Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA.
Department of Cardiac Surgery, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, 106 Zhongshan Er Road, Yuexiu District, Guangzhou, Guangdong 510060, China.
Eur Heart J. 2023 Nov 14;44(43):4579-4588. doi: 10.1093/eurheartj/ehad148.
This study aims to outline the 'true' natural history of ascending thoracic aortic aneurysm (ATAA) based on a cohort of patients not undergoing surgical intervention.
The outcomes, risk factors, and growth rates of 964 unoperated ATAA patients were investigated, over a median follow-up of 7.9 (maximum of 34) years. The primary endpoint was adverse aortic events (AAE), including dissection, rupture, and aortic death. At aortic sizes of 3.5-3.9, 4.0-4.4, 4.5-4.9, 5.0-5.4, 5.5-5.9, and ≥6.0 cm, the average yearly risk of AAE was 0.2%, 0.2%, 0.3%, 1.4%, 2.0%, and 3.5%, respectively (P < 0.001), and the 10-year survival free from AAE was 97.8%, 98.2%, 97.3%, 84.6%, 80.4%, and 70.9%, respectively (P < 0.001). The risk of AAE was relatively flat until 5 cm of aortic size, at which it began to increase rapidly (P for non-linearity <0.001). The mean annual growth rate was estimated to be 0.10 ± 0.01 cm/year. Ascending thoracic aortic aneurysms grew in a very slow manner, and aortic growth over 0.2 cm/year was rarely seen. Multivariable Cox regression identified aortic size [hazard ratio (HR): 1.78, 95% confidence interval (CI): 1.50-2.11, P < 0.001] and age (HR: 1.02, 95% CI: 1.00-1.05, P = 0.015) as significant independent risk factors for AAE. Interestingly, hyperlipidemia (HR: 0.46, 95% CI: 0.23-0.91, P = 0.025) was found to be a significant protective factor for AAE in univariable Cox regression.
An aortic size of 5 cm, rather than 5.5 cm, may be a more appropriate intervention criterion for prophylactic ATAA repair. Aortic growth may not be an applicable indicator for intervention.
本研究旨在基于一组未接受手术干预的患者，概述升主动脉瘤（ATAA）的“真实”自然史。
对 964 例未手术的 ATAA 患者的结局、危险因素和生长率进行了调查，中位随访时间为 7.9 年（最长 34 年）。主要终点是不良主动脉事件（AAE），包括夹层、破裂和主动脉死亡。在主动脉直径为 3.5-3.9cm、4.0-4.4cm、4.5-4.9cm、5.0-5.4cm、5.5-5.9cm 和≥6.0cm 时，AAE 的平均年风险分别为 0.2%、0.2%、0.3%、1.4%、2.0%和 3.5%（P<0.001），10 年无 AAE 生存率分别为 97.8%、98.2%、97.3%、84.6%、80.4%和 70.9%（P<0.001）。AAE 的风险在主动脉直径达到 5cm 之前相对平稳，之后开始迅速增加（P<0.001，非线性）。估计平均年增长率为 0.10±0.01cm/年。升主动脉瘤生长非常缓慢，很少见主动脉生长超过 0.2cm/年。多变量 Cox 回归分析确定主动脉直径[风险比（HR）：1.78，95%置信区间（CI）：1.50-2.11，P<0.001]和年龄（HR：1.02，95%CI：1.00-1.05，P=0.015）是 AAE 的显著独立危险因素。有趣的是，在单变量 Cox 回归中，高脂血症（HR：0.46，95%CI：0.23-0.91，P=0.025）被发现是 AAE 的显著保护因素。
5cm 的主动脉直径，而不是 5.5cm，可能是预防性升主动脉瘤修复的更合适的干预标准。主动脉生长可能不是一个适用的干预指标。
