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Aorta Disease (Drs. Kalahasti, Hammer, and Roselli 7/12/12)

Thursday, July 12, 2012 - Noon


It is crucial to know and understand the latest treatment options available if you have been diagnosed with a condition related to the aortic valve or aorta. Cardiovascular Surgeon, Dr. Roselli and Cardiologists Dr. Kalahasti and Dr. Hammer answer your questions about aorta disease.

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Medical Management

susanB: Can I stop taking metoprolol all at once or do I have to stop slow. I was put on it because I have a 4.9 ascending aortic aneurysm?

Dr__Kalahasti: Usually we taper metoprolol over a week or two. With an aneurysm of 4.9 cm, why do you want to stop your metoprolol?

KeithM: What non-invasive preventative measures can I take to minimize deterioration risk from a 4.6cm aortic root aneurysm that has been stable for at least past 7 years? (I am 6' 1" 170lbs, have 120 total cholesterol (10mg lipitor and 25mg toprol each every other day, 500mg magnesium daily), exercise regularly and am 70 years old; angiogram indicates no plaque build-up).

Dr__Kalahasti: You are doing an excellent job. Continue the same treatment.

Medical Management of Aorta Disease – Activity and Exercise

gggwx: I am a 65 year old male with a 4.5cm aortic root aneurism diagnosed a year ago April. I currently take 75mg of metoprolol daily. As a former "gym rat" I used to exercise a lot. My question is, how much exercise can I reasonably do now without negative cardio exercise, target heart rate et al. And secondarily, would a trip to the mountains at 10,000 feet (winter conference) be a problem with my condition? Thank you. Dave S.

Dr__Kalahasti: Dave, continue aerobic activity to 70% of target heart rate. A trip to the mountains at 10,000 feet should not be a problem.

boomer46: I have a 4.9 cm aneurysm. Are there any forms of aerobic exercise I should avoid?

Dr__Hammer: Most aerobic exercise is permissible and encouraged. Competitive exercise such as basketball or football or sprinting (sudden acceleration and deceleration ) should be avoided. And - no heavy weight training - it is discouraged.

chuckarc: My mom is 80 and has had a 5.1cm ascending aortic aneurysm for 2 years. She also has bronchiecstasis and her pulmonologist advised her to attend pulmonary wellness center. However, on the treadmill her bp rises to 160 systolic. Would this affect her aneurysm. The pressure comes down once she if off the treadmill. How much exercise should she do?

Dr__Hammer: I think what she is doing is fine. She should continue her exercise. This degree of elevation of transient BP should have no major affect on rate of remodeling of her aorta.

rkunglaub2: I was diagnosed with an ascending aorta aneurysm of 4.7 cm last fall. I an a very active athlete age 64. What are your recommendations for exercise, running biking swimming--heart rate limits and time limits? If I have surgery, are there any exercise limitations?

Dr__Hammer: Keep your HR at 80% of you max heart rate.

Dr__Roselli: Avoid heavy lifting as a general rule not more than 1/2 your body weight. I have had many patients return to competitive athletics after surgery.

Size of Aorta – Timing of Aorta Surgery

TomM: I am 61 year old white male good overall health with a bicuspid aortic valve and a 4.5mm aneurysm on the ascending aorta. My two questions are 1. What restrictions can I expect after healing form the surgery itself? 2. By not having the surgery am I damaging my heart? My doctor has stated surgery is not necessary until I develop symptoms. I have no other underling health issues. A catheterization in 2011 shows ne stents were required. I am currently taking 50mg metoprolol twice a day, 40mg lovastatin once per day and baby aspirin once per day. The medications keep my blood pressure and cholesterol levels ok.

Dr__Kalahasti: No surgery is needed at this time however, I do not have information about the valve leaking or if it is stenosis (narrowed).

Gabby: Last July, 2011, a MRA revealed that I have an enlargement of the aortic root. The measurements are: aortic root: 4.0 cm at the level of the sinuses of Valsalva. The ascending aortic measures 3.3 cm at the sinotubular junction and 3.6 cm at the level of the distal main pulmonary artery. The aortic arch measures 3.3 cm. The proximal descending thoracic aorta measures 2.7 cm. I am told by Columbia University Medical Center that I am not a candidate for surgery. Do you agree or can I be proactive and have the surgery to repair the enlargement? And, what are my limitations, if any?

Dr__Kalahasti: We agree with the recommendation from Columbia - you do not need surgery at this time. You do not have any limitations at this time.

