Tuesday, March 3, 2009
Lars Svensson, MD
Director of the Center for Aortic Surgery and Director of the Aorta Center, specializing in the treatment of Marfan Syndrome and Connective Tissue Disorders in the
Department of Thoracic and Cardiovascular Surgery
Cleveland Clinic has one of the largest aorta surgery practices in the world and has experience with every aorta repair and replacement technique, along with medical management strategies. Dr. Svensson, Director of the Center for Aortic Surgery and Director of the Aorta Center, specializing in the treatment of Marfan Syndrome and Connective Tissue Disorders, provides answers to your questions about the medical and surgical treatments for disease of the aorta.
Cleveland_Clinic_Host: Welcome Dr. Svensson, thank you for joining us. Thank you everyone for waiting to chat with Dr. Svensson we will begin with some of the questions you have already submitted.
Aortic Root Aneurysm
davidhud: I am 24. When I was 19 I had a Ross Procedure. Since then I have developed an aortic root aneurysm which measures about 5 cm by 5 cm. I'm getting conflicting opinions on whether it should be repaired now since I'm not having continuous symptoms although I do have intermittent chest pain. My EF is 45-50%. I take Toprol XL 50 mg daily and Lisinopril 20 mg p.o. daily. BP is okay most of the time. I'm scared this thing is going to rupture while the doctors are "watching" it with yearly CT angiograms. What do you think?
Speaker_-_Dr__Lars_Svensson: The decision when to operate is somewhat dependent on your height. We use a formula in which we calculate the maximal cross sectional area of the ascending aorta or aortic root and divide the total in square cm, by a patient's height in meters.
If that is more than 10, then we will usually recommend surgery. The reason is we have found inpatients with bicuspid valves or Marfan Syndrome with a ratio greater than 10, have an increased risk of aortic dissection or rupture. We also found that shorter patients dissect at a smaller size.
I suspect that you originally had a bicuspid valve and that may be why your aorta is enlarged. The other factor that comes into deciding when to operate is what your aortic valve looks like. In other words, if your aortic valve is leaking allot that may be another reason to re-operate. If your valve is working well - we can often preserve it during a reoperation for a Ross procedure.
Ascending Aortic Aneurysm
witter123: Can an ascending artery or arch be repaired/replaced with mini invasive surgery?
Speaker_-_Dr__Lars_Svensson: For patients with ascending aortic and arch surgery - acquiring just the first part of the arch to be replaced we can do that mini invasively including an aortic valve repair or replacement. When I first was developing the mini invasive technique, we replaced the entire aortic arch and also the elephant trunk procedures using the mini invasive J incision.
However, we found it took a bit longer and although not statistically significant we felt the results were not as good. Similarly, for reoperative aortic valve or ascending aorta surgery we can do them mini invasively but prefer not to unless there is a reason such as a patient is a Jehovah witness and the blood loss may be less. Nevertheless, all isolated mitral valve repairs or replacements, aortic valve repairs or replacements and ascending aortic aneurysms I will do as mini invasive procedures.
tommyg: Thank you for taking my questions, My brother has a Aneurysm on the Ascending Aorta that tapers on to the Arch (also Bicuspid and coarctation is involved). My questions is when first diagnosed by CT Scan with out contrast media showed the TAA size to be 4.5 centimeters, that was on 6/2006. ON 12/2008 current CT Scan with contrast media measured TAA at 5.0 centimeter. Then on 1/2009 (these last two measurements were taken at the same medical center)a MRA was performed which measured the TAA at 4.1 centimeters! Please which instrument or which measurement would you depend on to be most accurate and dependable. Thank you.
Speaker_-_Dr__Lars_Svensson: With your brother's history of increasing aorta size and associated chest pain, an aorta measuring 5.0 cm I would be concerned and would likely test him further for potential surgery. Bicuspid valves are associated with aortic aneurysms and also coarctation of the aorta - see previous discussion.
