Ascending aortic aneurysm

What is it?

An aortic aneurysm is a permanent localized dilatation of the aorta, of a diameter 50% or greater than normal, having all the layers of the normal aortic wall. Aneurysm is the most common condition of the thoracic aorta that requires surgical treatment. This pathological condition can lead to an increased risk of aortic wall free rupture or acute aortic dissection, both burdened with high mortality rate. According to the last European Guidelines surgery is indicated in patients who have an ascending aorta diameter more than 55 mm, with lower threshold in presence of elastopathy or bicuspid aortic valve with risk factors associated.

Causes and risk factors

The causes of aortic aneurysms development can be congenital, in presence of elastopathy (e.g. Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome), degenerative (the cystic medial degeneration is the most frequent pathologic condition that result in aneurysm of the ascending aorta), inflammatory, infected or mechanical. The risk factors are having a family history of aortic aneurysms, bicuspid valve or connective tissue disorder, smoking, dislipidemia and high blood pressure.

Which are the symptoms?

Many patients with thoracic aortic aneurysms are asymptomatic at presentation and the aneurysms are detected during testing fot other disorders. Symptoms relating to the aneurysm usually develop later in the course of enlargement of the aorta and result from impingement of the aneurysm on adjacent structures. Patients with aneurysms involving the aortic root with dilatation of the aortic anulus frequently present with symptoms referable tu the aortic valve regurgitation.

  • Shortness of breath (Dyspnea)
  • Fatigue during exerction
  • Weakness
  • Arrhytmia, palpitations
  • Tachicardia (high heart rate)
  • Chest pain

How is it diagnosed?

Findings on the chest radiograph may be rarely diagnostic of a ascending aortic aneurysm or a thoracic aortic aneurysm in general. CT scan with the use of contrast is the most widely used non invasive technique for diagnosing thoracic aortic disease. It provides information about size, location and extent of the aneurysm; it is of particular value in documenting the growth rate of aneurysms, determining timing of operative intervention in asymptomatic patients and evaluating patients postoperatively. Others diagnostic techniques are MRI, TEE and aortography.  

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How is it treated?

The surgical treatment of the ascending aorta aneurysms depends by the location and extent of the aneurysm in addition to the aortic valve function. In case of an aneurysm limited to the ascending aorta, over the sino-tubular junction, the aneurysmal segment is excised and replaced with a tube graft. When the aortic valve is diseased and requires replacement and the aortic root diameters are normal an aortic valve replacement with a mechanical or biological prosthetic valve is performed in addition to the ascending aorta replacement (Wheat operation). When the aortic root is involved the aortic valve and ascending aorta can be replaced en bloc using a composite valve conduit, mechanical or biological, with coronary ostia reimplantation (Bentall procedure). Finally, in some case of aortic root aneurysm, when the valve regurgitation only depends by the aortic root enlargement, the aortic valve can be repaired by remodeling or reimplantation techniques (valve-sparing aortic root replacement). The Remodeling procedure consists of removing the sinus aorta except for a small rim of aortic wall above the aortic valve anulus (Yacoub operation). In the Reimplantation procedure the aortic valve is reimplanted to the inside of the prosthetic graft (Tirone David operation). In both cases coronary ostia are reimplanted on the prosthetic graft. The ascending aorta surgery can be performed with a traditional full median sternotomy or, in selected cases, a partial upper sternotomy is used.

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Page edited by: Carlo De Vincentiis

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