What are the recommended treatment options for a 74-year-old Caucasian male with a stable ascending aortic aneurysm of 5 cm diameter?

Management of Ascending Aortic Aneurysm in a 74-Year-Old Male

For a 74-year-old physically fit male with a stable ascending aortic aneurysm of 5 cm diameter, elective surgical repair is recommended when performed by experienced surgeons in a Multidisciplinary Aortic Team.

Evaluation of Surgical Threshold

The decision for surgical intervention is based primarily on aneurysm size and patient-specific factors:

• Current guidelines from the American Heart Association/American College of Cardiology (2022) recommend elective surgical repair for ascending aortic aneurysms at a diameter of ≥5.5 cm in the general population 1.

• However, for this 74-year-old patient with a 5 cm ascending aortic aneurysm, several factors should be considered:

  • The patient is physically fit with good overall health, suggesting favorable surgical candidacy
  • The risk of rupture increases with aneurysm size, roughly doubling with every 1 cm of growth over 5 cm 1
  • The mortality rate for elective surgery is low (2.2%) compared to emergency surgery for rupture or dissection (17.2%) 1

Surgical Options

For an ascending aortic aneurysm at 5 cm, the following surgical approaches should be considered:

1. Aneurysm resection with interposition graft

   • Standard approach for isolated ascending aortic aneurysms 1
   • Involves replacement of the aneurysmal segment with a synthetic graft

2. Valve considerations

   • If the aortic valve is normal, a valve-sparing procedure may be reasonable 1
   • If valve pathology exists, a separate aortic valve intervention with ascending aortic graft is recommended 1

3. Hemiarch replacement

   • If the aneurysmal disease extends into the proximal aortic arch, extending the repair with a hemiarch replacement is reasonable 1

Medical Management

While awaiting surgical intervention or for patients who decline surgery, medical management should include:

• Beta-blockers as first-line therapy to reduce aortic wall stress with target heart rate ≤60 bpm 2
• Blood pressure control with target <140/90 mmHg 2
• Lipid management with target LDL-C <55 mg/dL 2
• Regular moderate aerobic exercise while avoiding strenuous isometric exercise and contact sports 2

Surveillance Recommendations

If surgery is delayed or declined:

• Imaging frequency: Every 6 months for aneurysms 4.5-5.4 cm in diameter 1, 2
• Imaging modality: CT or MRI with consistent technique for accurate comparison 2
• Warning signs: Growth rate >0.5 cm/year is concerning and would warrant more urgent intervention 1

Risk Stratification

The risk of aortic dissection or rupture is significantly related to aneurysm size:

• The median size at time of rupture or dissection is 6.0 cm for ascending aneurysms 3
• However, data from the International Registry of Aortic Dissection (IRAD) showed that approximately 60% of patients with acute type A aortic dissection had maximal aortic diameters of <5.5 cm at presentation 1

Important Considerations

• Surgical timing: While the general threshold is 5.5 cm, earlier intervention at 5.0 cm may be reasonable in this physically fit patient to prevent potential complications 1
• Surgical mortality: Elective surgery carries a significantly lower risk (2.2%) compared to emergency surgery (17.2%) 1
• Post-operative surveillance: Lifelong imaging surveillance is essential after surgical intervention 2

Conclusion

Given this patient's 5 cm ascending aortic aneurysm, good health status, and the risk of dissection or rupture, elective surgical repair is recommended when performed by experienced surgeons in a Multidisciplinary Aortic Team. The specific surgical approach should be determined based on the anatomy of the aneurysm and the condition of the aortic valve.