As far as testing, we often find, there is a variation in measured sizes particularly between echo measurements and CT and MRI. Interpretation of size on CT scans can also vary among radiologists depending on whether the size is measured at right angles to the aortic wall. Furthermore, echo measurements are typically internal measurements as are MRA measurements. Traditionally CT measurements have been external size measurements but some radiologists may measure the internal size on CTA.
kyoung: I had an AVR on 6/29/07. I also have a Mitral Valve Prolapse. I am currently being followed for a possible aorta aneurysm. Last measurement was 4.2cm and I have another MRI on 3/2. What can you tell me about Bicuspid aortic valve disease,things to watch for and if my aorta has as a good chance of getting to the point where it requires surgery? Also I am an endurance athlete. I did Ironman triathlons and marathons prior to my avr and did both after surgery. Any concerns now with this or if I need surgery for an aorta aneurysm,after? I belong to a group called Cardiac Athletes and there are many like me that are searching for active lifestyles before and after a cardiac event. www.cardiacathletes.org
Speaker_-_Dr__Lars_Svensson: It is unclear for me if you actually had the valve replaced or repaired. AVR usually surgically means replacement however you mention bicuspid aortic valve. If you have not had a bicuspid aortic valve replacement then a bicuspid valve we can repair in 80% of patients. Obviously that is a benefit in a young patient who wants to be active and not be on coumadin (blood thinner). In patients who have had previous aortic valve replacement and develop aneurysm above the valve replacement in the aorta - we will usually wait until the aorta is 5 to 5.5 cm before replacing it depending on a patients height. See previous discussion.
At 4.2 cm, the risk of you developing aortic dissection is small probably less than 1 percent per year. But you should avoid heavy lifting and exercises like squats and bench pressing. I cannot say that is entirely safe - but you should be able to keep up with running, swimming and cycling. Always check with your doctor before starting an exercise program - or continuing a vigorous one.
dexter_2: I had ct scan of lungs in Feb. 2004 and noted in scan was a 4.1cm aorta aneurysmal. I was in hospital Feb 2009 and Lung scan said now 4.1x3.9. Pulmonary Doctor was the first to address this and sent me to see a surgeon in Valley Hospital who claims to be expert on this., and he showed me a chart, and explained because I was a petite 5'2" woman weighing 125 lbs. I should have this repaired ASAP. Help
Speaker_-_Dr__Lars_Svensson: We use a formula for calculating when surgery is required. See previous discussion. Unless you are planning a pregnancy or you have Loeys-Dietz syndrome and you do not exceed the ratio of 10, we would not recommend surgery. If you have Turners Syndrome, then you may require a second opinion since you are fairly short.
shendr: I am a 68 year old white male, 6' 200lbs. Generally good health. Exercise regularly, smoke pipes and cigars. Drink moderately. I have an ascending aortic aneurysm. I am currently advised by some doctors to have the surgery done now and to wait and monitor by others. Since last August, I have had 3 CT scans and 1 catheterization with measurements ranging from 4.5 to 5.2 cm - the former was the latest measurement in January. Question: how can a surgery decision be made when the measurements vary so widely? Also, how important is body surface area? Any research being done on endovascular repair of ascending aortic aneurysms? Is minimally invasive/robotic surgery possible for this situation? Any other insights/recommendations? Thank you.
Speaker_-_Dr__Lars_Svensson: Generally CT scans done with 3D reconstruction are the most accurate way to measure aortic size. See previous discussions. If the calculated ratio of cross sectional area to height is more than 10 we will usually recommend surgery. Robotic surgery for ascending aorta or stent graft placement is not currently feasible. However, we will routinely do these replacements with a mini invasive approach
Bicuspid Aortic Valve
tsuch: What are the guidelines for aortic surgery for an asymptomatic patient with a bicuspid valve with moderately severe aortic regurgitation and an enlarged ascending aorta? What is the ascending aortic size that surgery would be recommended?
Speaker_-_Dr__Lars_Svensson: See the previous discussion.
We calculate the ratio of the cross sectional area to height - if the ratio is more than 10 we recommend surgery from the point of view of the aorta. as far as the aortic valve regurgitation, we wait until patients develop symptoms particularly fatigue, or if there are signs of early left pumping chamber failure. This is usually indicated by enlargement of the left ventricle or reduced contraction of it (less than 60%). In patients with bicuspid valves, it is usually easier to repair the valve when we see patients earlier in the disease process. Similarly for patients with 3 leaflet valves (tricuspid) we have more success with seeing patients earlier. Indeed for patients with tricuspid valves, and regurgitation, usually 95% of them we can repair and re-implant using a modification of the David procedure - see our website.
tommyg: Dr Svensson: Patients born with a bicuspid aortic valve have structurally inferior aortas,, making them prone to aortic aneurysm and dissection. Also some bicuspid valve patients may have aortic coarctation as well, as part of this syndrome. If being born with a bicuspid aortic valve is a very important cause of aortic diseases, especially since bicuspid valve disease is so common ( the most common congenital lesion of the human heart 1 to 2 % of the general population why is that standard procedure in newborns to be checked for this ?
