Aortic Valve and Ascending Aorta
Publication Date: June 1, 2013
Last Updated: March 14, 2022
Recommendations
Indications for Aortic Valve Surgery
Aortic Stenosis
AVR is recommended in patients with severe AS at the onset of symptoms of dyspnea, angina, or lightheadedness or syncope. (B, Class I)
316161
AVR is recommended, regardless of symptoms, with the identification of left ventricular (LV) systolic dysfunction (ejection fraction [EF] <50%). (C, Class I)
316161
AVR is recommended in patients with severe AS who are scheduled to undergo coronary artery bypass graft surgery (CABG), surgery on other cardiac valves, or surgery on the aortic root or ascending aorta. (C, Class I)
316161
AVR is reasonable in patients with moderate AS undergoing CABG or surgery on the aorta or other heart valves. (B, Class IIa)
316161
Exercise testing in asymptomatic patients with AS to determine the need for AVR may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses. (B, Class IIb)
316161
AVR may be considered for asymptomatic patients with severe AS and abnormal response to exercise (eg, asymptomatic hypotension). (C, Class IIb)
316161
AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. (C, Class IIb)
316161
AVR may be considered in patients undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcification, that progression may be rapid. (C, Class IIb)
316161
AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area [AVA] <0.6 cm2, mean gradient >60 mm Hg, and jet velocity >5.0 m/s) when the patient’s expected operative mortality is less than 1%. (C, Class IIb)
316161
AVR is not useful for the prevention of sudden death in asymptomatic patients with AS who have normal LV systolic function. (B, Class III)
316161
Aortic Regurgitation
AVR or repair is indicated for symptomatic patients with severe AR irrespective of LV systolic function. (B, Class I)
316161
AVR or repair is recommended for asymptomatic patients with chronic severe AR and LV systolic dysfunction (EF ≤50%) at rest. (B, Class I)
316161
AVR or repair is recommended in patients with chronic severe AR who are undergoing CABG or surgery on the aorta or other heart valves. (C, Class I)
316161
VR or repair is reasonable for asymptomatic patients with severe AR with normal LV systolic function (EF >50%) but with severe LV dilation (end-diastolic dimension >75 mm or end-systolic dimension >55 mm). (B, Class IIa)
316161
AVR or repair may be considered in patients with moderate AR who are undergoing CABG or surgery on the aorta or other heart valves. (C, Class IIb)
316161
AVR or repair may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (EF >50%) when the degree of LV dilation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive LV dilation, declining exercise tolerance, or abnormal hemodynamic responses to exercise. (C, Class IIb)
316161
AVR is not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest (EF >50%) when the degree of LV dilation is not moderate or severe. (B, Class III)
316161
Aortic Valve Endocarditis
AVR is recommended in patients with aortic valve infective endocarditis and severe heart failure or cardiogenic shock due to aortic valve dysfunction when there is a reasonable likelihood of recovery with satisfactory quality of life after surgery. (B, Class I)
316161
Surgery is recommended in patients with annular or aortic abscesses, heart block, infections resistant to antibiotic therapy, and fungal endocarditis. (B, Class I)
316161
Surgery to prevent embolization might be considered for patients with large vegetation size (>1.5 cm), especially if other relative indications for surgery are present (eg, severe AR) and the surgical risk is low. (C, Class IIb)
316161
Preoperative Testing and Assessment of Comorbid Disease and Frailty
Surgical Risk Scores
Performing risk score analysis is reasonable to evaluate patients undergoing surgical AVR or TAVR to quantitate PROM. (B, Class IIa)
316161
Performing risk score analysis may be reasonable to aid in determining which patients should undergo AVR, TAVR or medical therapy alone in high-risk patients. (C, Class IIb)
316161
Echocardiography
TTE is recommended for the diagnosis and assessment of AS or AR severity. (B, Class I)
316161
Echocardiography is recommended in patients with AS or AR for the assessment of LV wall thickness, size, and function. (B, Class I)
316161
