Dear Colleagues,

This Special Issue arises from London Aorta 2019, an annual pan-London Aortic meeting. The essence of the meeting is the close collaboration between interventional cardiologists, non-interventional cardiologists and cardiac surgeons, radiologists and geneticists to provide the best advice and treatment for our patients. We have selected 10 papers which reflect the range of subjects discussed.

Disease of the thoracic aorta is mostly indolent and is only discovered in the context of an emergency, such as dissection, or by serendipity during a radiological investigation for another disease. The aorta has been called the orphan organ and there are many claimants at the orphanage: cardiac surgeons, vascular surgeons, interventional cardiologists or radiologists. There is a strong argument to apply a team approach and to make this a truly patient-centric speciality. The impact of advanced imaging, CT and MRI in particular, has transformed the management of patients with aortic disease. By combining the diagnostic and interventional skills of individuals from different specialities who have a passion for this intriguing group of diseases we can provide timely and appropriate treatment for the patient.

Much of the research undertaken on the thoracic aorta has been of a technical nature to reduce the mortality and the morbidity of surgical procedures on patients who in the elective setting are often asymptomatic. Much effort has been expended on protection of the brain and spinal cord and on the development of alternative surgical approaches, such as de-branching of the head vessels and on new procedures in endovascular aortic interventions. These developments, which have arisen from experimental work on large mammals, have proved to be very effective but they have not been tested in a randomised controlled trial. It is focussed aortic teams who will take forward the leading edge of endovascular treatment into the ascending aorta, using branched devices in the arch and the visceral segment and protecting the spinal cord. 

Research of a translational nature has been less common, but there is a growing interest in the role of inflammation as a trigger for aneurysm enlargement in the thoracic aorta. Much effort continues to be expended on the genetic and genomic mechanisms underlying inherited disease of the aortic valve, aortic root and ascending aorta, but this is yet to have a major impact in clinical decision making. Next generation sequencing with “aortic panels” are in use in specialist centres. These panels allow for genetic scrolling of the entire spectrum of aortic defects in one test.

Operations for diseases of the aorta, once considered to be too high risk for many surgeons, are now a part of the daily routine. We have learned something about the nature of the aorta, how to analyse the images and how to correct the defects. While major surgery of the thoraco-abdominal aorta is likely to decline, TEVAR is in the ascendancy. Although the early results are encouraging and the morbidity significantly less than for open surgery, the long-term results remain uncertain. Whether the future will lie in hybrid procedures or be dominated by a stent-based approach is uncertain. What is certain is that this area of activity will continue to fascinate and challenge all those who choose to tread this path.

Prof. Dr. John Pepper
Guest Editor

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