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Aorta Disease - Drs. Hammer and Svensson

Monday, July 29, 2013 - Noon

Description

It has been reported by the Centers for Disease Control and Prevention that more patients die annually from aortic disease than breast cancer. It is crucial to know and understand the latest treatment options available if you have been diagnosed with a condition related to the aorta or the aortic valve. Take advantage of this rare opportunity to chat live about aorta disease with cardiologist Donald Hammer, MD and cardiac surgeon Lars Svensson, MD, PhD

More Information


Diagnostic Testing

jherrick: I recently had a MRI that measured my ascending aortic aneurism at 4.6 cm. I was diagnosed two years ago using a CT scan and a measurement of 4.5. In the interim, last year, an echocardiogram gave me a 4.3 reading. Why the discrepancy? Is my aneurysm growing, or is this a rounding error amongst the different methods of viewing?

Lars_Svensson,_MD,_PhD: A CT scan measures the external diameter - the echo the internal diameter, hence, the usual difference.

rdwardse:

  • Why is the term ectasia used to describe the aneurysm exactly what does it mean?
  • What is considered a significant increase in size of aortic aneurysm over a 6 month period such that intervention is required ?
  • Are measurements of studies done at different institutions reliable for comparison?
  • What are the symptoms that a patient might experience if the aneurysm is enlarging or dissection is about to occur?
  • For an aneurysm of the ascending aorta close to the pulmonary artery what is the usual course, prognosis and recommendations for treatment?
  • Is a patient with an ascending aortic aneurysm a candidate for the less invasive surgical stint option described as being part of a trial at Cleveland Clinic?
  • If you are not near a major center and possible rupture or dissection seems to be occurring what should the family member do in terms of getting to a medical center that can at least stabilize the patient what questions should they ask, what should they be prepared for ahead of time? Thank you.

Lars_Svensson,_MD,_PhD: Ectasia is non-specific but usually refers to a tortuous aorta.

JLK: My wife is 53 with a bicuspid valve, and her ascending aorta was first found in 2006 to be dilated to 4.8 cm per CT scan and echo ultrasound. In August 2011 her ascending aorta measured 5.0 cm per CT/echo, and we were told by Cleveland Clinic at that time that her index score for surgery was 11.2, and surgery was recommended. However at the beginning of this year, she increased her dose of Cozaar from 50mg/day to 100mg/day, and this past February (after one month on the increased dosage), her echo ultrasound of ascending aorta showed that the measurement had decreased to 4.7 cm from 5.0. What is her index now, and does she still need to have surgery right away or can we wait?

Donald_Hammer,_MD: I would rely heavily on the CT measurement which is far less prone to error. Based on the last CT findings I would think your wife remains a candidate for surgery.


Symptoms

molemanmsb: Im wondering: I had chest tightness actually for the past 7/8 days, with sometimes flickering pain and sometimes breathlessness and tingling on my left side of my fingers and toes. Had relaxed ECG, Blood Test, Urine Test and X-Ray and they all came out normal. What could be the cause? I'm 20 years old. Doctor said Intercostal muscle but I don't really feel pain. Please reply and inform me about your thoughts. He checked my nerve as well by assessing me when I raised my arms and hands straight up in the air which was ok.

In addition to this recently I've been having a tiny amount of blood in my saliva but a real tiny amount. Im also fasting eighteen hours a day because I'm muslim and its ramadhan. I'm also having abdominal pain for a few days now like a day after ramadhan started. He checked me with a stethoscope even just above my abdomen and it was normal with my clothes on though?? Although the abdomen pain has resolved itself the chest pain hasn't and I sneezed out a tiny piece of yellow thin piece with what looks red patches and have two blood tiny spatters on my pillow. I don't have nose bleeds.

