Management of Ascending Aortic Aneurysms in Women
For women with ascending aortic aneurysms, elective surgical repair is recommended when the diameter reaches ≥50 mm, which is a lower threshold than for men (≥55 mm) due to women's smaller body size and higher risk of complications at smaller absolute diameters. 1
Diagnosis and Initial Evaluation
When an ascending aortic aneurysm is identified in a woman, a comprehensive evaluation should include:
- Assessment of the entire aorta using cardiovascular computed tomography (CCT) or cardiovascular magnetic resonance (CMR) 1
- Evaluation of the aortic valve, especially for bicuspid aortic valve (BAV) 1
- Transthoracic echocardiography (TTE) to assess aortic valve function and root dimensions 1
- Screening for heritable thoracic aortic disease (HTAD), including Marfan syndrome, Turner syndrome, and other genetic disorders 1
Surveillance Protocol
For Standard Risk Women:
- For aneurysms <45 mm without risk factors: TTE annually 1
- For aneurysms 45-50 mm: TTE every 6-12 months 1
- For aneurysms in the distal ascending aorta or arch: CMR or CCT (not TTE) for surveillance 1
For Women with Turner Syndrome:
Turner syndrome requires special consideration with different thresholds based on indexed measurements:
- Use aortic size index (ASI, ratio of aortic diameter to BSA) or aortic height index (AHI, ratio of aortic diameter to height) 1
- Low risk (ASI <20 mm/m²): Evaluation every 5-10 years
- Moderate risk (ASI 20-25 mm/m²): Evaluation every 2-3 years
- High risk (ASI >25 mm/m²): Annual evaluation 1
Medical Management
- Aggressive blood pressure control is essential for all women with aortic aneurysms 2
- For women with Marfan syndrome: Beta-blockers (BB) and/or angiotensin receptor blockers (ARB) in maximally tolerated doses 1
- For women with Turner syndrome: Consider BB and/or ARB therapy similar to Marfan syndrome approach 1
- Avoid fluoroquinolone antibiotics as they increase risk of complications 2
Surgical Intervention Criteria
General Population:
- Women with tricuspid aortic valve: Surgery at ≥50 mm (lower than the 55 mm threshold for men) 1
- Women with bicuspid aortic valve: Surgery at ≥50 mm 1
Special Populations:
- Women with Marfan syndrome: Surgery at ≥50 mm 1
- Women with Turner syndrome: Consider surgery at >23 mm/m² ASI or >23 mm/m AHI with risk factors (bicuspid valve, coarctation, uncontrolled hypertension, rapid growth ≥3 mm/year) 1
- Women planning pregnancy with Turner syndrome: Consider surgery at >23 mm/m² ASI 1
Pregnancy Considerations
- Women with Marfan syndrome and aortic root >40 mm: Pregnancy should be discouraged 1
- Women with Turner syndrome and ASI >23 mm/m²: Surgery should be considered before pregnancy 1
- For pregnant women with aortic aneurysms: Close clinical and echocardiographic follow-up is mandatory 1
- Beta-blockers should be used throughout pregnancy in women with Marfan syndrome 1
Surgical Approaches
- Valve-sparing aortic root replacement is recommended when possible in experienced centers 1
- For women with aortic root dilatation, consider earlier intervention as outcomes after surgery are less satisfactory in women than men due to intervention often occurring at a later relative stage 1
Important Caveats
Women have historically had worse outcomes after aortic surgery because standard size criteria were developed based on male populations. When the same absolute diameter thresholds are used, women have reached a more advanced relative stage of disease 1.
For accurate risk assessment in women, aortic measurements should be indexed to body size (BSA or height) rather than using absolute diameters alone 1.
Growth rate is a critical factor - rapid expansion (≥3 mm/year) should prompt consideration for earlier intervention regardless of absolute size 1, 2.
The development of symptoms (chest pain, hoarseness, dysphagia) should prompt urgent evaluation regardless of aneurysm size 2.