TTE is recommended for reevaluation of patients with known AS or AR and changing symptoms or signs. (B, Class I)
316161
TTE is recommended for reevaluation of asymptomatic patients: every 6 months for severe AS or AR, every 1 to 2 years for moderate AS or AR, and every 3 to 5 years for mild AS or AR. (B, Class I)
316161
Intraoperative TEE is recommended to check repairs or replacements. (B, Class I)
316161
Exercise Testing
Exercise testing in asymptomatic patients with AS or AR may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses. (B, Class IIb)
316161
Exercise testing should not be performed in symptomatic patients with AS or AR. (B, Class III)
316161
Dobutamine stress echocardiography is reasonable to evaluate patients with low-flow/low gradient AS and LV dysfunction for possible AVR or TAVR
Dobutamine stress echocardiography is reasonable to evaluate patients with low-flow/low gradient AS and LV dysfunction for possible AVR or TAVR. (B, Class IIa)
316161
Cardiac catheterization for hemodynamic measurements with infusion of dobutamine can be useful for evaluation of patients with low-flow/low-gradient AS and LV dysfunction. (C, Class IIa)
316161
Cardiac Catheterization
Coronary angiography is recommended before AVR in patients with AS or AR at risk for CAD. (B, Class I)
316161
Cardiac catheterization for hemodynamic measurements is recommended for assessment of severity of AS or AR in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between noninvasive tests and clinical findings. (C, Class I)
316161
For patients aged less than 45 years, CT coronary angiography may be considered. (C, Class IIb)
316161
Cardiac catheterization for hemodynamic measurements is not recommended for the assessment of severity of AS before AVR when noninvasive tests are adequate and concordant with clinical findings. (C, Class III)
316161
Cardiac catheterization for hemodynamic measurements is not recommended for the assessment of LV function and severity of AS or AR in asymptomatic patients. (C, Class III)
316161
Cannulation Options for Aortic Valve and Root Surgery
For most patients requiring a simple aortic valve procedure without ascending aortic disease, the distal ascending aorta is recommended as the site for cannulation. (B, Class I)
316161
Mechanical Aortic Valves
Before mechanical AVR, all patients who have known CAD, have had a prior myocardial infarction, have angina pectoris as a symptom, or are greater than age 45, should have preoperative screening of their coronary arteries, either by direct coronary angiography. (C, Class I)
316161
All patients undergoing mechanical AVR should receive perioperative prophylactic antibiotics to cover both gram positive and negative organisms. (C, Class I)
316161
All patients receiving a mechanical aortic valve should receive postoperative anticoagulation, beginning after valve implantation. (C, Class I)
316161
Nasal mupirocin is probably indicated for methicillin resistant organism or routinely before and after operations. (C, Class IIa)
316161
Preoperative chlorhexidine showers and mouth washes should be considered. (C, Class IIa)
316161
Biological Valves
A bioprosthesis is recommended for AVR in patients of any age who will not take anticoagulation, either warfarin or the direct factor Xa or thrombin inhibitors or who have major medical contraindications to anticoagulation. (C, Class I)
316161
A bioprosthesis is recommended for AVR in patients aged 65 years or more without risk factors for thromboembolism. (C, Class I)
316161
Patient preference is a reasonable consideration in the selection of aortic valve prosthesis if appropriate surgical counseling is carried out. (-, Class IIa)
316161
A bioprosthesis may be considered for AVR in a woman of childbearing age who desires to have children. (C, Class IIb)
316161
A bioprosthesis may be reasonable for AVR in patients aged less than 65 years who elect to receive this valve for lifestyle considerations after detailed discussions of the risks of anticoagulation versus the likelihood that AVR may be necessary in the future. (C, Class IIb)
316161
Enlargement of the Aortic Annulus
Patch enlargement of the aortic annulus should be considered when the aortic annulus does not allow implantation of a heart valve with EOA index more than 0.65 cm2/m2. (B, Class I)
316161
