CONSERVATIVE VERSUS RADICAL TREATMENT OF ASCENDING AORTIC DILATION: COMPARATIVE ANALYSIS OF BASELINE CLINICAL DATA FOLLOWING WRAPPING, NO-TOUCH SURGICAL AORTIC VALVE REPLACEMENT, AND THE WHEAT PROCEDURE

Oleh  Zelenchuk; Illia  Nechai; Igor  Mokryk; Ihor  Stetsyuk; Vitaly  Demyanchuk; Borys  Todurov

doi:10.21272/eumj.2026;14(2);605-614

Oleh Zelenchuk Department of Cardiac Surgery, Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0002-5677-9311
Illia Nechai Department of Cardiac Surgery, Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0001-8984-0628
Igor Mokryk Department of Cardiac Surgery, Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0002-1823-4767
Ihor Stetsyuk Department of Cardiac Surgery, Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0001-8984-0628
Vitaly Demyanchuk Department of Cardiac Surgery, Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0001-6076-8685
Borys Todurov Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine https://orcid.org/0009-0000-2047-4447

DOI: https://doi.org/10.21272/eumj.2026;14(2);605-614

Keywords: Ascending aorta dilatation, Aortic wrapping, Aortic valve replacement, Wheat procedure, Aortic aneurysm

Abstract

Background: The optimal management of ascending aortic dilation in patients undergoing aortic valve replacement (AVR) remains debated. Although replacement of the ascending aorta is widely considered the standard, conservative strategies such as wrapping are still used in selected patients.

Objective: This study aimed to analyze baseline characteristics and etiological patterns in patients treated with wrapping, supracoronary replacement (Wheat procedure), or isolated AVR without intervention on the ascending aorta.

Methods: This retrospective, single-center analysis included 120 patients who underwent AVR in the presence of ascending aortic dilation (>40 mm) between 2016 and 2024. Patients with connective tissue disorders, prior aortic surgery, or acute aortic syndromes were excluded. After propensity score matching, 40 patients were assigned to each group: AVR with wrapping, Wheat procedure, and no-touch AVR. Demographic, clinical, and echocardiographic data were compared to identify factors associated with aortic dilation.

Results: Patients in the No-touch group were significantly older (69.5 ± 5.2 years) compared with the Wheat (51.2 ± 13.7 years) and Wrapping (50.4 ± 13.3 years) groups (p < 0.001). Bicuspid valve morphology predominated in the Wheat (72.5%) and Wrapping (62.5%) groups, while tricuspid valves were most frequent in the No-touch group (80%; p < 0.001). Ascending aortic diameters were larger in the Wheat and Wrapping groups compared with No-touch (p < 0.001). The No-touch cohort showed more advanced ventricular remodeling, higher rates of left ventricular dilation, reduced ejection fraction, and increased pulmonary pressures. Neurological events and preoperative atrial fibrillation were also more common.

Conclusion: Distinct etiological profiles exist among patients with ascending aortic dilation undergoing AVR. Wrapping and replacement were used mainly in younger patients with bicuspid valves and larger diameters, whereas the no-touch strategy was applied in older patients with tricuspid valves and ventricular dysfunction. These findings support individualized treatment based on valve phenotype, age, and etiology.

Downloads

Download data is not yet available.

References

Coselli JS, Greenn SY. A brief history of aortic surgery: Insight into distal aortic repair. J Thorac Cardiovasc Surg. 2013;145:S123-5.

Hamiko M, Jahnel K, Rogaczewski J, Schafigh M, Silaschi M, Spaeth A, et al. The long-term outcome and quality of life after replacement of the ascending aorta. J Clin Med. 2023;12 (13):4498. https://doi.org/10.3390/jcm12134498.

Zierer A, Melby SJ, Lubahn JG, Sicard GA, Damiano RJ Jr, Moon MR. Elective surgery for thoracic aortic aneurysms: late functional status and quality of life. Ann Thorac Surg. 2006;82:573-8.

Gonzalez-Santos JM, Arnaiz-Garcia ME. Wrapping of the ascending aorta revisited—is there any role left for conservative treatment of ascending aortic aneurysm? J Thorac Dis. 2017;9:S488-97.

Kim HH, Lee S, Lee SH, Youn YN, Yoo KJ, Joo HC. The long-term fate of ascending aorta aneurysm after wrapping versus replacement. J Thorac Cardiovasc Surg. 2022;164 (2):463–474.e4. https://doi.org/10.1016/j.jtcvs.2020.12.110.

Wu J, Zafar MA, Liu Y, Chen JF, Li Y, Ziganshin BA, et al. Fate of the unoperated ascending thoracic aortic aneurysm: three-decade experience from the Aortic Institute at Yale University. Eur Heart J. 2023;44 (43):4579–4588. https://doi.org/10.1093/eurheartj/ehad148.

Solomon MD, Leong T, Sung SH, Lee C, Allen JG, Huh J, et al. Association of thoracic aortic aneurysm size with long-term patient outcomes: the KP-TAA Study. JAMA Cardiol. 2022;7 (11):1160–1169. https://doi.org/10.1001/jamacardio.2022.3305.

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143 (5):e35–e71. https://doi.org/10.1161/CIR.0000000000000932.