Mymom: Female 80 diagnosed with ascending aortic aneurysm (5.1cm) and aortic stenosis, bicuspid aortic valve. SOB on exertion only. Would 5.1 cm be indicative for surgery for someone who is smaller in size? Stress ECHO from last Nov showed an EF of 71% and AVA of 1cm2, a repeated resting ECHO now showed EF 49% and AVA 0.8cm2. Does that imply a rapid deterioration? Are the results of a stress ECHO comparable to that of a resting ECHO? How urgent is the surgery if it is needed? Would minimally invasive surgery be an option? Should the kids be screened for bicuspid valve or aortic aneurysm? Thank you.

Dr__Kalahasti: Yes 5.1 cm is an indication for surgery and we would be happy to evaluate her here. It is a decrease from last year and also the EF has decreased. Yes the resting and stress echo results are comparable because even with a stress echo, they look at resting measurements. Yes the kids should be screened by echocardiogram. Minimally invasive surgery is usually not feasible in this case - but we can explore this.

tommydnj: I have an ascending aortic aneurysm of 5.1cm. Do you need to wait "until you have problems" or can you be more "pro-active" about the surgery

Dr__Kalahasti: You can be proactive in aneurysms greater than 5 cm. Do you have a history of bicuspid aortic valve. It also depends on your height and weight. We would be happy to see you for an evaluation.

waleslar1: I have a ascending aortic aneurysm (sp?) measuring 4.9 cm just above the root. I guess I'm waiting for it to grow to over 5.2 or up to 5.5 max, depending on who you ask. My aortic valve is bicuspid, but not stenotic. There's some regurgitation, but no symptoms, such as shortness of breath. My next scheduled CT Scan with contrast is in October. What number should cause me to start talking surgery - I mean size of aneurysm? I want to wait as long as possible, before getting cracked open. I like what I'm hearing about less invasive surgeries for the valve and the aneurysm. My surgeon at Shands Hospital Fl. said that he probably would not repair my bicuspid valve, because of eccentric jet and such. I'd rather get it repaired than replaced with cow or pig valve. So, I keep waiting, with the hope that I might get things my way in the end.

Dr__Roselli: Patients with aortopathy associated with a bicuspid aortic valve are at risk for complications from their aneurysm at a smaller size. Therefore we recommend elective repair when the ascending aorta is 5 cm or if the patient is short, then we recommend repair when the max aortic area to height in cm ratio is greater than 10. For bicuspid aortic valves that are predominately regurgitant we have a greater than 85% long term success at repairing them.

boomer46: Is there a universally accepted number for aneurysm size at which surgical intervention is indicated?

Dr__Hammer: No. Size is a guide. Depends on site, cause, size of patient and other co-existing conditions, and the nature of the aneurysm.

Diagnostic Tests and Monitoring

Blumen: Hello, I am a 55 year old male who was diagnosed with a 4.8 cm ascending aortic aneurysm and about a year later with a 2.3 rt. common iliac aneurysm coming off of the aorta. My aneurysm has gone from a 4.7 to 4.8 this past year and MY ILIAC ANEURYSM HAS GONE FROM 1.9 TO 2.2 cm. Additionally, they told me after an echo that I had a dilated aortic root of 4.3 CM and that my left ventricle is moderately dilated and there is mild aortic regurgitation. In your opinion, should I expect continued growth and is there anything I should be doing now? Lastly, is the iliac aneurysm something to be concerned about? Thank You

Dr__Kalahasti: Expect continued growth at 0.1 cm per year based on historical studies. I Recommend BP control to less than 120/80 mg Hg and no lifting weights greater than 50 pounds. You need to monitor your aneurysm on a yearly basis. We would be happy to see you here.

Keith233: KeithM Follow-up Q: have echocardiogram every 6mos to verify stability of aortic aneurism. Should CT or MRI be done periodically as well?

Dr__Roselli: Depending on the location of the aneurysm, echocardiogram may not be able to visualize the affected area. CT or MRI is better suited for visualizing the entire aorta. Echo typically measures the inner diameter of the aorta while CT measure wall of the aorta so they may vary by a few mm.

Dr__Hammer: Echo can be off axis and can also over or under estimate the true size.

Joe76: My aorta scan reading at my last physical exam 6mos ago was 2.5. I exercise regularly and have been in good health. Is it risky to do swimming and weight exercises as I have for a long time? I had a aorta scan last November because of passing out. I spent a period of time getting all the test related and everything was normal.