Donald_Hammer,_MD: You need to see a physician. Consider an echocardiogram, make certain we are not dealing with pericarditis. And go from there.

kmo123: I’m a 58 yr. old man who’s always been very athletic. After a heart attack 12 months ago, I had my ascending aorta replaced, along with CABGx3. 9 months ago, one of the bypass grafts became 90% blocked, and I was given a stent. I’ve gone through cardiac rehab, and try to exercise regularly (swimming, weights and stretching). In the past few months, I’ve had periods of extreme exhaustion, shortness of breath and chest pain, usually 1-2 days a week. On these days, I can barely get out of bed, and I sleep most of the day. Stress echo and nuclear stress tests don’t show any reason for these symptoms, nor did the spirometer test that my PCP administered. Can you recommend any other things that my doctors should be looking for, or any possible reasons for the symptoms?

Donald_Hammer,_MD: Your question is difficult to answer but yes I would think further evaluation is indicated. We would be happy to do so at Cleveland Clinic.


Aneurysm

figme: What is your opinion of a 5cm thoracic aneurysm. I have had this condition for 11 years since it was discovered while my aortic valve was being replaced. I have no symptoms, swim 30 laps and bicycle 11 miles, and feel good.

Donald_Hammer,_MD: I have additional questions for you. How old are you? How tall are you? Why was your aortic valve replaced (was it a bicuspid valve?). Before answering your question we would need more information.

dlrv: I have dilations of the ascending aorta 3.7-4cm transverse, supra renal aorta 2.9 x 3.2 and main pulmonary artery suggestive of pulmonary arterial hypertension. This is complicated my tortuous carotid and ocular vessels, Left ventricular hypertrophy, left atrium dilation and aortic and branch calcifications. An ER doctor became very concerned calling the one an aneurysm my family doctor sent me to a second doctor who said they are probably related to my RA and said he was "not really concerned". Are dilations of that size significant and do I need to seek a third opinion?

Donald_Hammer,_MD: Your aorta is mildly enlarged. There are a number of questions implied here. First, does the enlargement of the aorta have any relationship to your inflammatory disorder (RA)? But there are other etiologies to be considered such as hypertension, presence of a bicuspid aortic valve and so forth. The suggestion of pulmonary artery HTN is a separate question here that I can't begin to answer without additional data. Have you had an echo? If so - what were the findings? Please reply.

Dr. Frank: How does BSA or body surface area calculation affect the diagnosis, monitoring, and prognosis of aortic expansions beyond what seems typical, as, for example, mid-thoracic norm of 3.5 in a 6 foot 190 lb man who by ECHO and MRI registers a 4.1? 66 yr old male, 190 lbs, 5 ft 11 in, with MRI/ECHO mid ascending aorta of 4.1. Is this WNL or considered dilatation or aneurysm, etc.?

Donald_Hammer,_MD: Age, height, and body surface area have an effect on determinants of normal as you know. At 5'11" and 66 years of age, an aorta of 4.1 cm is just beyond normal, or mildly enlarged.

jherrick: I have an ascending aortic aneurysm, will a low BP, say 110/70, and a low BMI significantly increase the likelihood of my aneurysm remaining stable?

Donald_Hammer,_MD: They are helpful. Much of this depends on size at the present time and cause.

Vicki B: Thank you for inviting me. I am not certain if the aneurysm is at the root or higher on the ascending aorta. Will this affect treatment options or are they already limited by the fact that it is an ascending aortic aneurysm? I have been told the valve is fine even though the murmur has been present for many years.

My main reason for coming to Cleveland Clinic in the first place is that my current surgeon is recommending I wait until the aneurysm grows up to 6.0 before surgery. The American Heart Association recommendations suggest surgery at 5.5. I am not willing to wait longer than the AHA recommends. At what point do you recommend surgical intervention? Cleveland Clinic comes highly recommended. Therefore it is my first choice when seeking care for this condition. I already feel pain and as a side sleeper pull my shoulder back because my chest is uncomfortable when my upper arm is forward. I am due for another cat scan August 2nd. What are my treatment options if it has grown?

