What are the next steps for a patient with a dilated aortic root, ascending aorta, and pulmonary artery?

From the Guidelines

For a patient presenting with a dilated aortic root, ascending aorta, and pulmonary artery, surgical intervention is recommended if the aortic root dilatation exceeds 55 mm 1, or if there is evidence of progressive left ventricular dysfunction or significant aortic regurgitation.

Medical Therapy

Medical therapy with beta-blockers, such as metoprolol tartrate, at a dose of 25-50 mg orally twice daily, can help reduce hemodynamic stress on the aortic wall 1. Additionally, angiotensin II receptor blockers (ARBs), like losartan, may be considered at a dose of 50-100 mg orally daily to further reduce aortic wall tension 1.

Monitoring and Surveillance

Close monitoring with serial echocardiograms and computed tomography (CT) scans is recommended to assess the progression of aortic dilation and guide potential surgical intervention 1. The frequency of surveillance should be determined based on the patient's age, aortic diameter, rate of aortic growth, and family history 1.

Surgical Intervention

Surgical thresholds may incorporate indexing of the aortic root or ascending aortic diameter to either patient body surface area or height, or aortic cross-sectional area to patient height 1. In patients with Marfan syndrome or bicuspid aortic valves, even lower degrees of root dilatation (45 and 50 mm, respectively) have been proposed as indications for surgery, especially when there is a rapid increase of aortic diameter between serial measurements (5 mm per year) or family history of aortic dissection 1.

• Key considerations for surgical intervention include:
  • Aortic root dilatation exceeding 55 mm
  • Evidence of progressive left ventricular dysfunction
  • Significant aortic regurgitation
  • Family history of aortic dissection
  • Rapid increase in aortic diameter between serial measurements
• The choice of surgical technique should be adapted according to the following factors: associated root aneurysm, characteristics of leaflets, underlying pathology, life expectancy, and desired anticoagulation status 1.

From the Research

Next Steps for Patients with Aortic Root, Ascending Aorta, and Pulmonary Artery Dilatation

The next steps for a patient with a dilated aortic root, ascending aorta, and pulmonary artery involve careful monitoring and potential surgical intervention.

• Monitoring of the aortic root and ascending aorta is crucial to prevent complications such as dissection and rupture 2, 3, 4.
• Surgical intervention, such as aortic root surgery, may be necessary to address aortic regurgitation and prevent the risk of aortic dissection 2, 5.
• Medical management, including the use of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs), may be utilized to slow down the progression of aortic dilatation 3, 6.
• The use of ARBs has been shown to be effective in slowing down the progression of aortic root dilation in patients with Marfan syndrome 6.
• Echocardiography, computed tomography (CT), and cardiac magnetic resonance imaging (MRI) are used for diagnosis and surgical planning 3, 4.

Predictors and Rate of Progression

The rate of progression of aortic root and ascending aorta dilatation can be influenced by various factors, including:

• Baseline demographics and risk factors 4
• Medication use, such as beta-blockers and ARBs 6, 4
• Presence of connective tissue disorders, such as Marfan syndrome 3, 6
• Family history of aortic dissections 3

Surgical Interventions

Surgical interventions, such as aortic root enlargement and replacement of the ascending aorta, may be necessary in certain cases, such as:

• Severe aortic valve stenosis due to a type 0 bicuspid aortic valve and an aortic aneurysm 5
• Small aortic root, which can increase the risk of patient prosthesis mismatch 5