What Are the Current Guidelines for Treating Thoracic Aortic Disease?
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1 What Are the Current Guidelines for Treating Thoracic Aortic Disease? Eric M. Isselbacher, M.D. Director, MGH Healthcare Transformation Lab Co-Director, MGH Thoracic Aortic Center Associate Professor of Medicine, Harvard Medical School
2 Presenter Disclosure Information No relationships to disclose Will discuss the off-label use of ARBs
3 Ascending vs. Descending Aneurysms Hereditary influence Younger Age Degenerative Older Age Vapnik JS, Kim JB, Isselbacher EM, et al. Am J Cardiol 2016;117:
4 Ascending vs. Descending Aneurysms Marfan syndrome Loeys-Dietz syndrome Bicuspid aortic valve Familial thoracic aortic aneurysm syndrome Sporadic/idiopathic Hereditary influence Younger Age Degenerative Older Age Advanced age Hypertension Atherosclerosis Smoking Vapnik JS, Kim JB, Isselbacher EM, et al. Am J Cardiol 2016;117:
5 Thoracic Aortic Aneurysms: Natural History Asymptomatic TAA Growth
6 Rates of Growth 2 Rate of Growth (mm/yr) mm mm 0.25 mm Ascending Marfan Descending Kim JB, et al. J Am Coll Cardiol 2016;69: Coady MA, et al. J Thorac Cardiovasc Surg 1997;113:476-91
7 Thoracic Aortic Aneurysms: Natural History Asymptomatic TAA X Growth Rupture Dissection
8 Medical Management of Thoracic Aortic Aneurysms
9 Beta Blockers Proven benefit in Marfan syndrome No trials in TAAs of other etiologies Mainstay of therapy.
10 Newer Therapeutic Strategy For Treating Marfan Syndrome Hal Dietz et al Many consequences of Marfan syndrome result from excessive TGF-β signaling Losartan, an angiotensin II type 1 receptor (AT1) blocker, inhibits activity of TGF-β.
11 Efficacy of Losartan in Mouse Model of MFS: Aortic Growth Over 6 Months Aortic growth (mm) Hagashi J, et al. Science 2006;312: Control Marfan Marfan + propranolol 0.18 Marfan + losartan
12 Losartan to Treat Humans: Non- Randomized Trial Before and After Rx Brooke BS, et al. N Eng J Med 2008; 358:
13 Atenolol vs. losartan for MFS: A randomized blinded placebo-controlled trial Lacro RV, et al. N Engl J Med 2014;371:
14 Could Losartan Be More Effective as Add-on Therapy? Marfan-Sartan Trial A randomized, double-blind, placebo-controlled trial comparing add-on losartan vs. placebo in Marfan patients, 86% already on beta-blocker p=0.37 Milleron O, et al. Eur Heart J 2015; 36:
15 Medical Therapy of Thoracic Aneurysms: 2010 ACC/AHA Guidelines Class I Beta-blockers should be administered to all patients with MFS and aortic aneurysm unless contraindicated. Class IIa For patients with thoracic aortic aneurysms, it is reasonable to reduce BP with beta blockers and ACEIs or ARBs to the lowest point patients can tolerate without adverse effects. An ARB is reasonable for patients with MFS, to reduce the rate of aortic dilatation, unless contraindicated. ACC/AHA Guidelines for Management of Thoracic Aortic Disease, J Am Coll Cardiol 2010;55: e27-e129
16 Thoracic Aortic Aneurysms: Natural History Asymptomatic TAA Growth Repair Rupture Dissection
17 Weighing the Risk of Aortic Dissection vs. the Risk of Intervention
18 Rate of Aortic Events vs. Ascending Aortic Diameter Kim JB, et al. J Am Coll Cardiol 2016; 69:
19 Risk of Aortic Dissection vs. the Risk of Surgery Mortality of Unoperated Ascending TAA vs. Size Percent Sporadic Congenital Size (cm)
20 Indications for Intervention
21 Ascending Aortic Aneurysms: Indications for Aortic Repair Class I Idiopathic (sporadic) aneurysms: 5.5 cm High risk surgery: 6.0 cm Low risk for surgery: 5.0 cm Rapid expansion 0.5 cm/year Perhaps 0.3 cm/year, if consistent growth (extrapolated from ESC guidelines) Severe AR: Symptoms or LV dysfunction. J Am Coll Cardiol 2010; 55:e27-e129
22 Ascending Aortic Aneurysms: Indications for Aortic Repair Class I Marfan syndrome or familial: 5.0 cm Low risk for surgery: 4.5 cm Increased risk for dissection (FHx of AoD at a small diameter): 4.0 cm. J Am Coll Cardiol 2010; 55:e27-e129
23 Histogram of ages at time of AoD of sporadic vs. familial syndrome patients Chou AS, et al. Ann Thorac Surg 2017;103:546 50
24 Proband ages at AoD vs. other dissecting family member s ages at AoD Chou AS, et al. Ann Thorac Surg 2017;103:546 50
25 Should we be more aggressive for aneurysm patients with a BAV?
26 BAV and Risk of Aortic Dissection Presumed to be genetically mediated Histologically similar to Marfan syndrome.
27 2010: 5.0 cm threshold for surgery in BAV ACC/AHA Guidelines for Management of Thoracic Aortic Disease, J Am Coll Cardiol 2010;55: e27-e129
28 Maximal Root or Ascending Aortic Diameter at the Time of Dissection 5.6±1.1 cm 6.6±1.5 cm Eleid MF, et al. Heart 2013;99:
29 Equal Rates of Aortic Dissection / Rupture Kim JB, et al. J Am Coll Cardiol 2016; 69:
30 2016: 5.5 cm threshold for surgery in BAV A Statement of Clarification From the ACC/AHA, J Am Coll Cardiol 2016; 67:
31 Aneurysms: Size Matters
32 What About Patient Size?
33 Two women in their 50s with a bicuspid aortic valve 5.5 cm 4.5 cm
34 Factoring Height into a Threshold for Surgery Class IIa Elective aortic replacement is reasonable for patients with MFS or other genetic diseases, when the ratio of maximal ascending or aortic root area in cm 2 divided by the patient s height in meters exceeds 10 πr 2 (cm 2 )/height (m) >10 ACC/AHA Guidelines for Management of Thoracic Aortic Disease, J Am Coll Cardiol 2010;55: e27-e129
35 Factoring Height into a Threshold for Surgery in those with TAV Masri et al, Cleveland Clinic Consecutive patients with dilated aortic root or ascending aorta identified by echo or CT ( ) Followed a mean of 10.8 years 327 patients with a tricuspid aortic valve and aortic diameter cm 44% had an aortic root area/height ratio 10 78% died Aortic surgery associated with improved survival. Masri A, et al. Circulation 2016;134:
36 Cross-sectional area to height ratio 10 Root Ascending Masri A, et al. Circulation 2016;134:
37 Cross-sectional area to height ratio 10 Root Ascending Masri A, et al. Circulation 2016;134:
38 Next Guidelines? 38
39 Aortic Arch Aneurysms: Indications for Aortic Repair Class IIa Isolated arch aneurysm: 5.5 cm Aortic arch repair may be considered in pts with arch aneurysm who already have an indication for surgery of an adjacent aneurysm located in the ascending or descending aorta J Am Coll Cardiol 2010; 55:e27-e129 Eur Heart J 2014; 35:
40 Descending Aortic Aneurysms: Indications for Aortic Repair Class IIa Chronic dissection: 5.5 cm If due to connective tissue disorder, open repair rather than TEVAR Degenerative aneurysm TEVAR candidates: 5.5cm Requiring open surgery 6.0 cm Rapid expansion ( 0.5 cm/year). J Am Coll Cardiol 2010; 55:e27-e129 Eur Heart J 2014; 35:
41 Time is up! 10 cm
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