Treatment for Dilated Ascending Aorta

Medical Management

Blood pressure control is essential for all patients with aortic dilation, using any effective antihypertensive medication to reduce shear stress on the aortic wall, as recommended by the European Society of Cardiology 3, 4
Beta-blockers and angiotensin receptor blockers (ARBs) have conceptual advantages in reducing progression rate, but clinical studies have not definitively proven their benefit in non-Marfan patients, according to the American Heart Association 3, 5
In patients with Marfan syndrome, beta-blockers, ACE inhibitors, and ARBs may help reduce progression of aortic dilation, as suggested by the European Heart Journal 4
Smoking cessation is important as current smoking has been associated with faster aneurysm expansion (approximately 0.4 mm/year), as reported by the European Heart Journal 4
Competitive sports should be avoided in patients with enlarged aorta to prevent blood pressure spikes, as recommended by the European Heart Journal 4

For patients with aortic diameter >4.0 cm, regular imaging surveillance is recommended, with imaging frequency determined by the degree and rate of progression of aortic dilation, family history, and presence of risk factors, as suggested by the American College of Cardiology 6
For aortic diameter >4.5 cm, annual imaging is recommended, according to the American College of Cardiology 6
Consistent imaging modality should be used for serial measurements, as recommended by the European Society of Cardiology 1, 4
Echocardiography is recommended for initial assessment of aortic valve anatomy, function, and root dimensions, as suggested by the European Heart Journal 1
CT or MRI is recommended to confirm measurements, evaluate for asymmetry, and establish baseline diameters, according to the European Heart Journal 1

Surgery is recommended for patients with tricuspid aortic valve when the aortic diameter reaches ≥55 mm, as suggested by the European Heart Journal 1, 7
Surgery is recommended for patients with bicuspid aortic valve when the aortic diameter reaches ≥50 mm, according to the European Heart Journal 2
Surgery is recommended for patients with Marfan syndrome when the aortic diameter reaches ≥45 mm, as suggested by the European Heart Journal 2, 8

Valve-sparing aortic root replacement is recommended in experienced centers when durable results are expected, as suggested by the European Heart Journal 1, 7
Resection and graft replacement is the most commonly performed procedure for isolated ascending aorta dilation, according to the American Heart Association 8

Measurement technique matters: diameters should be measured perpendicular to the longitudinal axis of the aorta, as recommended by the European Heart Journal 4
Rapid growth (≥0.5 cm/year) is an indication for earlier intervention regardless of absolute diameter, as suggested by the American College of Cardiology 3, 6
Endovascular stent grafts are not FDA-approved for treatment of ascending aortic aneurysms, as reported by the American Heart Association 8