Patch enlargement of the aortic annulus may be considered when the aortic annulus does not allow implantation of the heart valve with EOA index of 0.85 cm2/m2. (B, Class I)
316161
Homograft (Allograft) Replacement of the Aortic Valve
Homograft replacement of the aortic root should be considered for patients with extensive active endocarditic destruction of the aortic annulus. (B, Class I)
316161
For patients undergoing homograft replacement of the aortic valve, a total root replacement technique is recommended. (B, Class I)
316161
Homograft replacement of the aortic valve can be considered for patients with endocarditis without annular destruction, especially when the potential for reinfection is elevated. (B, Class IIa)
316161
Homograft replacement of the aortic valve can be considered for patients undergoing reoperative aortic root surgery in whom anatomic or physiologic constraints mitigate against more conventional composite graft replacement or for whom life expectancy is less than the projected durability of the homograft. (B, Class IIa)
316161
Homografts are not recommended for routine AVR. Currently available xenografts have excellent hemodynamics, durability comparable to homografts and are simpler to replace. (B, Class III)
316161
Stentless Aortic Valves
Subcoronary Stentless Valve Implantation for Aortic Valve Replacement
Before subcoronary stentless AVR, all patients who have known CAD, have had a prior myocardial infarction, have angina pectoris as a symptom, or are more than 45 years of age, should have preoperative screening of their coronary arteries, by direct coronary angiography. (C, Class I)
316161
Intraoperative TEE is recommended to check the valve function. (C, Class I)
316161
Prophylactic antibiotics for any invasive procedure, including dentistry, are recommended. (C, Class I)
316161
Stentless valves may be a reasonable prosthesis choice in patients aged more than 70 years with nonregurgitant, trileaflet AS who desire a tissue prosthesis and are at risk for PPM. (C, Class IIb)
316161
Full Aortic Root Replacement With a Stentless Prosthesis
Before aortic root replacement, all patients who have known CAD, have had a prior myocardial infarction, have angina pectoris as a symptom, or are aged more than 45 years, should have preoperative screening of their coronary arteries by direct coronary angiography. (C, Class I)
316161
Intraoperative TEE is required to check the valve function. (C, Class I)
316161
Prophylactic antibiotics for any invasive procedure including dentistry are recommended. (C, Class I)
316161
Stentless aortic valve full root replacement may be considered in patients aged more than 70 years with aortic root dilation. (C, Class IIa)
316161
Stentless aortic valve full root replacement may be considered in patients aged more than 70 years at high risk for PPM who desire a tissue prosthesis. (B, Class IIb)
316161
Pulmonary Autograft (Ross Procedure)
The Ross procedure is recommended in infants and small children for whom no satisfactory alternative valve substitute exists. (C, Class IIb)
316161
The Ross procedure is not recommended for middle-aged or older adults when suitable alternatives to autograft replacement of the aortic valve are available with comparable results and without the need for replacement of the RVOT, as the latter adds the additional risk of pulmonary valve dysfunction and subsequent replacement. (C, Class III)
316161
The Ross procedure is not recommended for middle-aged or older adults when suitable alternatives to autograft replacement of the aortic valve are available with comparable results and without the need for replacement of the RVOT, as the latter adds the additional risk of pulmonary valve dysfunction and subsequent replacement. (C, Class III)
316161
Balloon Aortic Valvuloplasty
BAV can be useful as bridge to AVR in hemodynamically unstable adult patients with severe AS where immediate AVR is not feasible. (C, Class IIa)
316161
BAV should be considered for patients with contra indications to AVR who can potentially be bridged to AVR or TAVR in future. (C, Class IIa)
316161
BAV may be considered in patients with symptomatic severe AS who require urgent major noncardiac surgery. (C, Class IIb)
316161
BAV may be considered as a palliative measure in individual cases when surgery is contraindicated because of severe comorbidities. (C, Class IIb)
316161