Speaker_-_Dr__Lars_Svensson: You are right in that 1 - 2% of the population have bicuspid valves and 9 % of patients with bicuspid valves have blood relatives with bicuspid valves. There is a lot of controversy about the lifetime risk of developing problems related to the bicuspid valve are. Generally most patients will develop over a lifetime of 70 - 80 years either stenosis or regurgitation of the valve. In 20 % of the 3700 patients that we have had the aorta has also become aneurysmal because of the associated loss of elastic tissue in the aorta.
Conversely we know that 15% of patients who develop aortic dissection have a bicuspid valve. Marfan Syndrome is a more serious condition and we found that 15% of patients with an aorta less than 5 cm developed aortic dissection. For bicuspid valves, an analysis of our patients with aortic dissection and bicuspid valves showed that 12.5% had an aorta less than 5 cm. Hence - we developed the formula we use for both patients with bicuspid valves and Marfan Syndrome. See previous discussion.
rickkr: I have a leaky bicuspid valve but have no symptoms except for a low diastolic pressure of about 54. I do have a slight aortic aneurysm of 4.1 cm but I am 6'5". I am 55 years old and am looking to maintain an active lifestyle. What are the advantages of a bicuspid repair over a tissue valve replacement.
Speaker_-_Dr__Lars_Svensson: In comparing the benefits of aortic valve repair vs. replacement, there are a few things to bear in mind. In young patients, most surgeons would recommend a mechanical valve replacement - however, patients need to be on a blood thinner the rest of their lives to stop clot formation on the valve. Indeed the way we analyze this is that we look at event free survival and that is only 40% by 10 years after replacement with a mechanical valve. That means that 60% of patients by 10 years after surgery will either have died or developed a significant complication such as severe bleeding, stroke, infection, or formed clots on the valve
For patients in whom we choose biological valves, such as cow or pig valves, these have very good durability when inserted in patients over the age of 65. However, in young patients they fail more quickly - starting sometimes 5-7 years after insertion. Similar to mechanical valves, biological valves are prone to infections or associated with strokes.
Repairing valves particularly in young people if successfully done, are associated with a low risk of stroke and infections. Furthermore, if a aortic valve repair does not fail in the first year to 1.5 years, then the long term durability is very good. Indeed for our repaired three leaflet valves with the modified David procedure, the 9 year freedom from reoperation is 94%. For bicuspid aortic valve repairs when associated with an aortic repair at the same time, the freedom from reoperation at 9 years is 91%.
I want mention one more thing about bicuspid valves - we have operated on 3,700 patients with bicuspid valves up until August of last year. 20% of the patients we see have required their aorta to be replaced or repaired at the same time. Our overall risk of death for our series irrespective of age, urgency, or extent has been 1.1 percent. Clearly younger patients having repairs have a considerable lower risk of dying with surgery. Similarly, up until the end of last year, we had done 228 modified David reimplantation operations without any patients dying in hospital after surgery.
davidsil: Have there been any new procedures for an aortic valve replacement in the past 11 yrs. and are they less invasive than total open heart surgery procedure? What is the life expectancy of any new aortic tissue valve?
Speaker_-_Dr__Lars_Svensson: The changes that have occurred with aortic valve surgery are that we are doing a lot more repairs, we will routinely do all aortic valve procedures not requiring coronary artery bypass surgery utilizing minimally invasive procedures. This means we use a 2 to 3 inch incision to replace aortic valve.
We analyzed over 2500 who had minimally invasive operations and found their need for blood transfusion with surgery was lower and that they appear to recover quicker. We find that patients with mini invasive valve procedures go back to work earlier and can start driving earlier after surgery. Similarly for mini invasive mitral valve procedures - particularly repairs - the risks are very low (0.2% of death) and patients recover quicker after surgery.
In addition - in elderly high risk patients with a risk of death greater than 10% of undergoing regular open heart surgery, we insert valves through the groin or a small incision on the chest wall with guide wires and catheters. This is still an experimental procedure and we are conducting a prospective randomized trial. Fortunately our results have been on the whole - good, although in the first national trial, that involved 3 centers, including us, the risk of death was 7 % and stroke 9%. We believe these new percutaneous transcatheter valve procedures will get better with time.
KarenJ: I have aortic stenosis and I am 67. Would I be a candidate for the aortic stent? What is you opinion of the new stent procedure.
Speaker_-_Dr__Lars_Svensson: The percutaneous aortic valve transcatheter stent is only for high risk patients because of the risk of the procedure which was 7% risk of death when we first started using it. At your age, the risk of death with an open mini invasive operation would be less than 1%. Hence, you would not be a candidate for the percutaneous valve.
davidsil: I have had an aortic valve replacement 11 years ago at the age of 42 due to a bicuspid valve issue. At the time, I choose to have a tissue valve replacement instead of a mechanical valve because I work construction and did not want to be on Coumadin for the rest of my life. How many times in a life can I have an aortic tissue valve replaced?
