From the Guidelines
The next step for this 40-year-old male with abnormal ventricular septal motion and dilated proximal ascending aorta should be referral to a cardiologist for comprehensive evaluation, including cardiac MRI and genetic testing, as suggested by the most recent guidelines 1. The patient's condition is concerning for possible connective tissue disorders, such as Marfan syndrome, bicuspid aortic valve disease, or familial thoracic aortic aneurysm, which can lead to life-threatening complications like aortic dissection or rupture 1. Key considerations in the management of this patient include:
- Complete aortic assessment with CT angiography or MRI angiography to determine the exact dimensions of the aorta, extent of dilation, and to rule out dissection 1
- Blood pressure control with beta-blockers, such as metoprolol 25-50mg twice daily, or losartan 50-100mg daily, if tolerated, to reduce the risk of aortic dilation and dissection 1
- Avoidance of strenuous activities and heavy lifting until further evaluation 1
- Investigation into possible connective tissue disorders, including genetic testing, to guide management and screening of first-degree relatives 1 The abnormal septal motion may indicate right ventricular volume overload or conduction abnormalities requiring further investigation, and early intervention is crucial as aortic dilation increases the risk of life-threatening dissection, with surgical repair typically recommended when the ascending aorta reaches 5.0-5.5cm, depending on the underlying etiology 1.
From the Research
Next Steps for Abnormal Ventricular Septal Motion and Dilated Proximal Ascending Aorta
The patient's echocardiogram showing abnormal ventricular septal motion and a dilated proximal ascending aorta (39mm) requires careful consideration of the following:
- The size of the aorta and the underlying pathology of the aortic wall are crucial in determining the risk of spontaneous rupture or dissection 2
- The patient's age, the relative size of the aorta, and the structure and function of the aortic valve should be considered when recommending elective surgery 2
- The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention, and surgical guidelines for intervening in degenerative dilatation of the ascending aorta are mostly empiric due to a lack of natural history studies 2
- Abnormal septal motion can be observed in diseases beyond myocardial ischemia, and echocardiography can provide information about the possible underlying pathophysiological mechanism 3
- In patients with bicuspid aortic valve and dilated proximal ascending aorta, an abnormal ascending aortic area/height ratio is associated with increased longer-term cardiovascular mortality 4
Considerations for Surgical Intervention
- Elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement 2
- Composite replacement of the aortic valve and the ascending aorta remains the most versatile and widely applied method 2
- The choice of procedure is influenced by careful consideration of multiple factors, including the patient's age, underlying aortic pathology, and anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sino-tubular ridge 2
Diagnostic and Prognostic Considerations
- Echocardiography can provide valuable information about the motion of the interventricular septum and the possible underlying pathophysiological mechanism 3
- An abnormal ascending aortic area/height ratio is independently associated with cardiovascular death in patients with bicuspid aortic valve and dilated proximal ascending aorta 4
- The patient's clinical presentation, including symptoms and physical examination findings, should be carefully evaluated in conjunction with echocardiographic and other diagnostic findings 5, 6