Aim: The “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease” provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). Methods: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

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Aims Due to bioprosthetic valve degeneration, aortic valve-in-valve (ViV) procedures are increasingly performed. There are no data on long-term outcomes after aortic ViV. Our aim was to perform a large-scale assessment of long-term survival and reintervention after aortic ViV. Methods and results A total of 1006 aortic ViV procedures performed more than 5 years ago [mean age 77.7 ± 9.7 years; 58.8% male; median STS-PROM score 7.3% (4.2–12.0)] were included in the analysis. Patients were treated with Medtronic self-expandable valves (CoreValve/Evolut, Medtronic Inc., Minneapolis, MN, USA) (n = 523, 52.0%), Edwards balloon-expandable valves (EBEV, SAPIEN/SAPIEN XT/SAPIEN 3, Edwards Lifesciences, Irvine, CA, USA) (n = 435, 43.2%), and other devices (n = 48, 4.8%). Survival was lower at 8 years in patients with small-failed bioprostheses [internal diameter (ID) ≤ 20 mm] compared with those with large-failed bioprostheses (ID > 20 mm) (33.2% vs. 40.5%, P = 0.01). Independent correlates for mortality included smaller-failed bioprosthetic valves [hazard ratio (HR) 1.07 (95% confidence interval (CI) 1.02–1.13)], age [HR 1.21 (95% CI 1.01–1.45)], and non-transfemoral access [HR 1.43 (95% CI 1.11–1.84)]. There were 40 reinterventions after ViV. Independent correlates for all-cause reintervention included pre-existing severe prosthesis–patient mismatch [subhazard ratio (SHR) 4.34 (95% CI 1.31–14.39)], device malposition [SHR 3.75 (95% CI 1.36–10.35)], EBEV [SHR 3.34 (95% CI 1.26–8.85)], and age [SHR 0.59 (95% CI 0.44–0.78)]. Conclusions The size of the original failed valve may influence long-term mortality, and the type of the transcatheter valve may influence the need for reintervention after aortic ViV.

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Systolic flow displacement calculated from conventional 2D PC-MRI in the ascending aorta correlates with future aortic growth in patients undergoing routine surveillance imaging for BAV. With a cutoff valve of 0.2, flow displacement may be used to identify a subset of patients likely to have elevated growth rates and may better risk-stratify patients with BAV for aortic disease progression than vessel diameter alone.

Objective Transcatheter aortic valve replacement is established therapy for high-risk and inoperable patients with severe aortic stenosis, but questions remain regarding long-term durability. Valve design impacts durability. Increased leaflet stresses in surgical bioprostheses have been correlated with degeneration; however, transcatheter valve leaflet stresses are unknown. From 2007–2014, a majority of US patients received first-generation balloon-expandable transcatheter valves. Our goal was to determine stent and leaflet stresses in this valve design using finite element analyses. Methods 26mm Edwards Sapien (Edwards Lifesciences, Inc, Irvine, CA) underwent high-resolution micro-computed tomography scanning to develop precise 3D geometry of leaflets, stent, and dacron. Stent was modeled using 3D elements and leaflets using shell elements. Stent material properties were based on stainless steel, while those for leaflets were obtained from surgical bioprostheses. Non-cylindrical Sapien geometry was also simulated. Pressure loading to 80 and 120mmHg was performed using ABAQUS, finite element software (Dassault Systemes, Waltham, MA). Results At 80mmHg, maximum principal stresses on Sapien leaflets were 1.31MPa. Peak leaflet stress was observed at commissural tips where leaflets connected to the stent. Maximum principal stresses for stent was 188.91MPa, and located at stent tips where leaflet commissures were attached. Non-cylindrical geometry increased peak principal leaflet stresses by 16%. Conclusions Using exact geometry from high-resolution scans, 26mm Sapien showed that peak stresses for both stent and leaflets were present at commissural tips where leaflets were attached. These regions would be prone to initiate leaflet degeneration. Understanding stresses in first-generation transcatheter valves allow comparison to future designs for relative durability.

Significant differences were found in the compliance and fibrous structure of human pulmonary and aortic roots. These regional differences may impact pulmonary autograft remodelling and influence late autograft dilation.