Abstract 12701: Combined Allometric Normalization of Ascending Aortic Diameter and Assessment of Complication Risk May Support an Earlier Prophylactic Replacement Preventive of Type a Dissection

Introduction: Guideline recommendations of prophylactic surgery in ascending aortic dilation by maximum aortic diameter (MAD) fail to predict > 50% of type-A dissections (AD). Assessment of post-dissection diameters as reference and lack of somatometric normalization may preclude an appropriate risk estimation. Hypothesis: The combined assessment of Z-score and Svensson-index (cross-area/height) based on pre-dissection aortic diameters may be advantageous to indicate prophylactic ascending aortic replacement. Such an approach would include information on normalized vascular dilatation together with a clinical aortic risk indicator. Methods: During two years (2018-2019), data from 515 AD-patients were prospectively recorded at 32 tertiary Spanish hospitals (Registro Español Síndrome Aórtico-III). Pre-dissection aortic diameters were estimated based on the in vitro observations made by Williams et al. on the perimeter change of normal human aortas after the creation of a dissection (PMID: 9122399). Svensson indexes were correlated with ascending aorta Z-scores using quadratic regression. Results (Figure): Setting thresholds of increased risk at Svensson-index >10 cm 2 /m and aortic dilation at Z-score >3, 59% of patients had low Svensson and low Z-score category, 19% low Svensson but high Z-score and 22% high Svensson and high Z-score. No patient with Svensson-index <10 cm 2 /m and Z-score either < or > 3 had an indication for surgery according to guidelines. Among patients with Svensson-index >10 cm 2 /m and aortic dilation at Z-score >3, approximately 1/3 (32%) would have a surgical indication whereas 2/3 (68%) would not. Conclusions: According to current guidelines, only one third of high Svensson and high Z group (7% of the total cohort) would deserve elective surgery. More proactive guidelines, suggesting replacement of ascending aorta in patients with Svensson-index >10 and Z-score>3, would spare from dissection 22% of current cases.

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Pregnancy in women with bicuspid aortic valve

European Heart Journal ◽

10.1093/eurheartj/ehab724.2894 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

S Belkadi ◽

O Milleron ◽

L Eliahou ◽

F Arnoult ◽

G Delorme ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Dissection ◽

Bicuspid Aortic Valve ◽

Ascending Aorta ◽

Aortic Diameter ◽

Z Score ◽

Aortic Dilation ◽

Genetic Syndrome ◽

Pregnancy And Postpartum ◽

Ascending Aortic Diameter

Abstract Background Aortic dissection during pregnancy is uncommon, however, the risk of aortic dissection is increased if there is underlying aortopathy. Bicuspid aortic valve (BAV) is common in the general population and is associated with the presence of an aortic aneurysm, but this condition is mostly asymptomatic and ignored in women of childbearing age. Data on pregnancy in patients with BAV are scarce, and guidelines on this topic are based on the consensus opinion of experts. The risk of occurrence of aortic dissection as a function of aortic diameter during pregnancy remains poorly known in women with BAV. Purpose To investigate demographic and echocardiographic characteristics and aortic events associated with pregnancy in women with BAV and to estimate ascending aortic diameter at the time of pregnancy. Methods We performed a retrospective study using data from our tertiary centre. All women seen at our centre between 1996 and 2020 with BAV, at least 1 pregnancy, and no genetic syndrome were included. We have collected data from echocardiograms performed in and out of our centre and aortic events. Assuming from the literature an annual aortic dilation rate of 0.2 mm at the sinus of Valsalva and 0.4 mm at the tubular ascending aorta, we estimated ascending aortic size and Z-score at the time of pregnancy. Results We identified 47 women with BAV with occurrence of 103 pregnancies. The median age of BAV diagnosis was 43 years. The aorta was measured at a median of 13.3 years since the last delivery. At BAV diagnosis, the median largest ascending aortic diameter was 44mm, and the median Z-score was +4.3. Ascending aortic diameter was ≥40mm in 37/47 (79%) and Z-score ≥2 in 44/47 (94%). No aortic dissection was observed during pregnancy and postpartum in all 103 pregnancies. At the time of pregnancy, the estimated median diameter of the ascending aorta was 37mm and the estimated median Z-score was +3.3. The largest aortic diameter during pregnancy was estimated to be ≥40mm in 36/103 pregnancies, ≥45mm in 13/103, and ≥50mm in 1/103; Z-score was estimated to be ≥2 in 81/103 and ≥4 in 40/103. Type A aortic dissection occurred in 1 woman, 13 years after pregnancy, and type B aortic dissection in 1 woman, 14 years after pregnancy. Planned surgery was performed in 8 women at a median of 17.5 years after the last pregnancy: 1 isolated aortic valve replacement and 7 prophylactic aortic surgeries associated with aortic valve surgery. Conclusions In our population of women with BAV, pregnancy is not associated with the occurrence of aortic dissection even though, when estimating aortic diameter at the time of pregnancy, the rate of aortic dilation was high (Z-score ≥2 in 81/103 pregnancies). Prospective studies of a large population of women with BAV are needed to assess the risk of aortic complication during pregnancy according to aortic diameter. FUNDunding Acknowledgement Type of funding sources: None.

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Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery?

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa351 ◽

2020 ◽

Cited By ~ 3

Author(s):

Piergiorgio Tozzi ◽

Ziyad Gunga ◽

Lars Niclauss ◽

Dominique Delay ◽

Aurelian Roumy ◽

...

Keyword(s):

Aortic Dissection ◽

Survival Benefit ◽

Type A ◽

Ascending Aorta ◽

Aortic Diameter ◽

Maximum Diameter ◽

Type A Aortic Dissection ◽

Aorta Replacement ◽

Current Guidelines ◽

Ascending Aorta Replacement

Abstract OBJECTIVES Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort’s mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.

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Disturbed nitric oxide signalling gives rise to congenital bicuspid aortic valve and aortopathy

Disease Models & Mechanisms ◽

10.1242/dmm.044990 ◽

2020 ◽

Vol 13 (9) ◽

pp. dmm044990

Author(s):

Joshua C. Peterson ◽

Lambertus J. Wisse ◽

Valerie Wirokromo ◽

Tessa van Herwaarden ◽

Anke M. Smits ◽

...

Keyword(s):

Nitric Oxide ◽

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Neural Crest Cell ◽

Ascending Aorta ◽

Aortic Aneurysms ◽

Aortic Dilation ◽

Elastic Fibres ◽

Increased Risk

ABSTRACTPatients with a congenital bicuspid aortic valve (BAV), a valve with two instead of three aortic leaflets, have an increased risk of developing thoracic aneurysms and aortic dissection. The mechanisms underlying BAV-associated aortopathy are poorly understood. This study examined BAV-associated aortopathy in Nos3−/− mice, a model with congenital BAV formation. A combination of histological examination and in vivo ultrasound imaging was used to investigate aortic dilation and dissections in Nos3−/− mice. Moreover, cell lineage analysis and single-cell RNA sequencing were used to observe the molecular anomalies within vascular smooth muscle cells (VSMCs) of Nos3−/− mice. Spontaneous aortic dissections were found in ascending aortas located at the sinotubular junction in ∼13% of Nos3−/− mice. Moreover, Nos3−/− mice were prone to developing aortic dilations in the proximal and distal ascending aorta during early adulthood. Lower volumes of elastic fibres were found within vessel walls of the ascending aortas of Nos3−/− mice, as well as incomplete coverage of the aortic inner media by neural crest cell (NCC)-derived VSMCs. VSMCs of Nos3−/− mice showed downregulation of 15 genes, of which seven were associated with aortic aneurysms and dissections in the human population. Elastin mRNA was most markedly downregulated, followed by fibulin-5 expression, both primary components of elastic fibres. This study demonstrates that, in addition to congenital BAV formation, disrupted endothelial-mediated nitric oxide (NO) signalling in Nos3−/− mice also causes aortic dilation and dissection, as a consequence of inhibited elastic fibre formation in VSMCs within the ascending aorta.

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Development of a multivariable prediction model for patient-adjusted aortic risk morphology

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa131 ◽

2020 ◽

Vol 58 (4) ◽

pp. 692-699

Author(s):

Tobias Krüger ◽

Rodrigo Sandoval Boburg ◽

Hasan Hamdoun ◽

Alexandre Oikonomou ◽

Malte N Bongers ◽

...

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Aortic Dissection ◽

Prediction Model ◽

Type A ◽

Ascending Aorta ◽

Aortic Diameter ◽

Control Group ◽

Type A Aortic Dissection ◽

Brachiocephalic Trunk

Abstract OBJECTIVES Preventing type A aortic dissection requires reliable prediction. We developed and validated a multivariable prediction model based on anthropometry to define patient-adjusted thresholds for aortic diameter and length. METHODS We analysed computed tomography angiographies and clinical data from 510 control patients, 143 subjects for model validation, 125 individuals with ascending aorta ectasia (45–54 mm), 58 patients with aneurysm (≥55 mm), 206 patients with type A aortic dissection and 19 patients who had received a computed tomography angiography ≤2 years before they suffered from a type A aortic dissection. Computed tomography angiographies were analysed using curved planar reformations. RESULTS In the control group, the mean ascending aortic diameter was 33.8 mm [standard deviation (SD) ±5.2 mm], and the length, measured from the aortic valve to the brachiocephalic trunk, was 91.9 mm (SD ±12.2 mm); both diameter and length were correlated with anthropometric parameters and were smaller than the respective values in all pathological groups (P < 0.001). Multivariable linear regression analysis of the control group revealed that age, sex and body surface area were predictors of ascending aorta diameter (R2 = 0.40) and length (R2 = 0.26). Bicuspidity of the aortic valve was not included in the model; its prevalence was only 3.2% in the control group but >25% in the ectasia and aneurysm groups. CONCLUSIONS The regression model provides a patient-adjusted prediction of the thresholds for aortic diameter and length. In our retrospective data, the model resulted in better identification of aortas at the risk of dissection than the conventional 55-mm diameter threshold. The model is available as an Internet calculator (www.aorticcalculator.com).

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Early results of valve-sparing ascending aortic replacement in type A aortic dissection and aortic insufficiency

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2016-2-35-43 ◽

2016 ◽

Vol 20 (2) ◽

pp. 35 ◽

Cited By ~ 1

Author(s):

M. L. Gordeev ◽

V. E. Uspenskiy ◽

G. I. Kim ◽

A. N. Ibragimov ◽

T. S. Shcherbinin ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Dissection ◽

Aortic Regurgitation ◽

Type A ◽

Aortic Insufficiency ◽

Ascending Aorta ◽

Type A Aortic Dissection ◽

Aortic Replacement ◽

Ascending Aortic Replacement ◽

Valve Sparing

Aim: The study was designed to investigate predictors of effective valve-sparing ascending aortic replacement in patients with Stanford type A aortic dissection combined with aortic insufficiency and to analyze efficacy and safety of this kind of surgery. Methods: From January 2010 to December 2015, 49 patients with Stanford type A aortic dissection combined with aortic insufficiency underwent ascending aortic replacement. All patients were divided into 3 groups: valve-sparing procedures (group 1, n = 11), combined aortic valve and supracoronary ascending aortic replacement (group 2, n = 12), and Bentall procedure (group 3, n = 26). We assessed the initial status of patients, incidence of complications and efficacy of valve-sparing ascending aortic replacement. Results: The hospital mortality rate was 8.2% (4/49 patients). The amount of surgical correction correlated with the initial diameter of the aorta at the level of the sinuses of Valsalva. During the hospital period, none of patients from group 1 developed aortic insufficiency exceeding Grade 2 and the vast majority of patients had trivial aortic regurgitation. The parameters of cardiopulmonary bypass, cross-clamp time and circulatory arrest time did not correlate with the initial size of the ascending aorta and aortic valve blood flow impairment, neither did they influence significantly the incidence and severity of neurological complications. The baseline size of the ascending aorta and degree of aortic regurgitation did not impact the course of the early hospital period. Conclusions: Supracoronary ascending aortic replacement combined with aortic valve repair in ascending aortic dissection and aortic regurgitation is effective and safe. The initial size of the ascending aorta and aortic arch do not influence immediate results. The diameter of the aorta at the level of the sinuses of Valsalva and the condition of aortic valve leaflets could be considered as the limiting factors. Further long-term follow-up is needed.<div class="well well-small">Funding</div> The study has been performed within the framework of the 2015-2017 government task, “Cardiovascular diseases” platform, Theme No. 4 Research on genome/cellular mechanisms responsible for aorta/aortic valve pathology development and elaboration of new methods of its multimodality treatment including hybrid technologies. Conflict of interestThe authors declare no conflict of interest.AcknowledgementThe authors express their deep gratitude for assistance in diagnostics and management of patients with aortic pathologies, as well as in preparation of this article to A.Yu. Bakanov, PhD, Head of Research Laboratory of Perfusiology and Cardiac Protection; V.V. Volkov, Fellow of Research Laboratory of Perfusiology and Cardiac Protection; A.V. Naymushin, PhD, Head of Anesthesiology & Resuscitation/ICU-2 Department; I.V. Basek, Phd, Head of X-Ray Computer Tomography Department and the specialists of X-Ray Computer Tomography Department, as well as to the employees of Research Center for Non-Coronary Heart Diseases and to specialists of cardiovascular surgery departments.

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Inherited extremes of aortic diameter confer risk for a specific class of congenital heart disease.

10.1101/2020.08.12.20172817 ◽

2020 ◽

Author(s):

Catherine Tcheandjieu ◽

Daniela Zanetti ◽

Mengyao Yu ◽

James Priest

Keyword(s):

Left Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

Ascending Aorta ◽

Outflow Tract ◽

Aortic Diameter ◽

Polygenic Risk Score ◽

Specific Class ◽

Increased Risk ◽

Left Ventricular Outflow

Population based studies demonstrate strong familial recurrence of cardiac malformations particularly for individuals affected with a specific class of CHD, left-ventricular outflow tract (LVOT) obstruction. Recently we linked 99 lead variants across 71 loci to diameter of the ascending aorta derived from MRI measurements across multiple ethnicities in the UK Biobank. Using these data we created a polygenic risk score capturing ascending aortic diameter (PRSAoD) Among 2,594 individuals with CHD; a decrease by one standard deviation in PRSAoD was associated with an increased risk of congenital LVOT (OR=1.14[1.03-1.26], p=0.014) but not with other subtypes of CHD. Using Mendelian Randomization we observed strong evidence of a causal effect where inheritance of a smaller diameter of the ascending aorta corresponded to an increase in risk for congenital LVOT (p_IVW = 0.008). Our data may suggest that genetic determinants of a smaller ascending aorta act during early development to disturb blood flow through left-sided structures to increasing the risk of LVOT CHD, which is consistent with experimental evidence and the "no flow, no grow" paradigm in the formation of the left ventricular outflow tract.

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Watch-and-wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: a Japanese single-centre experience

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa080 ◽

2020 ◽

Vol 58 (3) ◽

pp. 590-597 ◽

Cited By ~ 4

Author(s):

Tadashi Kitamura ◽

Shinzo Torii ◽

Takashi Miyamoto ◽

Toshiaki Mishima ◽

Hirotoki Ohkubo ◽

...

Keyword(s):

Aortic Dissection ◽

Pain Score ◽

Acute Aortic Dissection ◽

False Lumen ◽

Type A ◽

Ascending Aorta ◽

Aortic Diameter ◽

Intramural Haematoma ◽

Watch And Wait ◽

Significant Difference

Abstract OBJECTIVES In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated. CONCLUSIONS The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy.

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Anatomy of the retrograde type A aortic dissection after endovascular repair of type B aortic dissection: a case report

Heart Vessels and Transplantation ◽

10.24969/hvt.2021.262 ◽

2021 ◽

Vol 0 (Ahead of Print) ◽

Author(s):

Uliana Pidvalna ◽

Marianna Mirchuk ◽

Anna Voitovych ◽

Dmytro Beshley

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Type A ◽

Ascending Aorta ◽

Medical Attention ◽

Acute Type ◽

Type B ◽

Type B Aortic Dissection ◽

Type A Aortic Dissection ◽

Aortic Replacement

Aortic dissection requires immediate medical attention. The optimal treatment approach of Type B aortic dissection is still a matter of debate. Possible options include open surgery, endovascular aortic repair (EVAR), and hybrid procedure. The indication for surgery is the dissection that involves the ascending aorta and the aortic arch (Type A Stanford, Types I and II DeBakey). Hybrid or endovascular procedures seem to be an attractive alternative treatment for patients with the complex aortic disease and a high risk of surgery. Endovascular treatment of acute Type B aortic dissections is designed to prevent the retrograde dissection of the ascending aorta and the aortic arch. The occurrence of retrograde Type A aortic dissection (RTAD) is rare, but the mortality rate is high. We report a case of a 55-year-old gentleman who had undergone thoracic EVAR. Thirty months after the given procedure he presented with RTAD and underwent supracoronary aortic replacement. The article is intended to remind the clinicians of the importance of early detection of the possible complications when performing EVAR, and the significance of a rapid response.

