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Department of Cardiac Surgery, Tor Vergata University, Viale Oxford 84, Rome 00133, Italy
(Email: carlo.bassano{at}fastwebnet.it).
We read with utmost interest the article by Reece and colleagues [1], in which an aggressive strategy toward concomitant dilatation of the proximal aorta in patients with aortic valve disease was strongly recommended, even in moderately dilated aortas (ie, with a diameter exceeding 5.0 cm).
To further support this thesis, we would like to report our personal experience with a cohort of 38 patients with slightly dilated proximal aortas (from 40 to 55 mm) and aortic valve disease that for several reasons were not submitted to any surgical procedure beside aortic valve replacement, and were subsequently followed-up over time (follow-up median duration: 36 months) [2].
Briefly, we identified three different behaviors of the proximal aorta during the follow-up: (1) no significant change, (2) increased growth velocity of the aortic diameter without reaching the limit of 55 mm (ie, the commonly accepted indication to an ascending aorta replacement), and (3) increase of the proximal aorta reaching 55 mm or actual rupture.
Two patients fell in the second group with a mean growth velocity of 1.1 and 1.5 mm per year, and therefore entered a close-interval follow-up protocol. Five of 36 early survivors reached an aortic diameter of 55 mm or larger (third group), and were subsequently operated on (1 with acute rupture).
The only predictive factor associated with a velocity growth exceeding 1 mm per year was the preoperative diameter (R = 0.60; p = 0.0004). A more complex polynomial fitting in the regression model demonstrated an abrupt increase of growth velocity in the aorta with a preoperative diameter of 50 mm or more (R = 0.83; p < 0.0001). Therefore, we advocated replacement (or at least a reduction plasty) of the ascending aorta at a level of approximately 48 to 50 mm, even in patients with no additional well-known risk factors, as the presence of a bicuspid aortic valve or a Marfan syndrome.
Once it was demonstrated that the combined operation could be performed without an additional risk, carrying the important advantage of eliminating the threat for later reoperations [1], we believe that an aggressive approach should be strongly suggested when dealing with the quite common setting of concomitant aortic valve and proximal aorta disease. Patients with additional risk factors should probably be submitted to ascending aorta replacement or repair even at lower levels of dilation (ie, at approximately 43 to 45 mm).
Just one word of caution might be used in the case of isolated aortic stenosis with mild dilatation of the ascending aorta, and that is, in our experience, the immediate resolution of the fluid-dynamics that led to aortic expansion by means of the valve replacement might be sufficient to prevent further dilatation. In patients with prevalent aortic regurgitation, the volume overload of the proximal aorta persists after valve replacement, thus perpetuating the hemodynamic harm to the aortic wall. Actually, in our series, the aortic growth velocity was –0.6 ± 1.5 mm per year in patients with prevalent stenosis, and 1.4 ± 4.8 mm per year in patients with prevalent regurgitation. However, this difference was only marginally significant, with p = 0.10 [2].
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  T. B. Reece and I. L. Kron Reply Ann. Thorac. Surg., April 1, 2008; 85(4): 1503 - 1503. [Full Text] [PDF]
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