From the Guidelines
The patient's normal left ventricular systolic function with an ejection fraction of 67% and absence of valvular pathology is reassuring, but the mild dilatation of the ascending aorta measuring 4.10 cm warrants regular monitoring and consideration of blood pressure control to prevent progression. The finding of a normal ejection fraction is a positive indicator of cardiac function, as outlined in the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. According to this guideline, LV systolic function is a crucial determinant of survival and functional status after aortic valve replacement (AVR), with optimal outcomes when surgery is performed before LVEF decreases below 55% 1. However, in this case, the ejection fraction is within the normal range, and there is no indication for immediate AVR.
Key Considerations
- The mild dilatation of the ascending aorta is a significant finding that requires regular monitoring, as it can be associated with an increased risk of aortic complications, such as dissection or rupture 1.
- Blood pressure control is essential to reduce the stress on the aortic wall and prevent progression of the dilatation, with a target blood pressure of <130/80 mmHg 1.
- Lifestyle modifications, including smoking cessation, moderate exercise, and avoidance of heavy weightlifting, are also important to reduce the risk of aortic complications.
- The use of beta-blockers, such as metoprolol 25-100 mg twice daily, may be considered, especially if the patient has hypertension, to reduce the stress on the aortic wall and prevent progression of the dilatation 1.
Monitoring and Follow-up
- Regular follow-up imaging, typically annual echocardiograms, is necessary to track any progression in aortic size and monitor for any changes in cardiac function 1.
- Patients should be educated on the importance of reporting any symptoms, such as chest pain, particularly if sharp or tearing in nature, which could indicate an aortic complication 1.
From the Research
Left Ventricular Systolic Function and Aortic Valve Pathology
- The left ventricular systolic function is normal with a calculated ejection fraction of 67% by biplane method, indicating no obvious issues with the left ventricle's ability to pump blood.
- No obvious valvular pathology is seen on this study, suggesting that the aortic valve is functioning properly without any significant stenosis or regurgitation.
Ascending Aorta Dilatation
- There is mild dilatation of the ascending aorta measuring 4.10 cm, which is below the threshold of 4.5 cm considered significant in some studies 2.
- The study by 2 found that dilatation of the proximal aorta is a frequent finding in bicuspid aortic valve disease and is independent of the severity of valve dysfunction.
- Another study by 3 compared the outcomes of different management strategies for dilated ascending aorta during aortic valve replacement and found that valve replacement alone achieved similar clinical outcomes to concomitant aortic wrapping or replacement.
Predictors of Aortic Expansion and Surgical Replacement
- A study by 4 identified predictors of ascending aorta dilatation and cardiac surgery in patients with bicuspid aortic valve, including aorta dimensions at baseline, severe aortic regurgitation developed during follow-up, family history of aortic aneurysm, and history of STEMI.
- The cause of ascending aortic dilatation in patients with bicuspid aortic valves is still debated, with some attributing it to genetic factors and others to turbulence 5.
Management of Dilated Ascending Aorta
- The optimal management of dilated ascending aorta during aortic valve replacement remains controversial, with different studies suggesting different approaches 3, 6.
- A study by 6 discussed the complex and controversial association between aortic valve dysfunction and dilated ascending aorta, highlighting the need for careful assessment of the underlying pathogenesis to guide surgical correction.