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Abstract 249: Thoracic Aortic Dilation in Patients with Bicuspid Aortic Valves is Marked by Accelerated Vascular Smooth Muscle Cell Aging

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.35.suppl_1.249 ◽

2015 ◽

Vol 35 (suppl_1) ◽

Author(s):

Brittany Balint ◽

Hao Yin ◽

Zengxuan Nong ◽

Stephanie Fox ◽

Stephanie Rogers ◽

...

Keyword(s):

Smooth Muscle ◽

Aortic Valve ◽

Nuclear Dna ◽

Cellular Aging ◽

Aortic Diameter ◽

Cell Aging ◽

Dna Breaks ◽

Aortic Dilation ◽

Cellular Mechanisms ◽

Increased Risk

Individuals with a bicuspid aortic valve (BAV) are at increased risk for ascending aortic dilation and dissection. Loss of aortic medial smooth muscle cells (SMCs) and disruption of the extracellular matrix are well-recognized pathologies, but the underlying cellular mechanisms remain elusive. We tested the hypothesis that the dilated aorta in patients with BAV was marked by accelerated cellular aging. Samples of human ascending aorta were obtained from individuals with BAV undergoing thoracic aorta replacement (n=37, age 54.7±2.2, aortic diameter 4.8±0.9 cm) or patients with a tricuspid aortic valve and non-dilated aorta undergoing heart transplantation or coronary bypass procedures (n=6, age 55.3±8.1, aortic diameter 3.1±0.3 cm). Assessment of fresh aortic samples for senescence-associated β-galactosidase revealed evidence for rare medial cell senescence that was 4.2-fold more prevalent in dilated aortas (0.83±0.10%) than in non-dilated aortas (0.20±0.10%, p=0.048). Expression of p16 was abundantly detected in medial SMCs within dilated aortas (27.0±2.1%) and 3-fold more abundant than in non-dilated aortas (8.9±1.8%, p<0.0001). Interestingly, immunostaining for γH2A.X (phosphorylated Ser139) revealed discrete nuclear DNA double-strand breakage signals in 25.7±3.8% of medial cells in dilated aortas from patients with BAV, which was 2.3-fold higher than that found in non-dilated aortas (11.0±4.9, p=0.03). CONCLUSION: These findings identify a previously unrecognized phenomenon of accelerated SMC aging in the aortas of patients with BAV, with cellular senescence and unresolved DNA breaks. Accelerated cell aging could thus be a driver of aortic wall degeneration in these patients and a potential therapeutic target.

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Elective replacement of the ascending aorta: is the 5.5-cm threshold appropriate? The insidious, small aorta

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa387 ◽

2020 ◽

Author(s):

Nikolaos A Papakonstantinou ◽

Filippos-Paschalis Rorris

Keyword(s):

Aortic Aneurysm ◽

Thoracic Aortic Aneurysm ◽

Ascending Aorta ◽

Prophylactic Surgery ◽

Common Disease ◽

Aggressive Approach ◽

European Guidelines ◽

Aortic Replacement ◽

Ascending Aortic Replacement ◽

Current Threshold

Summary OBJECTIVES As thoracic aortic aneurysm disease continues to cause significant morbidity and mortality in the general population, the cardiovascular community continues the search for the golden threshold of elective surgical replacement of the ascending aorta. METHODS Thoracic aortic aneurysm is a common disease, classified within the 20 most common causes of death in patients over 65 years old. Once aortic complications like dissection or rupture occur, they can prove fatal. Prophylactic surgical replacement of the ascending aorta remains the mainstay of treatment to prevent these complications. Current American and European guidelines agree that the threshold for the diameter for elective replacement of the ascending aorta in non-syndromic, asymptomatic aneurysmal disease is 5.5 cm. Overall, aortic dissection is related to poor prognosis, thus making early intervention paramount. RESULTS There is a critical size above which the risk of dissection or rupture becomes extremely high. However, a significant post-dissection increase in diameter is reported, thus rendering the predissection aortic diameter well below the current threshold for elective surgical replacement of the ascending aorta. Moreover, it is widely reported that the majority of acute aortic dissections would not meet the criteria for prophylactic surgery prior to dissection. Additionally, elective surgical ascending aortic replacement in the current era shows a significantly improved risk-benefit ratio, which justifies a more aggressive approach in the management of aortic aneurysmal disease. CONCLUSIONS As a result, there is a lot of discussion in the literature about the requirement of a leftward shifting of the surgical threshold for elective aortic replacement.

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