Director, Center for Aortic Surgery
Director, Marfan Syndrome and Connective Tissue Disorder Clinic
Specialties: Adult cardiac surgery; cardio-aortic and aortic surgery, including combined valve and aneurysm surgery; minimally invasive mitral and aortic valve surgery; blood conservation; prevention of stroke and paralysis after aortic surgery; Marfan syndrome; peripheral vascular surgery; and the Maze procedure.
Hello, I’m Lars Svensson. I’m the director for aortic surgery and the Marfans Syndrome Clinic at the Cleveland Clinic.
We are seeing a lot more patients with aneurysms that are denotations of the aorta. Indeed, over last year we did 1,000 aorta operations and 622 of those were in the aorta in the chest. Well, why are we seeing so many more patients with this problem? There are several reasons, partly because people are getting older. Aneurysms occur more frequently in older patients with a history of high blood pressure, smoking, and then there’s a group of patients who have a genetic propensity to developing these aneurysms. This includes patients with Marfans Syndrome, Ehlers Danlos, and polycystic kidney disease. The importance of detecting these aneurysms was illustrated in a report we did last year. Between 43,000 – 47,000 people died last year from these types of aortic diseases. In fact, it’s a silent epidemic. More deaths occur from aortic diseases every year then breast cancer or people who die in motor vehicle accidents. Motor vehicle accidents happen to be one of the causes of these aneurysms, but less frequently.
What happens with these aneurysms is that they can either burst, and typically that can result in patients dying fairly quickly, or the aorta splits, which is known as aortic dissection. When aortic dissection occurs, about 40 percent of patients die immediately. The risk of dying is then about one to three percent per hour until the patient has surgery. This would be emergency surgery and the risk of dying is 10 to 20 %. Eventually, patients typically require multiple operations. We try to intervene before patients develop these complications.
We usually like to operate on aneurysms when they are approximately one-and-a- half to twice the size of the normal aorta. For example, in what we call an ascending aorta, the part of the aorta between the heart and the blood vessels going up to the arms and the brain, would be at about 5 to 5.5 cm. It depends a lot on the other diseases the patient may have as well as how young they are. If they have Marfans Syndrome, for example, then we will operate much earlier, particularly in patients who have a history of aortic dissection. In the other parts of the aorta it varies a bit; it might be 5.5 cm in the chest going down to the abdominal organs, for instance.
For patients who have an aneurysm that segments or is in the abdominal aorta, one option is to put a stent graft in. This means we would put a catheter in through the groin [Femoral] artery and then we can feed up a tube to repair it without opening a patient’s chest. That obviously has benefits, but the long term durability may not be as good as an open operation.
In patients who have an aneurysm in the ascending aorta, the aortic valves are often involved. Many of those patients can have their valve preserved for them and repaired. We do an operation that is called the Modified David Operation. We then repair the valve, put it within a tube, and then check on an echo during the operation to make sure that the valves working well. That procedure has worked out very well for patients and, in fact, we have not experienced any deaths in over 120 patients. The long term durability is very good and this obviously has a lot of benefits as it is not necessary to put a mechanical or biological valve in. Either would require the use of Coumadin or have a risk of failing. So, that’s one of the options we have and apart from many newer operations that we’ developed for managing aortic disease.
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