Speaker_-_Dr__Lars_Svensson: Biological valves can be replaced repeatedly and we have done that up to 7 times - however, typically every subsequent operation carries more risk. For a first time operation we will typically quote less than 1% risk of death and in our hands reoperation and insertion of a new aortic valve has carried a risk of death between 1.9% and 2.1 % over the last few years.
The other option that we are researching and developing is the possibility of putting a percutaneous transcatheter valve within a previously placed biological valve. This is still experimental and over the next 5 years may very well turn out to be a useful option in high risk patients.
dianekt: My 25 year-old daughter was told last week that she would need Aortic Valve Replacement surgery this summer. We live in Florida and you are in Cleveland. Her surgeon is sending her to Emory in Atlanta for a state of the art echo but I keep pushing The Cleveland Clinic. She is so young and will need several valve replacements in her lifetime so I want the best for her. How soon can you fly after surgery? I would think a 20 hour car trip would be horrible after having this surgery. She was born with a bicuspid aortic valve and has had no problems until they noticed the calcification starting. She is .8 cm; 35.4 mean; 58 peak. Her aorta has also started to have calcification.
Speaker_-_Dr__Lars_Svensson: Once a patient has had aortic or mitral valve surgery and they are discharged from hospital, they can fly on commercial pressurized jets. We have many patients who do this to return home.
mikeyl: i have aortic stenosis, moderate to severe, no symptoms opening 1.0 good ejection factor. are there any meds or treatments to slow down progression to hold off surgical intervention. Would you or Cleveland clinic be willing to treat patients with meds etc, non invasively, don't want surgery unless all else is exhausted.
Speaker_-_Dr__Lars_Svensson: There has been a lot of interest in trying to slow down aortic valve stenosis progression in the medical literature. The data is somewhat mixed and although there is a slight association with slow down progression with cholesterol type statins, this is not definitive. Furthermore, there have been some studies suggesting the use of statins may improve the durability of mitral or aortic valve biological replacement. We however looked at 2700 patients who had aortic valve replacement and found no improved durability. Nevertheless, there are so many benefits from statins that it is worthwhile discussing with your physician whether you should be on them.
junjulaug_2: How soon will aortic valves be implanted using tissues from stem cells?
Speaker_-_Dr__Lars_Svensson: There has been interest in whether aortic valves can be improved by the use of stem cells or for that matter, valves made in animals with live tissue cells for implantation. At this stage there appears to be no major benefit but the research continues. Indeed the use of stem cells for weakened heart muscle has up until now only shown a 3 - 4% increase in muscle strength.
christographer: I have had aortic valve replacement 2 years ago, i contracted strep viridans after hip surgery and may need re surgery of aortic valve. is this surgery common and how are the results typically? Is it a specialty at Clev Clinic?Also, how is the recovery from re surgery on aortic valve replacement compared to originally replacement surgery? I have had problems with afib but am taking beta pace which controls good. Is it likely that I will have worse problem with afib after re surgery?
Speaker_-_Dr__Lars_Svensson: As far as valve infections on previous aortic valve replacement, the risk is somewhat increased depending on whether the infection is active or not or if an abscess has formed. It sounds like your infection is controlled and presumably your valve is leaking. Typically we will insert a new human valve under these circumstances called a homograft or allograft.
Since you have atrial fibrillation, you may require also a concurrent modified MAZE procedure to treat your atrial fibrillation but that would be a decision made by your surgeon. Recovery and hospital stay is typically a day or two longer with a reoperation but most patients experience less pain with the second operation. Furthermore, we give our patients a self controlled trigger to inject themselves with pain medications after surgery so that patients are essentially pain free.
karamatt: My husband is 40 years old, 10 years ago he had his aortic valve replaced with a homograft (in Des Moines, Iowa). Today (3/2/09) we found out that it needs to be replaced ( Atlanta, GA). But in addition to that the surgeon has told us that there is calcification on the aorta. How does this further complicate the replacement surgery?
Speaker_-_Dr__Lars_Svensson: Previous homograft replacements will typically calcify over time. This does somewhat increase the risk of stroke with a reoperation and in about 1/2 of the patients, the old homograft has to be completely removed. If a surgeon is used to doing these reoperations, then it should not be too much of a problem. But it is more risky than the first operation.
sfawbush: What is the target EF after AV replacement with tissue valve for a 22 year old patients status post surgery 10 months ago, preop EF 40%.