Dr__Roselli: Please keep exercising - 2.5 cm is a normal size aorta. Passing out is something that should be evaluated by a physician.

gdavis: Hello. I am 33 year old male. Diagnosed with Bicuspid aortic valve. Obviously this makes me pretty nervous. Recently had an echo. Results say my ascending aorta measures 3.8 cm, aortic root 3.4 cm, no stenosis, and no sclerosis with trivial (trace) regurgitation. Cardiologist says everything is in good shape. Ascending aorta is upper normal but nothing to worry about. He wants me to come back in 1 year for another echo. This is all kind of Greek to me. Does this sound like proper assessment? Upper normal is a bit of a confusing term. When does aortic size become problematic. Thanks for any insight. Geoff

Dr__Kalahasti: The current management is absolutely fine. The upper limit of normal usually means there is a gender difference and also differences with body surface area. An aneurysm is of concern when the aortic size is greater than 5 cm and from 4 - 5 cm it is called enlargement.

gm3: I have an AAA Stent in place since 7-2008 and have become concerned over the number of Cat Scans necessary during follow ups on the Stent procedure. How many Cat Scans is recommended on an annual basis and is there an alternate Scan procedure to check on the AAA/Stent performance?

Dr__Kalahasti: Recommended follow up is yearly CT scan for the first 5 years. If everything is stable at that point, then it may be reasonable to do CT scans every 2 years.

The devices are tested in the lab to be durable to at least 10 years. Most of the problems that develop late are not due to degradation of the device but rather due to progression of the aortic disease.

Sometimes, additional procedures are required. most often these are approached in an endovascular fashion but occasionally require conversion to an open surgery.

F94jL63: Of Echo, CT, and MRI, which gives the most accurate measurements of aortic dimensions? (Or is there a non-significant "margin of interpretation" that accounts for variations between Echo and CT taken on the same day?)

Dr__Kalahasti: See question just responded to - Keith 233


PghMa: With a diagnosis of a 4.3cm ascending aortic aneurysm in May 2012, is new, continuing mild hoarseness and loss of a few upper range singing notes significant?

Dr__Kalahasti: No - this is nothing that is related to your ascending aortic aneurysm.

wstpierre: I have a 4.0 cm thoracic aneurism and have difficulty breathing. is this related? my chest always feels congested.

Dr__Kalahasti: No - I don't think it is related to the thoracic aneurysm. Difficulty breathing should be evaluated by your physician.

PghMa: I was diagnosed with ascending aortic aneurysm as a result of a trip to ER for severe chest pains, breathlessness, headache, dizziness and high bp spike. The only finding was the aneurysm, some aortic valve regurg and some gastritis. I continue to randomly have strong chest pains and the dizziness and headaches have remained. How do I distinguish between chest pain that might be something innocuous vs. something related to the aneurysm?

Dr__Hammer: The difficulty in answering your question is knowing the full extent of your evaluation - were you worked up for coronary artery disease, had a stress test, etc. You can call my office for an appointment to discuss this further.

Aorta Surgery

Don: I had my bicuspid aortic valve with extreme calcification replaced in 2007, In 2010 a MRI test revealed that I now have an aorta aneurysm 5cm x 4.6cm. How likely percentage wise could this aneurysm be related to the aorta valve disease/ re there studies relating the two diseases, or is it of the same disease. And is open chest surgery required to repair the aneurysm? My aorta valve was replaced with a pig valve and will have to be replaced again someday they tell me, how many times is it healthy to have the sternum accessed in this manor?

Dr__Roselli: 2% of people are born with a bicuspid valve. It is estimated that up to half of those people also are at risk for ascending aortic aneurysms. Currently open chest surgery is required that kind of aneurysm. There is no limit to the number of sternotomies a patient can have. We have done 6th and 7th time resternotomies in Cleveland.

Dr__Hammer: My concern would be what segment of the aorta is the enlargement. If the root - this can be tricky as to how it is measured. But if it is the ascending aorta and truly 5 cm, we would recommend you getting this fixed relatively soon.

In addition, patients who have had aortic valve replacement for bicuspid aortic disease have a significant chance of having enlargement after aorta surgery due to associated aortopathy. At levels of approx. 5 cm and above are at risk for tear.

Mymom: what is the survival or success rate for ascending aortic aneurysm and aortic valve replacement surgery in an overall healthy 80yo?

Dr__Kalahasti: Age is not an independent predictor of outcome for these kinds of operations. In 2011, in over 400 patients undergoing elective repair of prox aorta at the Cleveland Clinic, mortality was 0.4%. The risk may be different in your mother but we would be happy to evaluate her.

