Commentary: Size matters, but not as much as surgeon preference

Central MessageAlthough guidelines suggest cutoffs for intervention, not all surgeons see these guidelines the same way.See Article page 17. Although guidelines suggest cutoffs for intervention, not all surgeons see these guidelines the same way. See Article page 17. Determining the ideal time to intervene for an ascending aortic aneurysm is, to say the least, complicated. The goal remains finding the optimal timeframe during which the risk of an acute aortic event outweighs the risk of surgery. In this issue of the Journal, the Canadian Thoracic Aortic Collaborative demonstrates that given differences in society guidelines, there exists practice variation among surgeons.1Guo M.H. Appoo J.J. Hendry P. Masters R. Chu M.W.A. Ouzounian M. et al.Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeons.J Thorac Cardiovasc Surg. 2023; 165: 17-25.e2Abstract Full Text Full Text PDF Scopus (3) Google Scholar Their group should be commended for ascertaining the size threshold for a variety of patient presentations among both high-volume and low-volume surgeons at 25 centers across Canada. Although current Canadian, American, and European guidelines agree on 5.5 cm as an absolute size threshold for a healthy, asymptomatic patient with a tricuspid aortic valve, they differ in recommendations for risk factors and an annual growth rate that should prompt earlier intervention.2Boodhwani M. Andelfinger G. Leipsic J. Lindsay T. McMurtry M.S. Therrien J. et al.Canadian Cardiovascular Society position statement on the management of thoracic aortic disease.Can J Cardiol. 2014; 30: 577-589Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar, 3Erbel R. Aboyans V. Boileau C. Bossone E. Di Bartolomeo R. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (3038) Google Scholar, 4Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.Circulation. 2010; 121: e266-e369Crossref PubMed Scopus (2038) Google Scholar Without the aid of a crystal ball, cardiac surgeons must consider and balance a variety of patient and physician factors in making this decision. A thorough history, physical examination, and review of the medical record are critical in identifying pertinent risk factors. Prophylactic repairs at lower size thresholds are advised for patients undergoing a concomitant cardiac surgery (4.5 cm) or diagnosed with a connective tissue disorder (4.5-5.0 cm).4Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.Circulation. 2010; 121: e266-e369Crossref PubMed Scopus (2038) Google Scholar In healthy asymptomatic patients who do not meet one of the aforementioned criteria, we consider earlier surgery if they have a family history of dissection, rapid growth, occupational risk factors, or meet the criteria of the Aortic Size Index. A family history of dissection is the only agreed-upon risk factor among all the guidelines, and it is not surprising that 92.8% of respondents lowered their threshold for surgery when this history was present.1Guo M.H. Appoo J.J. Hendry P. Masters R. Chu M.W.A. Ouzounian M. et al.Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeons.J Thorac Cardiovasc Surg. 2023; 165: 17-25.e2Abstract Full Text Full Text PDF Scopus (3) Google Scholar Time must be taken to truly delve into the family history, as aortic dissection is present more often than one may think. Finally, patients with severe anxiety over knowledge of their aortic aneurysm that limits their quality of life or prompts frequent cross-sectional imaging may benefit from early repair. The cardiac surgeon's experience with performing aortic surgery and knowledge of their individual complication rates should also factor into the equation. There has been a trend in the field of aortic surgery to intervene at a lower diameter to prevent dissection or rupture as studies show that modern day elective aortic surgery is safer.5Ziganshin B.A. Zafar M.A. Elefteriades J.A. Descending threshold for ascending aortic aneurysmectomy: is it time for a “left-shift” in guidelines?.J Thorac Cardiovasc Surg. 2019; 157: 37-42Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar While it is not a recommendation in current guidelines, we agree with 20% of survey respondents who advocate offering surgery at 5.0 cm to the average patient.1Guo M.H. Appoo J.J. Hendry P. Masters R. Chu M.W.A. Ouzounian M. et al.Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeons.J Thorac Cardiovasc Surg. 2023; 165: 17-25.e2Abstract Full Text Full Text PDF Scopus (3) Google Scholar This lower size threshold is one reason why the presence of a bicuspid aortic valve rarely factors into our decision making process. At the end of the day, the patient and surgeon must form a plan that both are comfortable with. The vast majority of patients do not require referral to an aortic center of excellence; however, for cardiac surgeons who do not want to practice outside of guideline recommendations, this could be considered in certain situations. We argue that guidelines do only as their name suggests—provide guidance. They are not steadfast rules and should not be allowed to dictate our practice. Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeonsThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 1PreviewThe survey aimed to assess the practice patterns of Canadian cardiac surgeons on the size threshold at which patients with ascending aortic aneurysm would be offered surgery. Full-Text PDF