Hemodynamic assessment including cardiac output, aortic, LV and pulmonary pressures may be considered before, during and after the procedure. (C, Class IIb)
316161
Rapid ventricular pacing may be performed to stabilize balloon during inflation unless self seating dumbbell shaped or other specifically designed balloons are available that do not require pacing. (C, Class IIb)
316161
Transcatheter Aortic Valve Replacement
TAVR With the Balloon-Expandable Valve
Evaluation for TAVR should be performed by a multidisciplinary team and panel. (A, Class I)
316161
TAVR should be performed by a multidisciplinary cardiovascular and cardiac surgery team. (A, Class I)
316161
If available as part of a research protocol or after FDA approval, transfemoral, transaortic, transaxillary, or transapical AVR with the balloon expandable valve can be considered in patients who are operative candidates and have a predicted surgical mortality greater than 15% and an STS score greater than 10% by two independent surgical assessments. (A, Class I)
316161
TAVR should be performed in a hybrid operating or catheterization room dedicated to the procedure and not with mobile c-arms. (B, Class I)
316161
Transfemoral aortic valve implantation with a balloon-expandable valve should not be performed in patients who are not at high risk for conventional surgery. (C, Class III)
316161
Transfemoral aortic valve implantation with a balloon-expandable valve should not be performed in patients who have other comorbidities that limit 1-year survival or whose extreme frailty limits the likelihood of functional recovery after TAVR. (C, Class III)
316161
Transapical Aortic Valve
Transapical insertion of a balloon expandable aortic valve is recommended in patients with symptomatic severe AS who are considered to be at excessive risk for conventional AVR and are not candidates for a transfemoral approach due to preexisting peripheral vasculature disease, and who have an expected survival of at least 1 year. (B, Class I)
316161
Evaluation for TAVR should be performed by a multidisciplinary team and panel. (A, Class I)
316161
TAVR should be performed by a multidisciplinary cardiovascular and cardiac surgery team with extensive experience with high-risk valve surgery and percutaneous coronary interventions and balloon valvuloplasty. (A, Class I)
316161
If available as part of a research protocol or after FDA approval, transfemoral, transaortic, transaxillary, or transapical AVR with the balloon expandable valve can be considered in patients who are operative candidates and have a predicted surgical mortality greater than 15% and an STS score greater than 10% by two independent surgical assessments. (A, Class I)
316161
TAVR should be performed in a hybrid operating or catheterization room dedicated to the procedure and not with mobile c-arms. (B, Class I)
316161
Transapical insertion of a balloon expandable aortic valve may be a reasonable alternative in patients with critical AS who have an estimated mortality of at least 15% as independently judged by two cardiothoracic surgeons, or who have a predicted risk of mortality using the STS-PROM algorithm of 10% or greater, and do not have access for the transfemoral approach. The PARTNER A trial was not powered to access noninferiority. (C, Class IIa)
316161
Transapical insertion of a balloon expandable aortic valve is not recommended for low-risk patients with critical AS who are considered good candidates for conventional valve replacement. (C, Class III)
316161
Transaortic Valve Replacement
Evaluation for TAVR should be performed by a multidisciplinary team and panel. (A, Class I)
316161
TAVR should be performed by a multidisciplinary cardiovascular and cardiac surgery team. (A, Class I)
316161
If available as part of a research protocol or after FDA approval, transfemoral, transaortic, transaxillary, or transapical AVR with the balloon expandable valve can be considered in patients who are operative candidates and have a predicted surgical mortality greater than 15% and an STS score greater than 10% by two independent surgical assessments. (A, Class I)
316161
TAVR should be performed in a hybrid operating or catheterization room dedicated to the procedure and not with mobile c-arms. (B, Class I)
316161
