What is the management of aortopathy in a woman in her 70s with an ascending aortic dimension of 55 millimeters (mm)?

From the Guidelines

The management of aortopathy in this 70-year-old woman with an ascending aortic dimension of 55mm requires urgent surgical intervention, as this size exceeds the threshold for surgery in women, which is typically lower than in men due to a higher risk of rupture at smaller diameters. According to the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1, women are more likely to rupture under surveillance and at a smaller aortic diameter, justifying a lower threshold for intervention.

Key Considerations

• The patient's ascending aortic dimension of 55mm is above the recommended threshold for surgical intervention in women, as evidenced by the 2024 ESC guidelines 1.
• While awaiting surgery, blood pressure should be strictly controlled with beta-blockers such as metoprolol 25-100mg twice daily or losartan 50-100mg daily to reduce aortic wall stress, as suggested by the Mayo Clinic Proceedings article on thoracic aortic aneurysmal disease 1.
• The workup for aortopathy should include a comprehensive imaging assessment with CT angiography or MRI of the entire aorta to evaluate the extent of dilation and identify any associated dissection.
• Echocardiography should be performed to assess aortic valve function and other cardiac abnormalities.
• Genetic testing should be considered to identify hereditary aortopathies like Marfan syndrome, Loeys-Dietz syndrome, or familial thoracic aortic aneurysm and dissection (FTAAD), especially if there's a family history.

Surveillance and Follow-up

• Regular surveillance imaging is essential post-intervention, typically with annual imaging if stable, as outlined in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
• The follow-up algorithm for patients with TAA, as proposed in the guidelines, suggests imaging at 6–12 months, depending on aetiology and baseline diameter, and subsequently annually if there is no expansion/extension or customized according to the underlying condition.
• The urgency for intervention is based on the significantly increased risk of aortic dissection or rupture when the ascending aorta reaches this size, which carries high mortality rates if left untreated, highlighting the importance of prompt surgical evaluation and repair.

From the Research

Management of Aortopathy

The management of aortopathy in a woman in her 70s with an ascending aortic dimension of 55 millimeters (mm) can be considered based on the following points:

• The optimal management of dilated ascending aorta during aortic valve replacement remains controversial, with options including valve replacement alone, aorta wrapping, or aorta replacement 2.
• A study comparing these management options found that valve replacement alone achieved similar clinical outcomes to concomitant aortic wrapping or replacement, with low risks of adverse aortic events or relevant aortic expansion in dilated ascending aorta 2.
• Prophylactic surgery is often recommended for patients with bicuspid aortic valve when the aorta reaches 50-55 mm in diameter, due to the perceived risk of aortic dissection 3.
• However, the use of size criteria to decide on when to intervene may not be appropriate in patients with syndromic inherited aortopathies, and there are generally no clear guideline indications for when to intervene on the aortic arch in these patients 4.
• The risk associated with aortopathy varies according to age and clinical setting, and decision-making regarding the timing of intervention needs to be made on the basis of the balance between the low risk of acute aortic events and the morbidity and mortality of surgery 5.

Key Considerations

Key considerations in the management of aortopathy include:

• The size of the ascending aorta, with prophylactic surgery often recommended at 50-55 mm in diameter 3.
• The presence of bicuspid aortic valve, which is associated with an increased risk of aortic dissection 3.
• The patient's age and clinical setting, which can affect the risk associated with aortopathy and the decision to intervene 5.
• The potential benefits and risks of different management options, including valve replacement alone, aorta wrapping, or aorta replacement 2.