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J Thorac Cardiovasc Surg 2005;130:677
© 2005 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Mechanical deterioration underlies malignant behavior of aneurysmal human ascending aorta

George Koullias, MD a , Raj Modak, MD b , Maryann Tranquilli, RN a , Dimitris P. Korkolis, MD a , Paul Barash, MD a , John A. Elefteriades, MD a , *

a Sections of Cardiothoracic Surgery and Cardiothoracic Anesthesia, New Haven, Conn.
b Yale University School of Medicine, New Haven, Conn.

Received for publication October 31, 2004; revisions received January 23, 2005; accepted for publication February 10, 2005.

* Address for reprints: John A. Elefteriades, MD, Section of Cardiothoracic Surgery, 121 FMB, 333 Cedar St, New Haven, CT 06510. (Email: john.elefteriades{at}yale.edu).

OBJECTIVE: The human ascending aorta becomes markedly prone to rupture and dissection at a diameter of 6 cm. The mechanical substrate for this malignant behavior is unknown. This investigation applied engineering analysis to human ascending aortic aneurysms and compared their structural characteristics with those of normal aortas.

METHODS: We measured the mechanical characteristics of the aorta by direct epiaortic echocardiography at the time of surgery in 33 patients with ascending aortic aneurysm undergoing aortic replacement and in 20 control patients with normal aortas undergoing coronary artery bypass grafting. Six parameters were measured in all patients: aortic diameter in systole and diastole, aortic wall thickness in systole and diastole, and blood pressure in systole and diastole. These were used to calculate mechanical characteristics of the aorta from standard equations. Aortic distensibility reflects the elastic qualities of the aorta. Aortic wall stress reflects the disrupting force experienced within the aortic wall. Incremental elastic modulus indicates loss of elasticity reserve.

RESULTS: Aortic distensibility falls to extremely low levels as aortic dimension rises toward 6 cm (3.02 mm Hg–1 for small aortas versus 1.45 mm Hg–1 for aortas larger than 5 cm, P < .05). Aortic wall stress rises to 157.8 kPa for the aneurysmal aorta, compared with 92.5 kPa for normal aortas. For 6-cm aortas at pressures of 200 mm Hg or more, wall stress rises to 857 kPa, nearly exceeding the known maximal tensile strength of human aneurysmal aortic wall. Incremental elastic modulus deteriorates (1.93 ± 0.88 MPa vs 1.18 ± 0.21 MPa, P < .05) in aneurysmal aortas relative to that in normal aortas.

CONCLUSION: The mechanical properties of the aneurysmal aorta deteriorate dramatically as the aorta enlarges, reaching critical levels associated with rupture by a diameter of 6 cm. This mechanical deterioration provides an explanation in engineering terms for the malignant clinical behavior (rupture and dissection) of the aorta at these dimensions. This work adds to our fundamental understanding of the biology of aortic aneurysms and promises to permit future application of engineering measurements to supplement aneurysm size in clinical decision making in aneurysmal disease.




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