Praz F, Borger MA, Lanz J, Marin-Cuartas M, Abreu A, Adamo M, et al.; ESC/EACTS Scientific Document Group. 2025 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2025. https://doi.org/10.1093/eurheartj/ehaf194.

Keane MG, Wiegers SE, Plappert T, Pochettino A, Bavaria JE, Sutton MG. Bicuspid aortic valves are associated with aortic dilatation out of proportion to coexistent valvular lesions. Circulation. 2000;102 (suppl 3):III35-9.

Yasuda H, Nakatani S, Stugaard M, Tsujita-Kuroda Y, Bando K, Kobayashi J, et al. Failure to prevent progressive dilation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve. Circulation. 2003;108 (suppl 1):II291-4.

McKellar SH, Tester DJ, Yagubyan M, Majumdar R, Ackerman MJ, Sundt TM III. Novel NOTCH1 mutations in patients with bicuspid aortic valve disease and thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 2007;134:290-6.

Shin HJ, Kim WK, Kim DK, Kim HJ, Kim JB. Prognosis of unrepaired ascending aorta after the surgical replacement of bicuspid aortic valves. J Chest Surg. 2023;56 (4):255-261. https://doi.org/10.5090/jcs.23.007.

Kaneko T, Shekar P, Ivkovic V, Longford NT, Huang CC, Sigurdsson MI, et al. Should the dilated ascending aorta be repaired at the time of bicuspid aortic valve replacement? Eur J Cardiothorac Surg. 2018;53 (3):560-568. https://doi.org/10.1093/ejcts/ezx387.

Hachiro K, Takashima N, Suzuki T. Later aorta operation after aortic valve replacement for bicuspid aortic valve. J Cardiothorac Surg. 2024;19:144. https://doi.org/10.1186/s13019-024-02638-6.

Kim YG, Sun BJ, Park GM, Han S, Kim DH, Song JM, et al. Aortopathy and bicuspid aortic valve: haemodynamic burden is main contributor to aortic dilatation. Heart. 2012;98:1822-7.

Robicsek F, Cook JW, Reames MK Sr, Skipper ER. Size reduction ascending aortoplasty: is it dead or alive? J Thorac Cardiovasc Surg. 2004;128:562-70.

Plonek T. A meta-analysis and systematic review of wrapping of the ascending aorta. J Card Surg. 2014;29:809-15.

Isselbacher EM, Preventza O, Black JH 3rd, Augoustides JG, Beck AW, Bolen MA, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146 (24):e334–e482. https://doi.org/10.1161/CIR.0000000000001106.

Hiratzka LF, Creaguer MA, Isselbacher EM, et al. Surgery for aortic dilatation in patients with bicuspid aortic valves. A statement of clarification from the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2016;133:680-6.

Van Hoof L, Verbrugghe P, Verbeken E, et al. Support of the aortic wall: a histological study in sheep comparing a macroporous mesh with low-porosity vascular graft of the same polyethylene terephthalate material. Interact Cardiovasc Thorac Surg. 2017 Jul 1;25 (1):89-95. https://doi.org/10.1093/icvts/ivx009.

Doyle M, Peeceeyan S, Bonar F, et al. Rarefaction of the aorta under dacron wrap: A rare complication. Interact Cardiovasc Thorac Surg 2014;19:341–3.

González-Santos JM, Arnáiz-García ME. Wrapping of the ascending aorta revisited—is there any role left for conservative treatment of ascending aortic aneurysm? J Thorac Dis. 2017 May;9 (Suppl 6):S488-S497. https://doi.org/10.21037/jtd.2017.04.57

Ang KL, Raheel F, Bajaj A, et al. Early impact of aortic wrapping on patients undergoing aortic valve replacement with mild to moderate ascending aorta dilatation. J Cardiothorac Surg 2010;5:58-61.

Park JY, Shin JK, Chung JW, et al. Short-term outcomes of aortic wrapping for mild to moderate ascending aorta dilatation in patients undergoing cardiac surgery. Korean J Thorac Cardiovasc Surg 2012;45:148-54.

Tymoshenko V, Zelenchuk O, Maruniak S, Sudakevych S, Demyanchuk V, Todurov B. Long-stay predictors in the intensive care unit after Bentall procedure: retrospective research. Cor Vasa. 2023;65 (6):821-825. https://doi.org/10.33678/cor.2023.071.

Demyanchuk VB, Pogrebnyak VV, Zelenchuk OV, Kvasha OI, Todurov BM. A novel method of treatment of ascending aortic aneurysm. Cardiac Surgery and Interventional Cardiology. 2020;4 (31):29-33. (in Ukr.)

Zelenchuk OV, Todurov BM, Stetsiuk IO, Demyanchuk VB, Loskutov DO, Yashchenko NO, Ponych NV. The effectiveness of David procedure for aneurysm of the root and ascending part of the aorta. Cardiac Surgery and Interventional Cardiology. 2023;3-4:23-29. http://doi.org/10.31928/2305-3127-2023.3-4.2329

Gill M, Dunning J. Is reduction aortoplasty (with or without external wrap) an acceptable alternative to replacement of the dilated ascending aorta? Interact Cardiovasc Thorac Surg 2009;9:693-7.

Zhang H, Lu F, Qu D, et al. Treatment of fusiform ascending aortic aneurysms: A comparative study with 2 options. J Thorac Cardiovasc Surg 2011;141:738-43