title: Modeling of predissection aortic size in acute type A dissection: More than 90% fail to meet the guidelines for elective ascending replacement.
abstract: OBJECTIVE
  The current guidelines for ascending aortic replacement were determined from already dissected aorta diameters. Previous computed tomography-based work on humans who underwent imaging before and directly after aortic dissection onset has shown an average 30% increase in the ascending aortic diameter with acute dissection. The present investigation evaluated the incidence of predissection ascending aortic dilatation in acute type A dissection.
  
  
  METHODS
  From 2002 to 2013, 495 patients presented with acute type A aortic dissection to 1 center. Of these cases, 343 were non-Marfan, nonbicuspid with spontaneous dissection etiology. In those with available preoperative computed tomography angiograms (n = 83) or transesophageal echocardiograms (n = 260), the predissection ascending aorta diameters were modeled from the dissected aorta diameters by subtraction of the average diameter increase rate.
  
  
  RESULTS
  Altogether 343 patients were included (age, 62 years; range, 53-73; 64% men). The median modeled predissection ascending diameter was 3.7 cm (first quartile, 3.3; third quartile, -4.1). Of the 343 patients, 334 (97%) and 315 (92%) had an ascending diameter before dissection onset of <5.5 cm and <5.0 cm, respectively. More than 60% of women and 70% of men had a nondilated ascending aorta before type A dissection onset. The median predissection ascending aortic diameter did not differ between women and men (3.7 cm; first quartile, 3.4; third quartile, 4.2; vs 3.7 cm; first quartile, 3.3; third quartile, 4.1; P = .810).
  
  
  CONCLUSIONS
  More than 60% of patients with spontaneous, non-Marfan, nonbicuspid, type A dissection will have a nondilated ascending aorta before dissection onset. Only 3% would meet the criteria for elective ascending replacement to prevent aortic dissection. Additional research on the genetic and biochemical predictors of aortic dissection is essential.
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa; Heart Center, University of Freiburg, Freiburg, Germany. Electronic address: bartosz.rylski@universitaets-herzzentrum.de.
authors.forename: Bartosz
authors.initials: B
authors.lastname: Rylski
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Branchetti
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Rita K
authors.initials: RK
authors.lastname: Milewski
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Nimesh D
authors.initials: ND
authors.lastname: Desai
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation; D017548:Echocardiography, Transesophageal; D017558:Elective Surgical Procedures; D005260:Female; D005858:Germany / Q000453:epidemiology; D019983:Guideline Adherence; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed