3rd Cardiac Surgery Department, Onassis Cardiac Surgery Center, Athens, Greece.
Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.
Eur J Cardiothorac Surg. 2021 Apr 13;59(3):554-561. doi: 10.1093/ejcts/ezaa387.
As thoracic aortic aneurysm disease continues to cause significant morbidity and mortality in the general population, the cardiovascular community continues the search for the golden threshold of elective surgical replacement of the ascending aorta.
Thoracic aortic aneurysm is a common disease, classified within the 20 most common causes of death in patients over 65 years old. Once aortic complications like dissection or rupture occur, they can prove fatal. Prophylactic surgical replacement of the ascending aorta remains the mainstay of treatment to prevent these complications. Current American and European guidelines agree that the threshold for the diameter for elective replacement of the ascending aorta in non-syndromic, asymptomatic aneurysmal disease is 5.5 cm. Overall, aortic dissection is related to poor prognosis, thus making early intervention paramount.
There is a critical size above which the risk of dissection or rupture becomes extremely high. However, a significant post-dissection increase in diameter is reported, thus rendering the predissection aortic diameter well below the current threshold for elective surgical replacement of the ascending aorta. Moreover, it is widely reported that the majority of acute aortic dissections would not meet the criteria for prophylactic surgery prior to dissection. Additionally, elective surgical ascending aortic replacement in the current era shows a significantly improved risk-benefit ratio, which justifies a more aggressive approach in the management of aortic aneurysmal disease.
As a result, there is a lot of discussion in the literature about the requirement of a leftward shifting of the surgical threshold for elective aortic replacement.
由于胸主动脉瘤疾病在普通人群中继续导致重大发病率和死亡率，心血管界继续寻找择期手术置换升主动脉的黄金阈值。
胸主动脉瘤是一种常见疾病，属于 65 岁以上患者死亡的 20 种最常见原因之一。一旦发生夹层或破裂等主动脉并发症，可能导致致命。预防性手术置换升主动脉仍然是预防这些并发症的主要治疗方法。目前美国和欧洲的指南都同意，非综合征、无症状动脉瘤性疾病择期置换升主动脉的直径阈值为 5.5cm。总体而言，主动脉夹层与预后不良有关，因此早期干预至关重要。
存在一个临界尺寸，超过这个尺寸，夹层或破裂的风险就会极高。然而，据报道，夹层后直径会显著增加，因此使夹层前主动脉直径远低于目前择期手术置换升主动脉的阈值。此外，广泛报道称，大多数急性主动脉夹层在夹层前不符合预防性手术的标准。此外，在当前时代，择期升主动脉置换手术的风险效益比显著提高，这证明了在管理主动脉瘤疾病方面采取更积极的方法是合理的。
因此，文献中对于需要向左移动择期主动脉置换手术阈值的问题进行了大量讨论。
