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    Original Investigation
    August 24, 2018

    Association of Mortality and Acute Aortic Events With Ascending Aortic Aneurysm: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
    • 2Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
    • 3Department of Cardiac Sciences, Kelowna General Hospital, Kelowna, British Columbia, Canada
    • 4Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
    • 5Department of Anesthesia, University of Calgary, Calgary, Alberta, Canada
    • 6Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
    JAMA Netw Open. 2018;1(4):e181281. doi:10.1001/jamanetworkopen.2018.1281
    Key Points español 中文 (chinese)

    Question  What are the growth rate and risk of complications in patients with moderately dilated ascending aortas?

    Findings  This systematic review and meta-analysis of 20 studies including 8800 patients found that the ascending aorta growth rate was 0.61 mm/y, and the incidence of elective aortic surgery was 13.82%. The linearized mortality rate was 1.99% per patient-year, while the rate of aortic dissection, aortic rupture, and mortality was 2.16% per patient-year.

    Meaning  More robust natural history data from prospective studies are needed to better inform clinical decision making in patients with ascending aortic aneurysms.


    Importance  The natural history of ascending aortic aneurysm (AsAA) is currently not well characterized.

    Objective  To summarize and analyze existing literature on the natural history of AsAA.

    Data Sources  A search of Ovid MEDLINE (January 1, 1946, to May 31, 2017) and Embase (January 1, 1974, to May 31, 2017) was conducted.

    Study Selection  Studies including patients with AsAA were considered for inclusion; studies were excluded if they considered AsAA, arch, and descending thoracic aneurysm as 1 entity or only included descending aneurysms, patients with heritable or genetic-related aneurysms, patients with replaced bicuspid aortic valves, patients with acute aortic syndrome, or those with mean age less than 16 years. Two independent reviewers identified 20 studies from 7198 unique studies screened.

    Data Extraction and Synthesis  Data extraction was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline; 2 reviewers independently extracted the relevant data. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance–weighted random-effects model. Metaregression was performed to assess the relationship between initial aneurysm size, etiology, and the primary outcomes.

    Main Outcomes and Measures  The primary composite outcome was incidence of all-cause mortality, aortic dissection, and aortic rupture. Secondary outcomes were growth rate, incidence of proximal aortic dissection or rupture, elective ascending aortic repair, and all-cause mortality.

    Results  Twenty studies consisting of 8800 patients (mean [SD] age, 57.75 [9.47] years; 6653 [75.6%] male) with a total follow-up time of 31 823 patient-years were included. The mean AsAA size at enrollment was 42.6 mm (range, 35.5-56.0 mm). The combined effect estimate of annual aneurysm growth rate was 0.61 mm/y (95% CI, 0.23-0.99 mm/y). The pooled incidence of elective aortic surgery was 13.82% (95% CI, 6.45%-21.41%) over a median (interquartile range) follow-up of 4.2 (2.9-15.0) years. The linearized mortality rate was 1.99% per patient-year (95% CI, 0.83%-3.15% per patient-year), and the linearized rate of the composite outcome of all-cause mortality, aortic dissection, and aortic rupture was 2.16% per patient-year (95% CI, 0.79%-3.55% per patient year). There was no significant relationship between year of study completion and the initial aneurysm size and primary outcomes.

    Conclusions and Relevance  The growth rate of AsAA is slow and has implications for the interval of imaging follow-up. The data on the risk of dissection, rupture, and death of ascending aortic aneurysm are limited. A randomized clinical trial may be required to understand the benefit of surgical intervention compared with surveillance for patients with moderately dilated ascending aorta.