Descending threshold for ascending aortic aneurysmectomy: Is it time for a “left-shift” in guidelines? Bulat A. Ziganshin, MD, PhD, Mohammad A. Zafar,

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Presentation transcript:

Descending threshold for ascending aortic aneurysmectomy: Is it time for a “left-shift” in guidelines? Bulat A. Ziganshin, MD, PhD, Mohammad A. Zafar, MBBS, John A. Elefteriades, MD, PhD (hon) The Journal of Thoracic and Cardiovascular Surgery Volume 157, Issue 1, Pages 37-42 (January 2019) DOI: 10.1016/j.jtcvs.2018.07.114 Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, Estimated probability of rupture or dissection of the ascending aorta by aneurysm size (The Y-axis represents the percentage point increase in “lifetime” probability of complications compared to baseline [between 4 and 4.25 cm]). B, Yearly risk of complications (aortic dissection, rupture, and death) in patients with ascending aortic aneurysm as a function of aortic diameter (horizontal axis) and height (vertical axis). (Reprinted with permission from Zafar and colleagues.6) The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Frequency of aortic sizes before and at the time of aortic dissection. (Note: In addition to simple arithmetic calculations, regression methods using “aortic dissection” as a variable influencing size mitigated the impact of elapsed time between pre- and post-images.) (Based on data from Mansour and colleagues.10) The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Simplified schematic illustration of ascending aorta dimensions for prophylactic surgical intervention divided by gene category: ECM genes, SMC contractile unit and metabolism genes, and TGF-β signaling pathway genes. TGF-β, Transforming growth factor-β; ECM, extracellular matrix; MFS, Marfan syndrome; EDS, Ehlers–Danlos syndrome; SMC, smooth muscle cell; LDS, Loeys–Dietz syndrome. (Reprinted with permission from Brownstein and colleagues.24) The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Is it time for a leftward shift in the intervention criteria for ascending aortic aneurysm? The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Is it time for a leftward shift in intervention criteria for ascending aortic aneurysm? The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

Video 1 Eight consecutive yearly computed tomography scans of a single patient documenting the slow growth of the ascending aorta and a subsequent scan at time of aortic dissection. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32822-8/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions

The Journal of Thoracic and Cardiovascular Surgery 2019 157, 37-42DOI: (10.1016/j.jtcvs.2018.07.114) Copyright © 2018 The American Association for Thoracic Surgery Terms and Conditions