Direct aortic insertion of a self-expanding or balloon expandable aortic valve may be a reasonable alternative in patients with critical aortic stenosis who are contraindicated for conventional aortic valve replacement and are not candidates for a transfemoral approach due to preexisting peripheral vasculature disease, and who have an expected survival of at least 1 year. (B, Class IIa)
316161
Transaxillary or Subclavian Valve Approach
Evaluation for TAVR should be performed by a multidisciplinary team and panel. (A, Class I)
316161
TAVR should be performed by a multidisciplinary cardiovascular and cardiac surgery team. (A, Class I)
316161
If available as part of a research protocol or after FDA approval, transfemoral, transaortic, transaxillary, or transapical AVR with the balloon expandable valve can be considered for patients who are operative candidates and have a predicted surgical mortality greater than 15% and an STS score greater than 10% by two independent surgical assessments. (A, Class I)
316161
Transaxillary or subclavian insertion of a self-expanding or balloon expandable aortic valve may be a reasonable alternative in patients with critical aortic stenosis who are contraindicated for conventional aortic valve replacement and are not candidates for a transfemoral approach because of preexisting peripheral vasculature disease, and who have an expected survival of at least 1 year. (B, Class IIa)
316161
Transaxillary or subclavian insertion of a self-expanding or balloon expandable aortic valve may be a reasonable alternative in patients with critical aortic stenosis who have an estimated mortality of at least 15% as independently judged by two cardiothoracic surgeons, or who have a predicted risk of mortality using the STS-PROM algorithm of 10% or greater and do not have access for the transfemoral approach. (C, Class IIa)
316161
Aortic Valve Leaflet Remodeling, Reimplantation, and Repair
Remodeling
Aortic valve repairs should be checked by intraoperative TEE after the repairs is completed. (C, Class I)
316161
Patients should be followed postoperatively by yearly echocardiograms after aortic valve repair. (C, Class I)
316161
Root remodeling may be considered for patients with significantly dilated roots and bicuspid valves or patients with acute aortic dissection, including excision of the non coronary sinus as a remodeling procedure, also known as the Wolfe procedure. (C, Class IIa)
316161
Root remodeling should be avoided in patients with connective tissue disorders. (C, Class III)
316161
Reimplantation
Root size, particularly at the sinuses of Valsalva should be measured by CT or MRI using the external diameter at its greatest extent. Conventionally TEE is used to measure the internal diameter at its greatest extent, usually from sinus to sinus. (B, Class I)
316161
Intraoperative TEE is recommended to check the repair. (C, Class I)
316161
Reimplantation is recommended for young patients, when feasible, who have aortic root dilation, with or without regurgitation, and a tricuspid aortic valve. (C, Class I)
316161
An aortic root greater than 5.0 cm is recommended as a threshold for prophylactic repair for most patients, including patients with Marfan syndrome. (C, Class I)
316161
In patient with a family history of aortic dissection and Marfan syndrome, surgery is recommended at a size of 4.5 cm in cross-sectional diameter. (C, Class I)
316161
Gram-positive and gram-negative prophylactic antibiotics should be administered at the time of surgery. (C, Class I)
316161
The patient should have yearly echocardiograms. (C, Class I)
316161
Prophylactic antibiotics for any invasive procedure including dentistry are recommended. (C, Class I)
316161
For patients with Loeys-Dietz syndrome, a threshold of 4.2 cm maybe considered for surgery. (C, Class IIa)
316161
The cross-sectional area of the root in square centimeters divided by the patient’s height in meters and exceeding 10 may be considered an indication for surgery. (C, Class IIa)
316161
In female patients with a connective tissue disorder who are considering pregnancy, a prophylactic repair may be considered when the aortic root exceeds 4.0 cm. (C, Class IIa)
316161
An antiplatelet agent should be considered postoperatively. (C, Class IIa)
316161
Bicuspid Valve Repair With or Without Aortic Tube Graft Replacement
All patients undergoing bicuspid repair should undergo intraoperative TEE. (C, Class I)
316161
