Early surgical intervention of ascending aortic aneurysm vs 2010 ACC guidelines

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gsl1956

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Mar 18, 2017
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Location
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In the Jan. 2018 edition of the medical journal Cardiology, Dr. John Elefteriades and colleagues published a new study on aortic dissection and diamter size. The Report is entitled “Prevention of Aortic Dissection Suggests a Diameter Shift to a Lower Aortic Size Threshold for Intervention.” I’ am curious if others on the forum are aware of this or if their cardiothoracic surgeon’s have alluded to it. Dr. Elefteriades of Yale is one of the pioneers of modern aortic research for the past 30 years and is highly influential in the medical community. The results from this study seems like a game-changer to me.

Here is link to the report: https://www.researchgate.net/publica...r_Intervention

Their research shows that “the aortic diameter increases substantially due to aortic dissection itself and, thus, aortas are being dissected at clinically meaningfully smaller sizes than natural history analyses have previously suggested. These findings have important implications regarding the size at which the risk of dissection is increased.”

His research also revealed that the significant impact of the dissection itself causes an estimated increase at onset in size of 7.65 mm (ascending aorta) and 6.38 mm (descending aorta). It says the mean aortic sizes at and immediately prior to dissection were 54.2 ± 7.0 mm and 45.1 ± 5.7 mm for the ascending aorta, and 47.1 ± 13.8 and 39.5 ± 13.1 mm for the descending aorta, respectively. Since most historical studies on the risk of dissection have relied on aortic diamter measurement from post-dissection imaging, it seems that all the guidelines for the timing of surgical intervention are significantly skewed too high - at least by 7.65 mm for ascending aortas. Hence, this paper suggest we need to lower the aortic diamter size threshold downward from the 2010 ACC guidelines of 5.5 cm standard and 5.0 or less for syndromes/connective tissue disorders.

I’ am a patient with a 4.6 cm ascending aortic aneurysm with a known family history of thoracic aortic dissection and also have a COL3A1 gene variant of unknown significance. If what this paper holds true, then someone at my diameter size is now in that zone of elevated risk of dissection. I’m going to be reaching out my cardiothoracic surgeon, Dr. Girardi at Weill Cornell, to get his perspective on this.

Finally, it appears from this study that much of the prior 2010 guidance on dissection risk and resulting treatment protocols are founded on a faulty assumption that the aortic diameter immediately prior to dissection was not significantly different than post-dissection. This study seems to completely debunk that. Seems the aortic experts need to go back to the drawing board on the protocol for surgical intervention vs. watchful waiting.

Welcome your comments or questions. Thanks.
 
Yes, that is my surgeon! He is amazing. He has authored other articles referencing body size and aorta size which emphasize that the 5.5 cm standard is not appropriate for everyone. I think having that gene may predispose you to needing surgery at smaller diameter, particularly with your family history. I also had a known gene. I had surgery when my aneurysm was quite small, but I am very petite (4’ ft 10” in) and my sister had the same exact surgery 6 months prior - her aorta was only 4.8 cm but basically came apart on the operating table. Dr E was her surgeon as well. Rest assured if you do need surgery, you will find lots of support here and, while it is daunting for the patients, it is a routine operation for these expert surgeons.
 
Thanks for posting this gsl. Very interesting. It makes a lot of sense. My measurements have been holding steady at 4.7-4.8 cm for a couple of years. I find it’s a battle just to arrange semiannual measurements, let alone actually see a cardiologist or surgeon. Perhaps if this paper is accepted I can get someone to take my case seriously.
 
When I had my bav repaired and my aortic aneurysm replaced the scans said it was 4.7 or 4.8cm but post surgery report said it was 4.99cm. It also said the wall was thin in some places , fwiw.
 
I had genetic testing done at Yale Aoric Institute. The good news is my children don't have the genes.
 
I had genetic testing done at Yale Aortic Institute. The good news is my children don't have the genes.
 
An update since I started this thread. My aortic/cardiothoracic surgeon at Weill Cornell called me to inform me that he endorses earlier surgical intervention In my case at my current 4.6cm given family history of aortic catastrophe and potential connective tissue disease. Will be having consultation next month to discuss and schedule surgery. Given Weill Cornell’s excellent operative outcomes for elective valve-sparing ascending aortic repair - last year at 0% operative mortality for over 300 elective open repairs- it is obvious that the risk of premature dissection or rupture exceeds operative mortality and morbidity (stroke at 2.4% and renal failure at 0.9%).
 
Hi

glad things are moving in the correct direction ...

gsl1956;n882328 said:
...My aortic/cardiothoracic surgeon at Weill Cornell called me to inform me that he endorses earlier surgical intervention In my case at my current 4.6cm given family history of aortic catastrophe and potential connective tissue disease. ...- it is obvious that the risk of premature dissection or rupture exceeds operative mortality and morbidity (stroke at 2.4% and renal failure at 0.9%).

agreed ... and (a slant not often seen by the surgeons is) if its inevitable that you'll need surgery (a when not an if) then the degradation of your health (which is harder to recover as you age) should also be a quality of life factor (and perhaps even a surgical survival factor).

It always seems to me that everyone focuses on surgery as the culmination of treatment .. while that may be (assuming you don't plan for reoperations, when it becomes the pilot marker for the series beginning) it fails to account for the number of years after surgery and the quality of life of that (which should also be of equal importance).

Best Wishes with it all
 

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