Outpatient monitoring of patients with chronic aortopathies is a standard responsibility for cardiovascular surgeons. Some centers even establish specialized units dedicated to managing complex aortopathies, particularly those related to collagen disorders. Standard care for these patients focuses on optimal blood pressure control, often using cardioselective beta-blockers and/or ACE inhibitors/ARBs, such as Losartan or Telmisartan, due to their matrix metalloproteinase inhibitory effects, alongside periodic imaging studies. However, there are no reliable clinical parameters to predict aortic diameter progression, and therefore, the increased risk of acute aortic syndromes or the need for additional surgical or interventional procedures. Two recent publications introduce new factors that could help in identifying patients with a higher likelihood of adverse aortic progression.

Ikeno et al. conducted a follow-up of 623 survivors of total aortic arch replacement from 1999 to 2018 (139 acute dissections, 101 chronic dissections, 383 aneurysms), excluding those with collagen disorders or prior descending or thoracoabdominal aortic surgery to maintain sample homogeneity. Among these patients, 232 also underwent some form of elephant trunk procedure, including 183 with aortic dissection (76.2%). Freedom from additional distal aortic dilation procedures was observed in 88.5% at 5 years and 80.2% at 10 years. Overall, freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis indicated that preoperative descending aortic diameter was a significant risk factor for unfavorable distal aortic events, with disease progression more common in patients presenting with acute aortic dissection.

In another study, Dolapoglu et al. evaluated the clinical utility of the C-reactive protein (CRP)/serum albumin ratio for predicting ascending aortic diameter progression in patients with moderate, non-surgical dilation (40–50 mm). CRP, an acute-phase reactant linked to systemic inflammation, is suggested to correlate with elevated matrix metalloproteinase activity and aneurysmal diameter progression. Despite this, a robust clinical correlation has not been proved. A total of 182 patients were included, assessing the annual growth rate of aortic diameter. Multivariable analysis revealed classic clinical factors linked to aortopathy progression, such as hypertension, chronic obstructive pulmonary disease, and positive family history. Notably, a CRP/albumin ratio cutoff of 0.84 (both in mg/dL) also emerged as an independent risk factor, with an ROC area of 0.771 for predicting significant growth in the ascending aorta. This study is pioneering in proposing this analytical parameter, with subanalysis indicating superior performance when compared to isolated CRP values.

COMMENTARY:

The findings from these studies offer insights for the ongoing management of patients with chronic aortopathies. In cases of aortic arch interventions, planning for future procedures must frequently be considered. Especially in patients undergoing surgery for acute or chronic dissection, often through elephant trunk techniques. Approximately 20% of patients at 10 years may require secondary procedures. European clinical guidelines currently classify type B dissection patients (primary or residual following type A or non-A-non-B correction) and those with descending aortic diameters >40 mm as “high risk for late aortic events.”

The second study provides a valuable tool in the CRP/albumin ratio. Beyond its predictive capacity for diameter progression in non-surgical ascending aortic dilation, it could aid decision-making in managing patients with ascending aortic dilation and borderline surgical indications (~45 mm), when concomitant procedures such as aortic valve replacement are necessary.

REFERENCE:

Ikeno Y, Yokawa K, Yamanaka K, Inoue T, Tanaka H, Okada K, et al. The fate of the downstream aorta after total arch replacement. Eur J Cardiothorac Surg. 2022 Oct 4;62(5). doi: 10.1093/ejcts/ezac443.

Dolapoglu A, Avci E, Kiris T. The predictive value of C-reactive protein to albumin ratio for ascending aorta progression in patients with ascending aortic diameter of 40–50 mm. J Cardiothorac Surg. 2022 Oct 4;17(1):254. doi: 10.1186/s13019-022-02003-5.