Speaker_-_Dr__Lars_Svensson: The course of the EF after aortic valve replacement is dependent on the original pathology. Patients with AV stenosis will typically recover to normal over 6 months if the EF is more than 25%. In patients with aortic valve regurgitation (leaking valve) if the EF is less than 35%, it may not recover.
chag: What type of aortic valve would be used for replacement of prosthetic aortic valve for re surgery?
Speaker_-_Dr__Lars_Svensson: At reoperation if it is not for an infected valve, the choice of the new valve will depend on your age and whether you have any other mechanical valve replacements. If you do not have another mechanical valve, or if you are over the age of 65, a biological valve may be a reasonable option. As long as you understand that there is a risk of a further reoperation.
chag: Dr Svensson, I submitted questions yesterday regarding blood infection a got after hip surgery last spring. I had aortic valve replacement jan, 07, and left atrial append augmentation. Subsequent tee's show leakage and probably will have to undergo re surgery for aortic valve. scares the hell out of me but I know you are the best. I'm 58 and am able to use treadmill for 30-35 every other day and do okay. I do experience some light headedness but could be due to beta pace I take for afib. Is re surgery common for this problem?
Speaker_-_Dr__Lars_Svensson: I am not entirely clear about your question, but if it is about the risk of a previous aortic valve replacement getting infected, then depending on which study one looks at - the annual risk is from 0.3 to 1 % per year. In 50% of patients who have infected valve, this can be successfully treated with antibiotics. However, if there is any evidence of the valve coming loose, abscess formation or bacterial vegetation formation on the valve more than a few mm in size then immediate surgery is recommended. In patients who have an operation for an infected aortic valve the risk of recurrence of the infection is about 5%.
Shibly: My daughter age 16 has severe aortitis due to an inflamed aortic root which is produced a valve opening 6 on January 7 and is now down to 4. She has also developed a coronary blockage on her LMCA. The Surgeons in Edmonton Canada are preparing to operate and as soon as her medications can be brought down. They are planning on root and valve replacement and coronary correction. Do you have any expertise here to share with us in determining the best options and asking all pertinent questions. My concern is that that the reason of the inflammation is still unknown. She has never had any symptoms related to Marfans, Takayasu or Beschets except this severe Aortitis. Do you have any thoughts in this matter.
Speaker_-_Dr__Lars_Svensson: Aortitis is a rare condition and usually when we see it patients fall into two broad categories - in young patients particularly females, it is often Takayasu Disease. In these patients, we suppress the inflammation with steroids and then operate on patients. In older patients, the aortitis is usually related to Giant Cell Arteritis and these patients often have a history of arthritis or temporal arteritis. There is often also a history of fevers of unknown origin. When one's aortitis burns out, patients are typically left with aneurysms and varying degrees of scar tissue in the aorta. Branch arteries coming off the aorta will often get narrowed and require bypass surgery.
Radiation Heart Disease
benlomondeast: I'm a 54 year old, 27 year survivor of Hodgkin's treated with total nodal XRT. My bulky mediastinal mass was treated with a tumor dose of 4600 cGy, the first 1000 cGy delivered in 200 cGy daily fractions without cardiac shielding. The remainder of the tumor treatment was delivered in 170 cGy daily fractions. My elder brother (also a Hodgkin's XRT survivor) died of V-fib two years ago, one month following surgical repair of his aortic root, aortic valve, ascending aorta, and tightening of his mitral. The surgeons description of what he found was far more dramatic than previous testing would indicate he might. A recent stress echo revealed my having aortic sclerosis and moderate mitral annular calcification with leaflet thickening and slight regurgitation. Should these signs be considered more ominous given my treatment history, and my brothers outcome? Also, is there any method of testing that is superior at defining extent of radiation induced valvular damage vs. disease incident to aging?
Speaker_-_Dr__Lars_Svensson: Patients with radiation heart disease typically after treatment for Hodgkins lymphoma or extensive radiation after breast cancer are at increased risk of surgery. In our analysis of patients operated between 2001 - 2007, at the Cleveland Clinic for isolated primary aortic valve replacement and less than 70 years of age - the risk of death was .25%. However, in patients with radiation heart disease, the risk is considerably higher. For that reason, patients with radiation heart disease we will often include in the percutaneous transcatheter aortic valve insertion study. See earlier discussion.
Cleveland_Clinic_Host: Thank you Dr. Svensson for being with us and staying and answering so many questions.
Speaker_-_Dr__Lars_Svensson: Thank you for having me.
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