Reappraisal of Surgical Threshold in Patients With Ascending Aortic Dilation: Moving Beyond Aortic Diameters?

Authors

Milind Y Desai, Mohammed Abusafia, Shada Jadam, Vidyasagar Kalahasti, Susan Keen, Lifu Deng, Susan Ospina, Sana Sultana, Andrew Gaballa, Patrick Vargo, Xiaoying Lou, Eric E Roselli, Brian P Griffin, Lars G Svensson

Published in

JACC. Advances. Volume 5. Issue 8. Pages 102859. Jul 15, 2026. Epub Jul 15, 2026.

Abstract

Indexing ascending aortic dimensions to height, rather than absolute diameters, may better identify at-risk ascending aortopathy (AA) patients who could benefit from earlier surgery.
This study evaluated whether height-indexed aortic dimensions improve long-term risk stratification in AA patients who do not meet current surgical guidelines.
A total of 11,083 patients (68 ± 13 years, 79% men, 28% with bicuspid aortic valve, 2,196 with aortic surgery and 8,887 unoperated) with AA (4-5 cm) diagnosed on echocardiography (2010-2023) were included. Patients with syndromic aortopathy and acute aortic dissection/rupture at presentation were excluded. The maximum AA diameter, AA height index (AHI) (cm/m), and AA cross-sectional area-to-height (CSAH) (cm²/m) index were calculated. The primary outcome was mortality.
The mean AA diameter, AHI, and CSAH were 4.4 ± 0.2 cm, 2.53 ± 0.3 cm/m, and 8.8 ± 1 cm²/m, respectively. At 6 ± 4 years, there were 84 (8.3%) deaths in the operated group and 1,058 (11.9%) in the unoperated group. There were 128 aortic dissections (1.4%) and 4 aortic ruptures (0.04%) in the unoperated group. Dividing the unoperated sample into a derivation cohort (n = 3,887), spline analysis demonstrated an increase in hazard for death in women with AA diameter ≥4.5 cm and in all patients with AHI ≥2.5 cm/m or CSAH ≥9 cm²/m. Validation in a separate cohort (n = 5,000) confirmed that AHI ≥2.5 cm/m and CSAH ≥9 cm²/m were associated with higher long-term mortality (both P < 0.05).
Indexing AA dimensions to height better identifies high-risk AA patients, particularly women, who fall below surgical criteria. Further studies are needed to determine if this cohort may benefit from earlier intervention at lower size thresholds.

PMID:
42456260
Bibliographic data and abstract were imported from PubMed on 16 Jul 2026.

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