Andreasmith30: Dr. I am sorry, not sure if my chat room is working or if my question got through. I have an 18 yr old son who was diagnosed with bicuspid valve at age 5. He was under not restrictions. Recently he began his D1 college soccer career. He was pulled by the University after 3 mos of playing. Echoes indicated an ascending aortic artery enlargement of 4.5. Previous echoes (3 mos and 1 yrs prior) indicated 4.1-4.3. Subsequent CAT scans and MRIs indicate 4.2 with no root involvement and mild regurgitation, mild to no stenosis. If we follow the Bethesda Conference guidelines (which is what the University says) than he is to be restricted from Competitive sports like soccer at a 4.0. Is there a possibility of surgery to repair the artery so he can return to sport at the college and even professional level. He has trained all his live for the opportunity and is highly scouted.

Dr__Roselli: It is not unreasonable to consider surgery - it is more than the raw number that goes into the decision. We would be happy to evaluate you. Please call Dr. Hammer's office to schedule an evaluation and second opinion.

Ninjagal63: My young daughter was born with both stenosis of the aorta as well as a bicuspid aortic valve. Her doctors expect that she will need surgery to replace the valve at some point. How does her stenosis affect the surgical intervention as well as the eventual outcome? Currently she is a healthy, active pre-teen.

Dr__Hammer: By your description I assume you mean your daughter had an aortic coarctation and my second assumption is that this has been repaired. These are very commonly associated.

Dr__Roselli: The way that aortic coarctation would affect surgery on the valve would depend on severity of aortic coarctation.

Sometimes we address both problems simultaneously. Aortic coarctation can be treated with open surgery, stent grafts, or extra-anatomic reconstruction. If she had the coarctation repair as Dr. Hammer suggested, she will need lifetime surveillance of her aorta. The 2 problems are associated, but Timing of surgery for either one is independent of each other.

RalphP: Just had ascending aorta surgery 1 month ago today. Since surgery, I've had a dry cough, mostly at night. What could be causing this and how do I fix it? Thanks.

Dr__Kalahasti: Sometimes it can be related to the surgery, but I expect it to get better with your recovery. If the cough does not improve in the next four weeks, you should see an ENT specialist for an evaluation. In the meantime, perhaps a moist humidifier and lozenges can help.

Boyrch19: Are there stents available for thoracic aortic aneurysm repair or arch reconstruction?

Dr__Roselli: Yes, there are stent grafts available for most segments of the thoracic aorta but the best choice of treatment depends on the specifics of the patient’s disease.

Causes of Aorta Disease

LHollow: If I have a connective tissue disorder, (Loeys-Dietz Syndrome), and my entire thoracic aorta dissected 9 yrs. ago, and has all (ascending, arch, descending) been replaced with dacron graft...what are the chances of my abdominal aorta dissecting or becoming aneurysmal as I get older? Does the fact that the upper aorta dissected, increase my risk for the lower aorta doing the same? I am 53.

Dr__Kalahasti: It is still possible as you get older. Yes the fact that the upper aorta dissected, does increase your risk for the lower aorta doing the same because you have Loeys-Dietz Syndrome.

Blumen: Does a 2.2 cm rt iliac aneurysm and a 4.8 cm ascending aortic aneurysm indicate possible additional aneurysms? And is the rt. common iliac aneurysm a concern? Thank you.

Dr__Roselli: Yes aneurysms in multiple locations are suggestive of a connective tissue disorder or at least a propensity for aneurysms occurring elsewhere.

cdrgarey: My husband recently received a diagnosis of a single dissecting aneurysm in the comm. what would typically cause this type of problem? Also, his vascular surgeon plans on endovascular grafting. What is the surgical risk and should we receive a second opinion? If so, what criteria should we consider in choosing a surgeon. Thank you, Sherryon right iliac.

Dr__Roselli: Aortic dissection is a very complicated problem. Best treated in a center with a lot of aortic surgical experience. Typically open surgery is the treatment of choice for chronic dissections but there is an evolving experience using endovascular therapies for this problem. The most common risk is HTN and a second opinion is not a bad choice. We are happy to see you.

baglady: What causes aortic disease?

Dr__Kalahasti: There are multiple different reasons for aortic disease including genetic causes, atherosclerosis, bicuspid aortic valve, and familial transmission.

Margaret: I have been told I have a root aortic aneurysm of 3.8 x 3.6 and a tortuous thoracic aorta. What is the significance of this? What are the chances of other aneurysms in other areas? Is by- pass surgery generally required to repair and at what size? Does the aortic valve have to be replaced at the same time? What are the complications of surgery? Is less invasive surgical repair possible at this time? I've been told to keep my BP down. How low is sufficient? Thank you for your response.

Dr__Kalahasti: I would call this a mild prominence not an aneurysm, hence it is not significant. The risk is very low for aneurysms in other areas. At this time your other questions are not a concern.