Lars_Svensson,_MD,_PhD: It is difficult to answer your question without knowing what your age is and if you have any underlying pathology. When we wrote the AHA guidelines, we chose 5.5 cm based on the literature as the cut off for patients who have no other predisposing factor for complications. This has to be taken into consideration in relation to all other factors. If a murmur is from a bicuspid valve, then we would tend to operate earlier. We would be happy to evaluate you.

Blumen: Hello Dr. Hammer, I am a 56 year old male with a couple of aneurysms/dilations. I have an ascending aortic aneurysm 4.8 x 5.0 cm, a right common iliac @ 2.2 cm, my aortic root is 4.3cm, and my external iliac's measure 1.5 and 1.4. I also have leakage at the aortic valve and my left ventricle measures 1.4cm. Also, I have had several eye surgeries for huge retinal tears (vitrealectomy, lensectomy, a buckle around one eye...) I also have a hiatal hernia (GERD), axial motor neuropathy, three foot surgeries for bone extrusions, one surgery even included a pelvic hip harvest to try to get the big toe longer (My two toes next to my large toe, on both feet, are both longer than my great toe). My question is: Is there a link to these conditions and is it important to do a test for a collagen type of disease? I am pretty frustrated because it seems like I am seeing doctors who only address issues in their field and it seems as if things just keep adding up. I am a veteran of 26 yrs/VA.

Donald_Hammer,_MD: From your description and extent of problems, my first concern would be whether or not you have a connective tissue disorder. I would be happy to evaluate your situation at the Clinic.

Spiderman: I had my aorta valve replaced in February of 2007, with a biological valve (pig’s valve), in may of 2011, a MRI revealed a 5cm thoracic aortic aneurysm. A cat scan of Dec 2011 the aneurysm measured 4.9cm, My question is this; is it more likely than not, that the aneurysm is related or caused by the spectrum of the bicuspid diseased value?

Lars_Svensson,_MD,_PhD: The likelihood is that the aneurysm is related to the underlying bicuspid valve pathology. Your aorta will need long term follow up and if the size exceeds about 5.2 - 5.3 cm, depending if you have any co-morbidities, it may require repair.

Nana333: Have you seen a 3.9 ascending aortic aneurysm that stayed at 3.9? How quickly should I expect to need surgical intervention with such an aneurysm?

Donald_Hammer,_MD: First of all, I would not define your aorta to be aneurysmal at this size. It may actually be upper limits of normal or at most mildly enlarged. This would depend on your age, height and body surface area. Knowing these, we could determine whether or not this is a long term concern or simply upper limits of normal.

cardio_al: Hello. I have a thoracic aortic aneurysm 3.9 cm. also, diagnosed with coronary artery disease, carotid artery plaque of 50-70% left side.. Also atrial fibrillation. I have regular visits to keep monitored these conditions. No operations so far. So.. what advice for the best preventative measures for me now? Thank you.

Donald_Hammer,_MD: How old are you? By that I mean your management with in particular atrial fibrillation is dependent on advanced age; other risks for stroke. Prevention of the latter may be simply low dose aspirin if you have a CHADS or CHADS-VASc of 0 -1 - or if higher - then coumadin. In addition, the presence of mild to moderate aortic disease would suggest the prudence of lipid lowering treatment, to be specific a statin as well as dietary alteration.

Albertskiba1: Have you seen many patients that have had the "Ross Procedure" where after time their replacement aortic valve starts to fail and an aortic aneurysm is created? I had this procedure in 1999 and they had to reduce the aortic root down to 3.7 cm and now I am at 5.2 cm. Does the same "rule of thumb" of 5.5 cm before repair still exist or should I be looking at a different metric to determine when to repair?

Lars_Svensson,_MD,_PhD: As a general rule, we try and find out what the first operation was for. If it was for bicuspid valve and the aorta has been enlarging, we tend to operate again when it gets to about 5.2 - 5.3 cm.


