Treatments of Aortic Root and Aortic Diseases

The aorta is our largest vessel, leaving the heart to carry blood to the entire body, and it is the one under the highest internal pressure. Just like the main water pipe of a city, a problem that develops here can affect the whole system. Diseases developing in the aortic root (the first segment of the aorta closest to the heart, which also contains the aortic valve) and in the other parts of the aorta are among the conditions we follow with great care in our clinic. I will address the treatment of aortic stenosis and occlusions, complex angiographic aortic treatments (EVAR-TEVAR-PMEG), and the causes and diagnostic methods of aortic diseases in separate articles; in this article I focus directly on the treatment options we apply for the aortic root, aortic aneurysm (enlargement) and aortic dissection (tearing).

Which Treatment for Whom? Size and Growth Rate Determine Our Decision

When an aneurysm (enlargement) is detected in the aortic root or the ascending aorta, the timing of surgery is largely determined by the diameter of the vessel and its rate of growth. In the general population, our surgical threshold for sporadic (non-familial) aortic root and ascending aortic aneurysms is 5.5 cm; in experienced centres we can lower this threshold to 5.0 cm in selected patients. In hereditary connective tissue diseases such as Marfan syndrome, or in patients for whom valve surgery is planned in the same session, the threshold falls further, in some cases down to 4.5 cm. Alongside size, the annual growth rate is at least equally important: growth of 0.5 cm in one year in sporadic aneurysms, or 0.3 cm per year in two consecutive years, and in patients with hereditary aortic disease or a bicuspid aortic valve even growth of 0.3 cm in a year, is on its own enough to indicate surgery. In defining these threshold values we take the current 2022 ACC/AHA Aortic Disease Guideline as our reference.

Treatment Options

Close Follow-Up and Medical Treatment: In aneurysms below the surgical threshold we control blood pressure tightly, use medications that slow the heart rate (beta-blockers) and monitor the diameter of the vessel at regular intervals (usually every 6-24 months) by measuring it with computed tomography or magnetic resonance angiography. Valve-Sparing Aortic Root Surgery (David Procedure): If the aortic root is enlarged but the patient’s own aortic valve is structurally sound, we replace only the root with a graft without removing the valve; in this way the patient is spared the lifelong burden of taking valve medication (anticoagulants). Bentall Procedure (Combined Root and Valve Replacement): If the valve is diseased as well, we perform a replacement with a graft that contains both the aortic root and the valve; it is a method we have been applying safely for decades and which gives very robust results. Ascending Aorta and Arch Surgery: If the disease extends beyond the root into the ascending aorta or the aortic arch (the curved segment where the aorta branches into the neck vessels), we extend the operation to cover these segments as well; in some complex cases we prefer hybrid approaches that combine open surgery with angiographic techniques. Minimally Invasive Approaches: In suitable patients we also perform minimally invasive aortic surgery through small incisions, without fully opening the breastbone; I will discuss the details of this method in a separate article.

A Race Against Time in Acute Aortic Dissection

Aortic dissection (a sudden tear and separation between the layers of the aortic wall) is one of the most urgent conditions in vascular surgery. If the dissection involves the ascending aorta (Type A dissection), this is a true surgical emergency that can be fatal within hours, and we take the patient to the operating room as soon as the diagnosis is made; according to large registered international data, in-hospital mortality in surgically treated Type A patients is around 26%, whereas in patients who cannot be operated on this rate can rise to 58% — the difference clearly shows how life-saving timely surgery is. If the dissection involves only the descending aorta (Type B dissection), as long as it is uncomplicated we generally prefer medical treatment with strict blood pressure control; in complicated Type B cases that impair organ perfusion, carry a risk of rupture, or in which the pain cannot be brought under control, we turn to angiographic treatment (TEVAR).

The Post-Procedure Period and Long-Term Follow-Up

After aortic root or ascending aortic surgery, we monitor our patients in intensive care for a short period and then usually discharge them within a week. Blood pressure control and regular imaging after surgery (more frequently in the first year, then annually) continue for life, because the parts of the aorta that were not operated on may also change over time. In every patient in whom we suspect a hereditary aortic disease, we recommend that first-degree relatives also be screened with imaging and, where necessary, receive genetic counselling; because in these families early diagnosis can prevent a future dissection.

Frequently Asked Questions

There is an enlargement (aneurysm) in my aorta, do I need surgery right away? Most of the time, no. If the size is below the surgical threshold, close follow-up with regular imaging is sufficient. The decision is personalised according to the diameter of the vessel, its growth rate and any accompanying conditions.

What is the difference between the David and Bentall procedures? In the David procedure the patient’s own aortic valve is preserved and only the root is replaced. In the Bentall procedure, when the valve is diseased as well, the root and the valve are replaced together with a single graft.

Can sudden, severe chest and back pain be an aortic dissection? Yes; chest pain of sudden onset, tearing in character and radiating to the back in particular is the classic symptom of aortic dissection; in this situation urgent assessment is life-saving.

There is aortic aneurysm or dissection in my family, am I also at risk? When hereditary aortic diseases are involved, screening of first-degree relatives is also recommended; for this reason, if there is a family history of aortic disease we ask you always to tell us.

In Summary

In aortic root and aortic diseases, the treatment decision is a personalised process shaped by the size of the vessel, its growth rate, any accompanying valve disease and the patient’s genetic risk profile. Across this range of options, extending from close follow-up to valve-sparing root surgery and from the Bentall procedure to emergency dissection surgery, our aim is always the same: to save lives with timely and correct intervention.

If there is a history of aortic aneurysm or dissection in your family, or if an enlargement has been detected in your aorta on routine imaging, you can book an appointment for a detailed assessment.

References

1. Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation. 2022;146(24):e334-e482.
2. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): New Insights into an Old Disease. JAMA. 2000;283(7):897-903.
3. Aboyans V, Bauersachs R, Mazzolai L, et al. 2024 ESC Guidelines for the Management of Peripheral Arterial and Aortic Diseases. Eur Heart J. 2024;45(36):3538-3700.
4. David TE, Feindel CM. An Aortic Valve-Sparing Operation for Patients with Aortic Incompetence and Aneurysm of the Ascending Aorta. J Thorac Cardiovasc Surg. 1992;103(4):617-621.