This poll asked readers to consider the appropriate treatment for a patient with an aneurysmal aortic root and ascending aorta that do not currently meet the guideline-recommended threshold for surgical intervention. Also affecting decision-making is whether surgical intervention will involve sparing or replacing a normally functioning aortic valve.

The majority (60%) of readers would continue to follow the current 2010 multi-society guidelines for thoracic aortic disease that, in the absence of genetically mediated aneurysm, family history of acute aortic syndrome or sudden death, or rapid growth, recommend intervention at a maximum diameter of 5.5 cm.¹ Although blood pressure management is a mainstay of medical treatment, activity restrictions vary somewhat based on practitioner and institution. The guidelines recommend avoiding isometric exercise and Valsalva maneuver as well as job-related heavy physical and manual labor with isometric activity.¹ This patient may or may not spend a good part of the day lifting construction materials. Do the activity restrictions mean that the patient has to quit his job if accommodations cannot be made, even with a physician's letter? Would the patient be "disabled" if he is unable to procure employment due to restrictions? Many of us who treat aortic patients are confronted with these dilemmas. Currently, the data are lacking. A recent study did find a higher prevalence of ascending or aortic root dilation (>40 mm) in approximately 20% of "masters-level" athletes (aged 50-75 years), suggesting that long-term exercise may promote vascular remodeling/dilation.² Of additional consideration is the fact that size may not be the best predictor for acute aortic dissection (though risk of mortality in acute type A dissection is not necessarily related to size).³

In this patient, surgical options are valve-sparing root replacement (chosen by 34% of readers) versus composite aortic root replacement with a bioprosthetic (4%) or mechanical (1%) valved conduit. Valve-sparing aortic root replacement for root aneurysm and tricuspid aortic valve has low operative mortality/morbidity and excellent long-term results,^4,5 though these results are likely best achieved at high-volume centers with experienced surgeons. During intra-operative valve assessment, findings of excessive leaflet fenestrations or leaflet calcification may require valve replacement in 5-10% of cases. The discussion and decision-making regarding prosthesis choice are similar to those for aortic valve replacement, though re-operation for structural valve degeneration after previous aortic root replacement will be more complex.

At the time of surgery, the aneurysmal ascending aorta would be replaced as well, and the distal extent of the aneurysm (e.g., dilation of the proximal arch) would influence possible need for circulatory arrest, with additional risk for morbidity and mortality.

References

1. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol 2010;55:e27-e129.
2. Churchill TW, Groezinger E, Kim JH, et al. Association of Ascending Aortic Dilatation and Long-term Endurance Exercise Among Older Masters-Level Athletes. JAMA Cardiol 2020;5:522-31.
3. Pape LA, Tsai TT, Isselbacher EM, et al. Aortic diameter >or = 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2007;116:1120-7.
4. David TE, Feindel CM, David CM, Manlhoit C. A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014;148:872-9.
5. Mastrobuoni S, de Kerchove L, Navarra E, et al. Long-term experience with valve-sparing reimplantation technique for the treatment of aortic aneurysm and aortic regurgitation. J Thorac Cardiovasc Surg 2019;158:14-23.

Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Heart Failure, Exercise

Keywords: Aortic Valve, Valsalva Maneuver, Blood Pressure, Prevalence, Dilatation, Aortic Aneurysm, Aneurysm, Dissecting, Aorta, Aortic Aneurysm, Thoracic, Prostheses and Implants, Athletes, Exercise, Dissection, Death, Sudden, Decision Making

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