Aortic Dissection

D.Ray : I have an Aorta dissection which was torn by my high blood pressure almost 2 years ago with no measurable changes since. If no changes continue will I still need to have surgery or will I continue to live with this as long as I control my blood pressure?

Donald_Hammer,_MD: Without knowing more information, such as the size of your dissection, its extent, and cause, I am unable to satisfactorily answer your question. In general, the likelihood of additional surgery over 5 years of follow up is at least 50%. Again, this is dependent on cause, size, location and extent of the dissection among other risk criteria for further remodeling or enlargement. Certainly, it is imperative that your blood pressure is well controlled as I assume has been the case to this point. But I would be more definitive in answering your question with additional information such as above.


Surgery

Up The Creek: I have an ascending (thoracic) aorta aneurysm that was discovered November 2012. I was told it was next to the heart. Big surprise to me. It was 41mm at that time. It was checked again in April and was 45mm. I am due for recheck in September. I do have some chest discomfort at times. I was advised by a physician (not my cardiologist) that it might be a good idea to see a surgeon just for awareness. If I do have surgery, of course, I am interested in the least invasive procedure. I have heard there may be one where the surgery is done through the side of the back. Am I being too concerned even thinking about surgery at this point? Thanks.

Donald_Hammer,_MD: From your description, that is location of your enlarged aorta, I am to assume this is the ascending segment. This can be managed by minimally invasive surgery but one that requires a small sternal incision rather than lateral chest approach. The more concerning issue here is rate of change. Appropriately, you have been recommended a follow up at 6 months. Further changes in dimension might necessitate surgery in the near future but this is to be determined. I would indeed suggest consulting cardiothoracic surgeon for a second opinion and one that at least gives you the opportunity to be followed closely.

knute: Is it possible to repair an ascending aneurysm on the aortic valve minimally invasively. Thank you.

Lars_Svensson,_MD,_PhD: Yes. We routinely do ascending aortic repairs and aortic valve repairs or replacements with a minimally invasive keyhole approach.

jhoffman@magnallc.com: What are the primary/best methods for repairing an aneurysm at the sinus of valsalva (5mm in diameter, normal Ao valve and normal remainder of Ao diameters)?

Lars_Svensson,_MD,_PhD: The operation we mostly do for repair of aortic root aneurysms exceeding 5 cm is a modified David reimplantation of the aortic valve with preservation of the aortic valve. Have a look at our youtube video and that will show the operation (and also our website). we have done over 420 of these operations and the risk of death is about 0.5% after the operation. The long term durability of the repair is such that 95% of patients have not needed another operation within 10 years of surgery and by 20 years it will probably be about 85-90%.

Sra Fran: I am scheduled for surgery on my ascending aorta at the Clinic on Tues. Is an aneurysm normally a one time thing, or does this 'disease' sometimes reoccur? Also, does surgery fix the problem well enough that one can resume high energy activities enjoyed before without concern?

Donald_Hammer,_MD: Your question is appreciated. I have very little detail to determine the best answer. You do not specify location, size, and or extent of the aneurysm nor do you state its underlying cause. These all have a bearing on long term expectations. I would be certain to ask this of your surgeon prior to undergoing surgery or at the very least subsequent so that you can be properly apprised of your long term expectations.


Abdominal Aortic Aneurysm

wjsg: What is the abdominal aortic aneursym measurement at which surgery is recommended? And---are there complications with an existing hiatal hernia---one in which quite a large amount of the stomach has protruded above the opening of the diaphragm?

Lars_Svensson,_MD,_PhD: The size at which surgery is recommended is somewhat dependent on whether stent can be used. The literature is somewhat mixed and much depends on age, co-morbid disease such as hiatal hernia and how extensive the repair is that needs to be done. As a generalization, most aneurysms more than 5.5 cm below the renal arteries are repaired and above the renal arteries greater than about 6 cm.


