, as recommended by the 2022 aortic disease guideline-at-a-glance 1. Blood pressure should be strictly controlled to less than 130/80 mmHg. Physical activity restrictions are necessary, including avoidance of heavy lifting (nothing over 50 pounds), competitive sports, and isometric exercises.

Some key points to consider in the management of this patient include:

• The risk of catastrophic complications like aortic dissection or rupture increases substantially at diameters above 55 mm, with annual risk exceeding 10% at diameters above 60 mm.
• Regular imaging follow-up with CT or MRI every 6 months is recommended until surgery.
• A multidisciplinary team approach is recommended for determining the optimal medical, endovascular, and open surgical therapies 1.
• Shared decision-making involving the patient and a multidisciplinary team is highly encouraged to determine the optimal treatment plan 1.

The goal of treatment is to prevent life-threatening complications, which carry mortality rates of 25-50% even with emergency surgery. Therefore, elective surgical repair of the aorta should be performed as soon as possible.

From the Research

Management of Aortic Root and Ascending Aorta Dilation

The management of a patient with significant aortic root and ascending aorta dilation (~55 mm at the level of the main pulmonary artery (PA)) involves surgical intervention.

• The decision to operate is based on the diameter of the aneurysm, with current guidelines recommending surgical treatment when the diameter exceeds 50 mm 2.
• For patients with a family history of aortic dissection or with Loyes-Dietz syndrome, surgery should be considered even when the diameter is smaller 2.
• The standard procedure involves replacement of the valve and root with a composite mechanical conduit or tissue root prosthesis 3.
• Valve-sparing root reconstructive options are also available and have shown promising results 3.
• The choice of procedure depends on various factors, including the patient's age, underlying aortic pathology, and the condition of the distal aorta 4.

Surgical Techniques

• Composite replacement of the aortic valve and ascending aorta is a widely used method 4.
• The button modification of the Bentall procedure is a commonly used technique, with excellent long-term survival results 4.
• Repair of the aortic root with preservation of the aortic valve is also an option, with acceptable early and late results 5.
• Isolated supracoronary graft replacement is another technique used in some cases 5.

Medical Therapy

• Medical therapy for Marfan syndrome, which is a genetic disorder that can cause aortic root dilation, includes the use of β-blockers and angiotensin II receptor blockers to reduce the rate of aortic dilation 6.
• Medical therapy should be individualized according to patient tolerance and risk factors, such as age, aortic size, and family history of aortic dissection 6.