Fabio De Robertis, Consultant Cardiac and Transplant Surgeon and structural heart disease specialist at Royal Brompton and Harefield Hospitals discusses the importance of diagnosis in early aortic disease
Aortic disease is one of the most complex and potentially life-threatening areas of cardiac care. Conditions affecting the aorta and aortic valve can progress silently over many years before symptoms become obvious, yet once advanced they can carry significant risks, including heart failure, aortic dissection and sudden cardiac events.
What makes aortic disease particularly challenging is that no two patients are the same. Some patients present later in life with degenerative valve disease or aneurysms. Others are much younger, living with inherited connective tissue disorders such as Marfan syndrome or congenital abnormalities that place them at lifelong risk of progressive aortic enlargement and serious complications.
As surgeons, our role is not simply to replace diseased anatomy. Increasingly, it is to preserve as much of the patient’s own heart and normal physiology as possible while tailoring treatment around their age, lifestyle and long-term outlook.
At Royal Brompton and Harefield Hospitals, we manage the full spectrum of complex aortic disease, including aneurysms, dissections, valve disease and infective endocarditis. The service combines highly specialised imaging, multidisciplinary decision-making and advanced surgical and endovascular techniques to treat patients whose conditions often require extremely individualised approaches.
Personalised decision-making
My own clinical work focuses on complex aortic surgery, transplantation and structural heart disease, including the management of some of the highest-risk aortic cases referred nationally and internationally. One of the most important developments in modern aortic care has been the shift towards increasingly personalised surgical strategies, particularly for preserving the native aortic valve whenever possible.
Historically, many patients with aortic root disease would automatically undergo valve replacement alongside replacement of the diseased aorta. While valve replacement remains an excellent and life-saving treatment for many patients, preserving the patient’s own valve can offer important advantages.
Valve-sparing aortic root procedures, including David and Yacoub operations, allow surgeons to replace diseased sections of the aortic root while retaining the patient’s natural valve. This approach can help patients avoid lifelong anticoagulation and preserve more natural cardiac function over the long term.
We have specialist interventions for younger patients such as PEARS, (personalised external aortic root support) and the Ross-PEARS approach, both of which were pioneered at Royal Brompton Hospital. Many of these young patients are otherwise healthy individuals facing major surgery in the prime of their lives, so preserving the native valve can help reduce the long-term burden associated with prosthetic valves and repeat interventions.
Continuing innovation
The PEARS procedure is suitable for selected patients with connective tissue disorders and progressive aortic dilatation. The technique uses advanced imaging and custom-designed 3D-printed mesh supports tailored precisely to the patient’s anatomy. Stabilising the aorta before severe enlargement develops can help patients avoid much more invasive surgery later in life.
Equally important has been the development of hybrid and minimally invasive approaches for patients who may not be suitable for conventional open surgery. Advances in endovascular technology now allow many aortic conditions to be treated using combinations of surgical and catheter-based techniques that significantly reduce procedural risk and recovery time.
At Royal Brompton and Harefield Hospitals, our teams perform a wide range of highly specialised endovascular procedures, including TEVAR (thoracic endovascular aortic repair) for thoracic aortic disease, minimally invasive repair of dissections and complex hybrid arch reconstructions. Some of these procedures would have been considered impossible only a decade ago.
Selected patients can now undergo keyhole aortic valve replacement procedures that avoid full sternotomy, reducing postoperative pain and accelerating recovery while maintaining excellent surgical outcomes.
Evaluating the risks
However, despite technological advances, successful aortic care still depends fundamentally on careful patient selection and multidisciplinary expertise. Every decision must balance surgical risk, long-term durability and the patient’s wider health and life circumstances.
In younger patients, where the long-term implications of surgical choices may extend across decades, such decisions are crucial. A procedure performed successfully today must still serve the patient well many years into the future, reinforcing the importance of personalised decision-making in modern aortic surgery.
Another major change in the field has been the growing importance of integrated multidisciplinary teams. Complex aortic disease increasingly requires close collaboration between surgeons, cardiologists, imaging specialists, anaesthetists and intensive care teams. At Royal Brompton and Harefield Hospitals, I chair the endocarditis and complex aortic root MDTs where decisions are discussed to ensure patients benefit from the full breadth of specialist expertise.
Early diagnosis also remains critical. Patients may initially experience relatively subtle symptoms such as breathlessness, palpitations, declining exercise tolerance or struggle with activities which were previously manageable. Such symptoms can easily be overlooked or attributed to ageing or reduced fitness. In some cases, potentially dangerous aortic disease may remain undetected until a serious complication occurs.
Improved imaging and greater awareness are helping identify more patients earlier, creating opportunities for planned intervention before emergency treatment becomes necessary. This shift towards earlier and more proactive care is one of the most important developments in modern cardiac surgery.
Mr De Robertis is an internationally-recognised consultant with expertise in a broad range of cardiac surgery aspects, offering procedures for aortic aneurysms and aortic valve repair and replacement.
Contact: gsst.privatepatientenquiries@nhs.net
Tel: +44 203 131 6858
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