Aortic Valve

kahuna8: Eligibility/Decision logic for TAVR vs Open Heart - is it a MD/Patient decision or dictated by insurance/Medicare? I am Medicare/Tricare for Life. Risk of complications as to the above - in other words risk/reward. Age 77, excellent overall health, 46mmHg mean gradient, valve area .95cm2. Ejection fraction - 55. Thank you. Henry W.

Donald_Hammer,_MD: The decision concerning TAVR vs. minimally invasive AVR is dependent on the patient's comorbid disease. At Cleveland Clinic, for the last 2 years our risk of death for a minimally invasive AVR has been 0.4% to 0.6%. In most studies including the PARTNER trial that we participated in, the mortality rate has been 3.5% - 6% and indeed in the PARTNER trial the risk of stroke with transfemoral TAVR was 3 times higher than AVR. (4.6% vs. 1.4%, p=0.04)

mlr09: Hello. I had a heart cath on 10/31/12 that showed a bicuspid aortic valve, mild stenosis, moderate regurgitation and a mildly dilated aortic root. No blockages. My dr. advised me not to let my heart rate go above 120, no sit-ups and no weights. Now, without any further testing, he says I can lift weights up to 10 lbs. Do you agree that this is safe? My next echo will be very soon. Should I wait for results or start using my weights again? Also, he told me my aortic root was "softened" and in most people it's more stiff. I can't find any info on a "softened" aorta online. Can you tell me more about this?

Donald_Hammer,_MD: It would be in your best interest to gather more specific information regarding size of aorta; aortic valve gradients; and a more careful assessment of the degree of insufficiency to answer your question. However, the presence of mild or mod valvular insufficiency in the absence of a frankly dilated aorta should not prevent you from moderate aerobic exercise. Whether or not heavy weight training is permissible is another matter - one I would tend to avoid in this situation. But - 10 pounds seems to be a rather restrictive recommendation and I think we could be far more liberal than that.


Sports and Exercise

kjg48: My son is now 16 years old and was born with a bicuspid aortic valve. Since the age of two, when a murmur clued us in, the function of the valve has been monitored through EKG and echo once a year. No significant amount of blockage or insufficiency has been noted to date. However, about 18 months ago, some growth in the diameter of his ascending aorta was noted during his first MRI, but not enough to warrant any activity change beyond the no chest impact recommendation that he has always had. Six months ago, December 2012, his echo/EKG appointment showed significant growth in the aortic diameter, up from ~3.9 cm to the 4.3-4.4 cm range. Based on this change, he has been advised to no longer run competitively, one of his passions, and we are restricting him to the lower left four quadrants of the activity chart for athletes with aortic aneurysms. He was also diagnosed type 1 diabetes 14 months ago. Finally, my questions are: when should surgery be considered? What are the surgical options? Will the valve need to be a part of the surgical procedure? Will he ever be capable of "normal" physical activities again? Thank you so much for your consideration, Keith.

Lars_Svensson,_MD,_PhD: Based on the size and activity and that he is still growing, it would be safest that he not participate in any contact sport or any sport that involves rapid upper chest movement like baseball and tennis. If he is of normal height we would not typically recommend surgery unless he gets to about 5 cm unless there is rapid growth.

Adelino: Hi and Thank You for taking my question. I've been diagnosed with an ascending aorta aneurysm it’s 4.2 cm, MRI, no Marfans, 3 leaflets, normal EKG, no other heart issues. I was told by the Cleveland rep never to play golf even though all my cardiologist doctors and surgeon say play. I will listen to the CC, but my question is after surgery is it possible to play golf again? Wanted to become a PGA teaching Pro and if I could never play golf again I need to re-think my future. I'm 49 years old.

Donald_Hammer,_MD: From your description of aortic size your aorta is mildly enlarged, without an underlying disorder that would pose high risk for dissection, I would not think that golf in particular would put you at any major risk and you can continue to play. The aorta should be periodically monitored however and conservatively every year for now.


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