More national history data needed for ascending aortic aneurysm

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There was a low growth rate for moderately dilated ascending aorta, according to a systematic review and meta-analysis published in JAMA Network Open.

Ming Hao Guo, MD, of the division of cardiac surgery at University of Ottawa Heart Institute, Canada, and colleagues analyzed data from 8,800 patients (mean age, 58 years; 76% men) from 20 studies from 1946 to May 2017. Studies were included in the meta-analysis if they reported rate of dissection or rupture, growth rate or all-cause mortality in patients with ascending aortic aneurysm.

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Data that were extracted include study design, demographics, follow-up, sample size, initial aneurysm diameter, patient risk factors and comorbidities, incidence of dissection or rupture, aneurysm growth rate during follow-up, incidence of elective ascending aortic surgery, size at dissection or rupture and all-cause mortality. Total follow-up time was 31,823 patient-years.

At enrollment, the mean initial aneurysm size from 13 studies was 42.6 mm.

All studies had a combined effect estimate for annual growth rate of 0.61 mm per year (95% CI, 0.23-0.99; I2 = 92%). During a median follow-up of 4.2 years, the pooled incidence of elective aortic surgery was 13.82% (95% CI, 6.45-21.41; I2 = 56%).

The linearized rate of the composite outcome of aortic dissection, all-cause mortality and aortic rupture was 2.16% per patient-year (95% CI, 0.79-3.55, I2 = 64%). The linearized rate for all-cause mortality was 1.99% per patient-year (95% CI, 0.83-3.15; I2 = 84%).

Researchers did not find a significant relationship between the year of study completion and primary outcomes and initial aneurysm size.

“These results require cautious interpretation as a large number of patients in the studies who met guideline criteria for intervention underwent elective aortic surgery,” Guo and colleagues wrote. “More robust natural history data from prospective studies or randomized clinical trials are necessary to better inform clinical decision-making in patients with ascending aortic disease.”

In a related editorial, Thoralf M. Sundt, MD, chief of the division of cardiac surgery and director of the Corrigan Minehan Heart Center at Massachusetts General Hospital, wrote: “To be sure, for patients, once they have been told they have an aneurysm (read, ‘time bomb in your chest’), it is very hard to turn back the clock and reassure them that the likelihood of a catastrophe is low. I suspect the same is true, to some degree, among caregivers. Who among us wants to sit by watching and hoping that we do not get a phone call that an aorta has dissected? Furthermore, our outcome information is asymmetric. The absence of dissection is a nonevent; we do not see it because there is nothing to see. And, of course, we can never know how many of those aortas we replace would or would not have dissected.” – by Darlene Dobkowski

Disclosures: The authors and Sundt report no relevant financial disclosures.

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