Indexed parameters, particularly CSAH, improve risk stratification beyond absolute diameters and highlight size-based differences in AA and provide an individualized precision imaging-based approach to surgical decision-making.
Abstract
Background
Ascending aortopathy (AA) is largely asymptomatic but carries risk for death, dissection, or rupture. Typical guidelines approach of recommending surgery based on aortic diameters is limited, as most dissections occur at AA diameters <5 cm.
Objectives
The authors compared transthoracic echocardiography (TTE) and gated contrast-enhanced (CE)-computed tomographic angiography (CTA) for AA assessment and evaluated the prognostic utility of indexed parameters (aortic diameter height index [AHI] and cross-sectional area to height ratio [CSAH]).
Methods
In 7,459 patients with AA (≥4 cm) undergoing both TTE and CTA, the authors assessed the concordance of aortic measurements and the prognostic value of absolute and indexed metrics for adverse outcomes (mortality, dissection, or rupture).
Results
Compared with CE-CTA, TTE underestimated aortic size (particularly for aneurysms ≥5 cm) in 58% of aortic roots and 37% of mid-ascending aortas. At 3.6 ± 3.6 years, there were 865 (11.6%) composite events (708 [9.5%] deaths, 173 aortic dissections [2.3%], and 12 ruptures [0.2%]). Addition of individual AA cutoffs provided incremental prognostic value for the composite endpoint (all P < 0.001) as follows: 1) aortic diameter ≥5 cm (HR: 2.42; 95% CI: 1.77-2.99); 2) AHI >3.20 cm/m (HR: 3.24; 95% CI: 2.22-4.17); and 3) CSAH ≥10 cm2/m (HR: 2.09; 95% CI: 1.55-2.39). In 5,213 unoperated patients, 63% and 86% events occurred at diameters <5 cm and AHI ≤3.21 cm/m, respectively, whereas CSAH ≥10 cm2/m was associated with 53% events.
Conclusions
Indexed parameters, particularly CSAH, improve risk stratification beyond absolute diameters and highlight size-based differences in AA. CE-CTA-derived indices provide an individualized precision imaging-based approach to surgical decision-making.
As abdominal aortic aneurysms (AAA) rupture results in a high mortality rate, early detection and risk stratification are critical for timely elective intervention. Although the maximum diameter is the sole imaging metric used to assess risk, other factors may provide complementary information. This study investigated the role of inflammation and hemodynamics in AAA progression. Methods: Patients with AAA underwent hybrid 18F-fluorodeoxyglucose ([18F]FDG) PET/CMR imaging, including a four-dimensional flow sequence and contrast-enhanced magnetic resonance angiography, and were followed to assess AAA diameter growth rate. Abdominal aorta hemodynamics and [18F]FDG PET target-to-background (TBR) were quantified at 28 standardized regions. Correlations between AAA diameter, hemodynamics, PET and growth rate were assessed. Results: Thirty-two AAA patients (84.4% men) with a median age of 73 and an interquartile range of [68; 77] years were prospectively recruited. The AAA maximum diameter was 48.1 [44.8; 55.0] mm, and the growth rate was 2.7 [1.3; 4.0] mm/year during a follow-up of 2 [1.1; 3.5] years. The AAA maximum diameter (R = 0.443, p = 0.011) and flow vorticity (R = 0.453, p = 0.009) showed significant bivariate correlation with the growth rate. When correcting for the aneurysm diameter, the helicity density was significantly correlated with the growth rate (p = 0.045), while the AAA thrombus volume was inversely associated with it (p = 0.042). Aneurysms with negative helicity density (counterclockwise rotation) grew significantly faster (p = 0.042) than those with positive helicity. In multivariable analysis, beyond the AAA diameter, the thrombus volume, helicity density and TBR were inversely related to the growth rate. Conclusions: Integrating flow, inflammatory and thrombus information may improve AAA growth rate prediction beyond the maximum aneurysm diameter.
M. Ferrer-Cornet, M. García-Reyes, M. Bragulat-Arévalo et al.· Life· 0 citations
Background 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. Objectives This study evaluated whether height-indexed aortic dimensions improve long-term risk stratification in AA patients who do not meet current surgical guidelines. Methods 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. Results 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). Conclusions 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.
Milind Y Desai, M. Abusafia, S. Jadam et al.· JACC: Advances· 1 citation
CT-derived AVA demonstrates strong agreement with TTE and provides complementary information for severity assessment and risk stratification in patients with aortic stenosis, particularly in cases with discordant or borderline findings.