Prophylactic antibiotics including both gram-positive and gram-negative coverage should be used for patients undergoing bicuspid valve repair. (C, Class I)
316161
Postoperative beta-blockers should be considered after bicuspid valve repairs. (C, Class I)
316161
ACE inhibitor therapy should be considered in patients with low EF postoperatively. (C, Class I)
316161
Patients should be given prophylactic antibiotics at any time that an invasive procedure is done, including dental procedures, after a bicuspid valve repair. (C, Class I)
316161
Management of Acute Aortic Root and Ascending Aortic Dissection
Timely diagnosis is recommended utilizing cross-sectional imaging techniques or TEE. The latter can be performed in the operating room before sternotomy if needed to confirm the diagnosis. (B, Class I)
316161
Ascending aortic replacement (including resection of primary aortic tear) should be performed for patients with acute type A aortic dissection. (B, Class I)
316161
An open distal anastomotic, hemiarch or total arch replacement technique is effective for the distal reconstruction of an acute type A dissection. (B, Class I)
316161
Ascending aortic and aortic arch replacement is indicated for patients with acute type A aortic dissection and a primary or secondary tear within the arch that involves or extends beyond the left common carotid arterial ostium with marked dilation of the aortic arch (>50 mm). (C, Class I)
316161
Aortic root replacement is indicated for patients with acute type A aortic dissection and a primary tear that extends or originates in the left or right coronary sinuses or marked dilation (>45 mm) of the aortic root below the sinotubular junction. (C, Class I)
316161
Arterial inflow cannulation for cardiopulmonary bypass during type A dissection repair should perfuse the true lumen directly. (C, Class I)
316161
Long-term radiologic surveillance after aortic dissection with or without surgical reconstruction should be performed at regular intervals of at least every 6 months for the first year and then annually. (C, Class I)
316161
Long-term annual echocardiographic surveillance is recommended for patients in whom an aortic valve-preserving reconstruction or bioprosthetic valve replacement was performed. (C, Class I)
316161
It is reasonable to use ABP or RBP with HCA to complete aortic arch reconstructions to reduce neurologic complications. (B, Class IIa)
316161
It is reasonable to utilize either an aortic valve-sparing or valve-replacement strategy when managing acute type A dissection if an acceptably low mortality rate can be achieved. (B, Class IIa)
316161
It is reasonable to treat acute type A IMH with urgent surgical intervention. (B, Class IIa)
316161
Postoperative, lifelong cross-sectional radiologic surveillance is reasonable in patients with residual aortic dissecting beyond the replaced aortic segment. (C, Class IIa)
316161
Medical management and longitudinal surveillance may be considered to treat high-risk patients with asymptomatic, radiologically stable type A IMH. (C, Class IIb)
316161
Medical management and longitudinal surveillance may be considered in patients with type B dissections involving the aortic arch. (C, Class IIb)
316161
Annual echocardiography may be considered in type A aortic dissection patients in whom the aortic valve was resuspended, preserved or replaced with a bioprosthesis. (C, Class IIb)
316161
Ascending Aorta and Aortic Arch
All patients with suspected thoracic aortic disease on the basis of family history, symptoms, or physical examination should have the entire thoracic aorta imaged. (C, Class I)
316161
All patients with a bicuspid aortic valve should undergo imaging of the thoracic aorta. (B, Class I)
316161
All patients with Marfan syndrome or Loeys-Dietz syndrome or mutations associated with aortic disease or dissection should have the entire aorta imaged and appropriate blood testing performed for genetic mutations. (B, Class I)
316161
First-degree relatives of young patients with a bicuspid aortic valve or genetic mutation associated aortic disease of the thoracic aortic disease should be advised to be further investigated. (C, Class I)
316161
All patients for whom planned elective valvular surgery is planned and who have associated thoracic aortic disease should undergo preoperative cardiac catheterization. (B, Class I)
