What is the next step in management for a patient with a dilated proximal ascending aorta of 39 mm?

From the Guidelines

For a patient with a dilated proximal ascending aorta of 39 mm, the next step in management should focus on regular monitoring and risk factor modification. This approach is based on the latest guidelines and evidence, which emphasize the importance of surveillance and preventive measures in managing aortic diseases 1. The patient should undergo surveillance imaging with echocardiography, CT, or MRI every 6-12 months to monitor for progression of the aortic dilation, as recommended by the American Heart Association and American College of Cardiology 1. Key aspects of management include:

• Blood pressure control with a target of less than 130/80 mmHg using beta-blockers or angiotensin receptor blockers as first-line agents
• Lifestyle modifications such as smoking cessation, moderate aerobic exercise, and maintaining a healthy weight
• Avoiding competitive sports and activities with potential for bodily collision
• Considering genetic testing if there is a family history of aortic disease or connective tissue disorders While the 39 mm measurement falls below the typical surgical threshold of 50-55 mm for the ascending aorta in most patients, closer follow-up is warranted if there is rapid growth (>3-5 mm/year), family history of aortic dissection, or presence of genetic syndromes like Marfan syndrome 1. Regular monitoring and risk factor modification are crucial in preventing complications and improving outcomes in patients with aortic diseases, as highlighted in the 2014 ESC guidelines on the diagnosis and treatment of aortic diseases 1 and the 2015 American Heart Association and American College of Cardiology statement on eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities 1.

From the Research

Management of Dilated Proximal Ascending Aorta

The management of a patient with a dilated proximal ascending aorta of 39 mm involves careful consideration of the risk of dissection or rupture.

• The size of the aorta is an important factor in determining the risk of dissection or rupture, with larger diameters associated with a higher risk 2.
• However, the majority of patients with acute type A aortic dissection present with aortic diameters less than 5.5 cm, suggesting that size alone may not be a reliable predictor of risk 2.
• Other factors, such as the underlying pathology of the aortic wall, the presence of hypertension or other comorbidities, and the patient's age and overall health status, must also be taken into account 3, 4.

Surgical Intervention

Surgical intervention may be necessary to prevent dissection or rupture, especially in patients with a dilated ascending aorta greater than 5.5 cm 4.

• Elective ascending aortic replacement is recommended to prevent acute type A aortic dissection when any segment of the proximal aorta is greater than 5.5 cm 2.
• However, the decision to operate must be individualized, taking into account the patient's overall health status, the presence of comorbidities, and the potential risks and benefits of surgery 4.
• Preventative replacement of the ascending aorta at 4.5 cm should be considered, especially at high-volume aortic surgery centers and in patients having cardiac surgery for other indications 2.

Medical Management

Medical management is also crucial in the management of patients with a dilated proximal ascending aorta.

• Beta-blockers are known to protect a vulnerable aorta from acute dissection, as well as reducing the risk of recurrent dissection 5.
• Aggressive medical management of patients with ascending aortic diameters over 4 cm is warranted, including the use of beta-blockers and other medications to control hypertension and reduce the risk of dissection 2.