Associazione Nazionale Medici Cardiologi Ospedalieri



Prediction of Acute Aortic Syndromes in Patients with Dilatation of Ascending Aorta: is it the Holy Grail of Contemporary Cardiac Surgery ?

Totaro Pasquale Pavia(Pavia) – SC Cardiochirurgia, IRCCS Fondazione Policlinico San Matteo | Amoroso Filippo Pavia(Pavia) – SC Cardiochirurgia, IRCCS Fondazione Policlinico San Matteo | Kushta Eraldo Pavia(Pavia) – SC Cardiochirurgia, IRCCS Fondazione Policlinico San Matteo


Acute aortic syndromes (AAS) represent the most frequent emergency situation in cardiac surgery. Despite improvements in surgical outcomes in recent decades, postoperative mortality in these situations is still significant (5-20%). The study of potential markers able of identifying patients at high-risk for AAS has been widely evaluated for many years. Although many potential markers have been identified, current guidelines are based, in the absence of morphological signs, on two keys: maximum dilation and its evolution over time. In this work we have reviewed our twenty-year experience to better elucidate the clinical history that led to AAS in the current era. We also evaluated the real role of monitoring a known dilatation of the ascending aorta over time in the prevention of AAS.

Materials and methods

Data from 267 patients undergoing emergency surgery for AAS (acute dissection, intraparietal hematoma, ulcerated plaque rupture) were examined. For each patients, the past medical history was reviewed including the diagnostic / instrumental evaluations carried out before the acute event.


As Summarized in Figure 1A, despite history of hypertension was common, only a minority of patients had underwent adequate diagnostic evaluation of the thoracic aorta before AAS. Furthermore, out of 267 patients, only 3 patients had a known AAA > 50mm and all had previously refused surgery. The remaining patients (Fig 1B) presented dilatation without surgical indication according current international guidelines. In 1 patient a CT Scan was performed 1 week before AAS and maximum dilatation was 43mm (Fig 1C) with no sign of increased risk of dissection. At the time of dissection dilatation reached 52 mm (Fig 1D) .


Our analysis, based on twenty years of experience, has clearly shown that only a minimal part of patients experiencing an AAS have a clear history of progressive aortic dilatation , amenable to analysis and risk weighting. In our series, the minority of patients with previous history of aortic dilatation, however, did not have aortic dilations at high risk of AAS according to international guidelines. The ‘real life’ in contemporary cardiac surgery, therefore, seems to confirm the substantial unpredictability of an acute aortic event in the absence of systematic surveillance protocols to be adopted on the entire population at risk