Aortic Valve Disease

lmgaiso: My aortic regurgitation was found 11 years ago and classified as trivial to mild at one Institution A and mild by Institution B. Today it is considered mild by Institution A and mild to moderate by Institution B. That is, both institutions agree that there has been minor progression. However, my chamber dimensions and ejection fraction have remained the same. The AV is tri-cuspid. I am 44. What is the chance of this progressing to needing surgery? I have been doing aerobic exercise and weight lifting during these 11 years. Thanks

Dr__Kalahasti: It is difficult to predict progression in aortic regurgitation in patients with tricuspid valves. I would recommend continued monitoring. No surgery treatment is required.

gdavis: 33 year old male. Diagnosed with BAV a few years ago. Recent echo shows ascending aorta at 3.8 cm and aortic root at 3.4 cm. Trivial trace regurgitation and no stenosis. Dr. Seems pleased with these results. I am 5'10" 205 pounds. Are these within normal limits and how often should I have them measured. I also play a lot of basketball. Is this a safe form of exercise with my condition? What are exercise restrictions? Thanks

Dr__Hammer: Keep exercising. I would not restrict your exercise. Your upper aorta is just at the normal limits of normal.

tennisball99: I have both the aortic valve stenosis and the mitral valve leakage. The aortic valve problem is mild and I get or will get tested annually. It is said to be related to the aging process. I do see reference to a syndrome my son has called Noonan's and that fathers of those children develop some heart valve and aortic problems in middle age. I am age 67 and maybe was diagnosed 8 to 10 years ago with the aortic one.

Dr__Hammer: We would like more information at to the status of both of your valves and your cardiovascular status before answering this question.

JAK_1: Hello Doctors, I have a 16 yr old son who was diagnose w/ a BAV w/in the past yr. I would like to know if swimming would be a healthy and safe activity for him. Also he has complained about the veins in his arms swelling and he feels best holding them up. Is this normal or should I look into it before his next apt. in sept.? he is 6ft and weighs about 120-125 lbs. Should I be trying to put weight on him? Thank you for your help, Judy

Dr__Kalahasti: Swimming is an ok activity because he does not have any regurgitation or stenosis. The veins in the arms do not seem to have any relationship to the bicuspid valve. Talk with your pediatrician. He sounds a little thin - but your pediatrician knows your son best.

ianbarrod: I had a faulty aortic tissue valve replaced 6 weeks ago with a mechanical valve. My prescription for metoprolol runs out in 3 days time. Can I just stop taking it then or do I need to taper it down?

Dr__Kalahasti: Call your physician before stopping your medication for instructions.

fullmoon57: what's your thoughts on On-X valve for an uncomplicated Bicuspid Aortic Stenosis in a healthy 53 year old and what do you anticipate as approval time frame for it and possibility/( and how soon) of patient not requiring Coumadin therapy ?What is typical recovery period post surgery and chances of infection if you travel abroad to a third world country after 3 months ? What's the best comparable alternative to On-X mechanical valve ? What are complications of Coumadin therapy ?

Dr__Roselli: We have completed enrollment but do not have date yet. Recovery period is typically 5 - 7 days in hospt. 6 weeks for wounds to heal and to go to rehab. 10 - 12 weeks before endurance returns. Rate of infection is 1 % per year regardless of where you live. It should be safe to travel after 3 months. A biologic valve is a good alternative to a mechanical valve.

Dr__Kalahasti: Bleeding is the major complication of Coumadin but there are others.

lmgaiso: When do you think that TAVI will be ready prime time in less than high risk people?

Dr__Roselli: The technology is currently being studied in a randomized controlled fashion in moderate risk patients. It may never be applicable to the lowest risk patients. However, newer techniques at less invasive aortic valve replacement are continuously improving.

lmgaiso: What is the mortality rate at CCF for aortic valve only replacement and for the Ross procedure?

Dr__Roselli: Aortic valve mortality with replacement is approximately 1% and the Ross mortality is less but the indications for Ross procedure are limited.

Levi26: Does a diagnosis of moderate aortic stenosis indicate a need for valve repair and/or replacement?

Dr__Kalahasti: No. In patients with aortic regurgitation, aortic valve repair is an option in select patients.

Hypertrophic Cardiomyopathy

RGambate: I am a 70 year old male. See last September at the Cardiology Unit of the CC. I have mild to moderate AS with mild to moderate HOCM. I am asymptomatic but have noticed that I can't do the same tasks as vigorously as last year. I have also gained weight. I'm considering have valve replacement surgery with a septal myectomy now rather than later when symptoms become more noticeable. What do you think?

Dr__Kalahasti: Please come back and see your cardiologist for a follow up evaluation.

Reviewed: 07/12

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