316161
Additional testing to quantitate a patient’s comorbid status and develop a risk profile is recommended. These tests may include for particularly high-risk patients CT of the chest if not already done, PFTs, 24-hour Holter monitoring, noninvasive carotid screening, brain imaging, echocardiography, neurocognitive testing, and assessment of degree of frailty. (C, Class I)
316161
Intraoperative TEE is recommended for all patients undergoing surgery for thoracic aortic disease. (C, Class I)
316161
Surgical repair is recommended when the ascending aorta or aortic root exceeds 5.5 cm if the patient has no genetically based aortic disease and is otherwise a suitable candidate for surgery. (B, Class I)
316161
Patients with genetically associated aortic diseases, including those with a bicuspid aortic valve, should undergo surgery at diameters exceeding 5.0 cm unless a family history of aortic dissection is present, then it is acceptable to lower the threshold to 4.5 cm. Alternatively, patients with a maximal ascending aortic area (Πr2, cm2) to height in meters ratio exceeding 10 should be considered for surgery. (B, Class I)
316161
Patients with a growth rate exceeding 0.5 cm per year should be recommended to undergo surgery if no other limitations apply. (B, Class I)
316161
For patients with Loeys-Dietz syndrome or confirmed TGFBR1 or TGFBR2 mutation should be evaluated for repair of the aorta when the diameter exceeds 4.2 cm. (C, Class I)
316161
For patients undergoing cardiac surgery other than for aortic indications, aortic repair is recommended when diameter exceeds 4.5 cm. (B, Class I)
316161
Aortic diameters should be measured at right angles to the axis of flow, which requires the use of three-dimensional reconstructive software. The maximal diameters at each segment of the aorta should be reported. Echocardiography measures internal diameters while CT and MRI measures external diameters, and thus some allowance should be made for echocardiographic measurements being smaller. (C, Class I)
316161
Separate valve and ascending aortic replacement are recommended for patients without significant aortic root dilation, for elderly patients, and for young patients with minimal dilation in whom a biological valve is being inserted or a bicuspid valve is being repaired. (B, Class I)
316161
Patients with Marfan, Loeys-Dietz, and Ehlers-Danlos syndromes and root dilation should undergo excision of the sinuses in combination with a modified David valve reimplantation procedure if technically feasible or insertion of a valve graft conduit. (B, Class I)
316161
For more complicated arch reconstructions requiring extended periods of circulatory arrest, use of adjunctive brain perfusion techniques is recommended. (B, Class I)
316161
Regular echocardiography and MRI or CT evaluation after repair of thoracic aortic disease is reasonable. (C, Class IIa)
316161
Recommendation Grading
Overview
Title
Aortic Valve and Ascending Aorta
Authoring Organization
Society of Thoracic Surgeons
Publication Month/Year
June 1, 2013
Last Updated Month/Year
June 26, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The question may be asked why another Guideline manuscript is needed. The reasons are fivefold: (1) to outline pros and cons of treatment options; (2) to outline areas where further research is needed, potentially from updated Society of Thoracic Surgeons (STS) data collection variables as there are few randomized trials that give more absolute answers to questions; (3) to provide technical guidelines for aortic valve and aortic surgery; (4) to provide background for recommended quality measures and suggest quality measures; and (5) to present the new STS valve data collection variables that address issues related to the preoperative testing and technical aspects of aortic valve surgery.
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D001020 - Aortic Stenosis, Subvalvular, D021921 - Aortic Stenosis, Supravalvular, D001022 - Aortic Valve Insufficiency, D017544 - Aortic Aneurysm, Abdominal, D001014 - Aortic Aneurysm, D017545 - Aortic Aneurysm, Thoracic, D001015 - Aortic Arch Syndromes
Keywords
aortic repair, surgical aortic valve replacement
Source Citation
Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures
Svensson, Lars G. et al.The Annals of Thoracic Surgery, Volume 95, Issue 6, S1 - S66