Treatment of Dilated Aorta

Initial Assessment and Surveillance Strategy

The European Society of Cardiology recommends surgery when the ascending aorta or aortic root reaches ≥55 mm in diameter for patients with a tricuspid aortic valve, with lower thresholds of ≥50 mm for bicuspid aortic valve and ≥50 mm for Marfan syndrome 1, 2
The entire aorta must be assessed at baseline and during follow-up to identify all affected segments, according to the European Heart Journal 1
Transthoracic echocardiography (TTE) is recommended at diagnosis to assess aortic valve anatomy, aortic root, and ascending aorta diameters, as per the European Heart Journal 1
Cardiac CT (CCT) or cardiac MRI (CMR) is recommended to confirm TTE measurements, rule out aortic asymmetry, and establish baseline diameters for follow-up, according to the European Heart Journal 1
CCT or CMR (not TTE) is recommended for ongoing surveillance of aneurysms in the distal ascending aorta, aortic arch, or descending thoracic aorta, as per the European Heart Journal 1
Duplex ultrasound (DUS) is the recommended modality for AAA surveillance, according to the European Heart Journal 1
Surveillance intervals for small AAA (30-55 mm): every 3 years for 30-39 mm, every 2 years for 40-44 mm, and annually for >45 mm, as recommended by the European Heart Journal 3, 2
Every 6 months for men with AAA 50-55 mm and women with AAA 45-50 mm, according to the European Heart Journal 1

Strict blood pressure control is mandatory, targeting SBP 120-129 mmHg if tolerated, and definitely <140/90 mmHg, as recommended by the European Heart Journal 3, 2
LDL-C goal <1.4 mmol/L (55 mg/dL) with >50% reduction from baseline is recommended in patients with atherosclerotic peripheral arterial and aortic diseases, according to the European Heart Journal 3, 2
Beta-blockers are first-line therapy for Marfan syndrome to reduce aortic root growth rate, as per Circulation 4
Angiotensin receptor blockers (ARBs) effectively slow aortic root growth in Marfan syndrome, with combination beta-blocker plus ARB therapy being reasonable, according to Circulation 4

Surgery is recommended at ≥55 mm diameter for the ascending aorta or aortic root in patients with a tricuspid aortic valve, as per the European Heart Journal 1, 2
Surgery is recommended at ≥50 mm diameter for the aortic root or ascending aorta in patients with a bicuspid aortic valve, according to Circulation 6, 7
Surgery is recommended at ≥50 mm diameter (external measurement) for patients with Marfan syndrome, as per Circulation 4
Elective repair is recommended at ≥55 mm diameter for non-heritable thoracic aortic disease, according to the European Heart Journal 1
Elective repair is recommended at ≥60 mm diameter for degenerative TAAA, as per the European Heart Journal 1
Elective repair is recommended at ≥55 mm in men or ≥50 mm in women for abdominal aortic aneurysm, according to the European Heart Journal 1

Valve-sparing aortic root replacement is recommended in patients with aortic root dilatation if performed in experienced centers and durable results are expected, as per the European Heart Journal 1
Lifelong vitamin K antagonists (VKAs) are required for all patients with a Bentall procedure using a mechanical heart valve prosthesis, according to the European Heart Journal 1

Surveillance is recommended at 1, 6, and 12 months, then yearly after endovascular repair (TEVAR/EVAR), as per the European Heart Journal 3, 2
Re-intervention is mandatory for type I or type III endoleaks to achieve a seal, according to the European Heart Journal 1
Early CCT within 1 month, then yearly CCT follow-up is recommended for thoracic aorta after open repair, as per the European Heart Journal 1
First follow-up imaging within 1 year, then every 5 years if findings are stable is recommended for AAA after open repair, according to the European Heart Journal 3, 2