Shehroz Sultan, Neeraj Joshi, A. H. Awan et al.· 0 citations
Aortic stenosis (AS) is the most common degenerative valvular disease in elderly patients and is linked to high morbidity and mortality. Accurate diagnosis and risk stratification are critical for effective management. Transthoracic echocardiography is the standard diagnostic tool, but its reliance on flow-dependent parameters can lead to inconsistent grading, especially in low-flow, low-gradient, or normal-flow, low-gradient AS. Advanced echocardiographic methods, such as 3D imaging, stress echocardiography, and Doppler indices, such as the mean gradient-to-effective orifice area ratio, improve the evaluation of AS severity and assist in clinical decision-making. Computed tomography provides a flow-independent evaluation of AS. It uses noncontrast calcium scoring with sex-specific thresholds, along with contrast-enhanced angiography, for detailed anatomical assessment. These modalities are essential for procedural planning, particularly for transcatheter aortic valve replacement. Cardiac magnetic resonance (CMR) provides additional prognostic information. It quantifies myocardial remodeling and fibrosis, which are associated with outcomes and recovery potential. Emerging technologies are expanding diagnostic capabilities in AS. Examples include 18F-sodium fluoride positron emission tomography for detecting microcalcification, artificial intelligence-based ECG and echocardiography for early diagnosis, and 4D flow CMR. Integration of echocardiography, computed tomography, CMR, and emerging positron emission tomography and artificial intelligence-based approaches can help address diagnostic uncertainty. This integration helps refine AS subtype classification and inform individualized intervention strategies.
H. Itani, M. Moumneh, A. Zayed et al.· Cardiology in Review· 0 citations
In bicuspid aortic valve (BAV) aortopathy, concomitant aortic coarctation (cBAV) is considered an aggravating risk factor which may indicate earlier prophylactic intervention. This assumption is challenged by recent studies in children or young adults, reporting smaller aortic diameters in cBAV patients compared to those with isolated BAV disease (iBAV), but these findings should be confirmed in adult patient populations.
To assess the association between aortic coarctation and aortic dilatation in adult BAV patients.
and results
In a prospective cohort study, we included 141 cBAV patients and 828 iBAV patients from outpatient clinics. Maximal diameters of the aortic root and tubular ascending aorta were measured on transthoracic echocardiograms (TTE). Aortic diameters, significant aortic dilatation at baseline (≥50 mm or Z-score≥4) and annual aortic growth rates were compared between groups taking possible confounders into account. Compared to iBAV patients, cBAV patients had smaller crude and adjusted diameters (adjusted mean difference: -3.27 mm [-4.49 mm; -2.05 mm]) and a lower likelihood of significant aortic dilatation at baseline (adjusted OR [95% CI]: 0.55 [0.30;1.01], p = 0.05). We observed no differences in aortic root dimensions or in aortic growth rates between cBAV and iBAV patients.
cBAV was associated with less pronounced dilatation of the tubular ascending aorta in adult BAV patients.
S. Wulffeld, M. D. Schmiegelow, R. Oksjoki et al.· European Heart Journal· 0 citations
BACKGROUND
Bicuspid aortic valve (BAV) is the most common congenital heart defect and is frequently associated with thoracic aortopathy. Risk stratification remains challenging, as predictors of aortopathy are incompletely understood, and prior studies have been limited by modest sample sizes or incomplete echocardiographic characterization.
METHODS
We retrospectively analyzed 1602 patients diagnosed with BAV. Aortopathy was defined as dilation of the sinus of Valsalva or ascending aorta using guideline-recommended thresholds. Clinical and echocardiographic predictors included age, sex, body surface area, hypertension, diabetes mellitus, medications (including beta blockers, calcium channel blockers, angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB) and statins, BAV morphology (Sievers type I-III), presence of raphe, valve calcification severity, aortic regurgitation (AR), and stenosis (AS) severity and coarctation. Missing data were addressed by multiple imputations. Univariable and multivariable logistic regression identified independent predictors of aortopathy.
RESULTS
Aortopathy was present in 64.7% of patients. On multivariable analysis, older age (odds ratio [OR] 1.011 per year, p=0.005), male sex (OR 0.76 for female vs male, p=0.03), BAV type I (reference; type II OR 0.6, p=0.01; type III OR 0.57, p=0.04), valve calcification severity (OR 2.31 per grade, p<0.001), and AR severity (OR 1.20 per grade, p=0.002) were independently associated with aortopathy. AS severity (OR 0.87 per grade, p=0.02) was inversely associated with aortopathy. Raphe, coarctation, hypertension, diabetes mellitus, consuming beta-blockers, calcium channel blockers, ACEi/ARB, and statins were not significant predictors. The model demonstrated good discrimination (AUC 0.79, 95% CI 0.76- 0.81), excellent calibration, and a Brier score of 0.18, indicating good overall predictive accuracy.
CONCLUSION
In a large echocardiographic cohort, age, sex, BAV type, valve calcification, AS, and AR severity were independently associated with aortopathy. These readily available variables refine risk stratification in BAV. Prospective, multicenter validation is warranted to incorporate these predictors into clinical practice.
Niloufar Javadi, Chaitanya Tumuluri, Prabhjot Hundal et al.· Journal of the American Soci...· 0 citations