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An updated guideline for the diagnosis and management of aortic disease from the American College of Cardiology (ACC) and American Heart Association (AHA) endorsed new surgical thresholds and considerations for their adjustment.

Certain selected patients will be eligible for surgery sooner, as the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms was reduced from 5.5 cm to 5.0 cm -- and even lower in specific scenarios for patients with heritable thoracic aortic aneurysms -- when performed by experienced surgeons.

Notably, this is said to be reasonable (a class IIa recommendation) only if the surgeon is part of a "Multidisciplinary Aortic Team," in which cardiac and vascular surgeons with extensive experience managing complex aortic disease at a center with a high volume of aortic interventions (i.e., at least 30 aortic procedures annually) work together with experienced imaging specialists, anesthesiologists, and critical care clinicians.

The guideline was in the ACC's Journal of the American College of Cardiology and the AHA's Circulation.

Potentially widening the pool of surgical candidates further, the guideline allows for some flexibility around surgical cutoffs to account for patients who are significantly smaller or taller than average (class IIa recommendation).

Moreover, the definition of rapid aortic root growth or ascending aortic aneurysm growth, an indication for intervention, expanded from ≥0.5 cm in 1 year to ≥0.3 cm per year in 2 consecutive years for those with sporadic aneurysms and ≥0.3 cm in 1 year for those with heritable thoracic aortic disease or bicuspid aortic valve disease.

"There has been a host of new evidence-based research available for clinicians in the past decade when it comes to aortic disease. It was time to re-evaluate and update the previous, existing guidelines," said guideline writing committee chair Eric Isselbacher, MD, MSc, of Massachusetts General Hospital and Harvard Medical School in Boston.

"We hope this new guideline can inform clinical practices with up-to-date and synthesized recommendations, targeted toward a full multidisciplinary aortic team working to provide the best possible care for this vulnerable patient population," he noted in a press release.

Isselbacher and colleagues said that the multidisciplinary aortic team should determine the most suitable intervention in cases of acute aortic disease requiring urgent repair (class I recommendation) and should be referred to for asymptomatic patients for whom intervention is an option (class IIa recommendation).

Other recommendations in the guideline include:

• Patients with acute type A aortic dissection, if clinically stable, should be considered for transfer to a high-volume aortic center, where surgery should entail at least an open distal anastomosis rather than just a simple supracoronary interposition graft.
• In patients with uncomplicated acute type B aortic dissection who have high-risk anatomic features, endovascular management should be considered.
• Family screening (including genetic testing and imaging) is strongly recommended for first-degree relatives of individuals with aneurysms of the aortic root or ascending thoracic aorta, or those with aortic dissection.

The updated ACC/AHA guideline replaces recommendations going and is to be used concurrently with the 2020 valve disease guideline.

It was developed in collaboration with the American Association for Thoracic Surgery, American College of Radiology, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and Society for Vascular Surgery, and was endorsed by the Society of Interventional Radiology and Society for Vascular Medicine.

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