ATS November 2009: Ono et al. Current surgical management of ascending aortic aneurysm in children and young adults.  Ann Thorac Surg 2009;88:1527-33.

In the November Annals, the Hanover experience with ascending aortic aneurysm in children and young adults is discussed and analysed. The authors note that the low incidence of aortic aneurysm in this age group limits information about etiology, surgical indications, procedures of choice, and operative results. Over the past 5 years, 35 patients aged 7 to 35 years (mean 21) underwent replacement of the ascending aorta for 19 ascending aortic aneurysms and 16 aortic root aneurysms. Underlying diseases included congenital aortic stenoses, bicuspid aortic valve, congenital heart diseases, Marfan syndrome, and aortitis. Indications followed for surgery were maximal diameter of 200% of normal for isolated aneurysms, and 160% of normal in case of associated aortic valve dysfunction or symptoms. Surgery consisted of 27 ascending aortic replacements with or without aortic valve replacement (including 22 conduits) and 8 valve-sparing operations, performed in 6 patients with Marfan syndrome and 2 with congenital heart disease. There was 1 surgical mortality. Survivors and are in NYHA class II or less at a maximum of 5 years of follow-up, with no reoperation, and 1 thromboembolic event. Aortic valve function is good in all 8 patients with valve-sparing operations. The authors conclude that ascending aortic aneurysm in children and young adults can be treated with excellent midterm outcome, following the surgical indications presented. Conduit implantation is the gold standard, but vslve-sparing operation couldbe performed in selected patients with encouraging results.

There has been extensive ongoing discussion regarding surgical indications in children with dilated aortic roots, and the authors present a diagnosis specific approach based primarily on normalised root diameter. The excellent results are undisputed. Of course many of these patients would remain well without surgery as well, and the predictive value of root diameter, especially for non-Marfan patients, might be arguable. We invite commentary from other groups performing this type of surgery, specifically regarding criteria for operation.

Please read the article at http://ats.ctsnetjournals.org/cgi/content/full/88/5/1527 and add your own comments in the Dilemmas in Pediatric Cardiac Surgery discussion forum. Other models of care would be of particular interest.