From the Guidelines
Surgical intervention is indicated for patients with aortic root aneurysms who have symptoms attributable to the aneurysm, or for asymptomatic patients with a maximum diameter of ≥5.5 cm, as recommended by the 2022 ACC/AHA guideline 1. The management of aortic root aneurysms involves a multidisciplinary approach, including medical therapy, surgical intervention, and lifestyle modifications.
Medical Therapy
Medical therapy focuses on reducing aortic wall stress through blood pressure control with beta-blockers, such as metoprolol or atenolol, and angiotensin receptor blockers like losartan, which may be particularly beneficial in patients with Marfan syndrome 1.
Surgical Intervention
Surgical intervention is generally recommended when the aortic root diameter reaches 5.0-5.5 cm in most patients, though earlier intervention at 4.5-5.0 cm is advised for those with Marfan syndrome, bicuspid aortic valve, or family history of aortic dissection, as supported by the 2022 Aortic Disease Guideline-at-a-Glance 1.
Lifestyle Modifications
Lifestyle modifications are also crucial, including avoiding heavy lifting, competitive sports, and activities that cause Valsalva maneuvers, to prevent the catastrophic complications of aortic dissection or rupture.
Key Recommendations
Key recommendations from the guidelines include:
- Surgery is indicated for patients with symptoms attributable to the aneurysm or for asymptomatic patients with a maximum diameter of ≥5.5 cm 1.
- In patients with Marfan syndrome, an aortic root diameter ≥4.5 cm and features associated with an increased risk of aortic dissection, surgery to replace the aortic root and ascending aorta is reasonable when performed by experienced surgeons in a Multidisciplinary Aortic Team 1.
- For patients with bicuspid aortic valve, a diameter of the aortic root or ascending aorta of 5.0 to 5.4 cm and an additional risk factor for aortic dissection, surgery to replace the aortic root and/or ascending aorta is reasonable when performed by experienced surgeons in a Multidisciplinary Aortic Team 1.
From the Research
Management and Treatment Approach
The management and treatment approach for a patient with an aortic root aneurysm involves several surgical options. The primary goal is to prevent complications such as aortic dissection, rupture, and regurgitation.
- Surgical repair strategies are available for patients with aortic root aneurysms, including valve-sparing aortic root replacement and composite valved graft placement 2.
- 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 2, 3.
- Patients with aortic root aneurysms who are symptomatic or reach the recommended size criteria (diameter exceeds 50 mm) should undergo surgical repair 4.
- The presence of normal aortic leaflet tissue and minimal regurgitation, including those with connective tissue disorders, should be evaluated for valve-sparing aortic root replacement 2, 4.
Surgical Options
Several surgical options are available for patients with aortic root aneurysms, including:
- Composite replacement of the aortic valve and ascending aorta (Bentall procedure) 4, 5.
- Valve-sparing root replacement (David procedure) 3, 5.
- Aortic valve-sparing operations, which preserve the aortic cusps in aortic root dilation with aortic insufficiency 3.
Outcomes and Complications
The outcomes and complications of surgical treatment for aortic root aneurysms include: