Wednesday, September 12th, 2018 | Noon
At Cleveland Clinic’s Aorta Center, our mission is to bring together a knowledgeable and experienced multidisciplinary team of cardiology and vascular doctors and surgeons and other experts to provide a thorough evaluation of patients using state-of-the art diagnostic testing, ongoing comprehensive care of patients with disease of the aorta, connective tissue disorder and Marfan Syndrome, genetic screening for families of patients with genetic disorders, and ongoing research and education to provide patients with high quality and innovative therapies. Vascular Surgeon F. Ezequiel Parodi, MD and cardiac surgeon Eric Roselli, MD answer your questions.
- View more information on aorta disease or learn more about our Aorta Center.
- If you need more information, contact us or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
- View previous chat transcripts.
Abdominal Aorta Aneurysm
ceylonteas: My CT Scan showed ectasia of the abdominal aorta measures 3.5cm in size. Is this something thing that I should worry about right now and can that be reduced or any treatment that could be taken to either control or reduce the size? My cholesterol is under control and BP on the border line varying from 124/83 to sometimes going up as much as 153/90 and on medication now.
Ezequiel Parodi, MD: This is a small aneurysm. The important thing with anyone with an aneurysm is to image the whole aorta and make sure we do not have any aneurysms in whole aorta. If this is the case, we recommend follow up every 12 months with a vascular surgeon. This can be done with a vascular ultrasound. We also like to check popliteal arteries since they have a 10% chance of having aneurysms in those. Risk factor modification is important - smoking cessation, blood pressure control
marilynk: My recent CT scan showed ectasia of the abdominal aorta measures 4.0 cm in size. Is there anything at this time I could do to reduce the size?
Ezequiel Parodi, MD: Same recommendations as before - This is not considered a large aneurysm but requires surveillance as described before.
Sammy: What is the size that an abdominal aorta should be operated on? I have heard differing reports
Ezequiel Parodi, MD: Abdominal aortic aneurysms are repaired at 5.0 cm in females and 5.5 cm in males in patients who are at good risk for surgery.
paz: is it possible to have AAA and not have any thinning or weaknesses in the aorta walls?
Ezequiel Parodi, MD: No - once you have an aneurysm the wall of the aorta is diseased and we know over time the aorta tends to grow and needs surveillance.
Thoracic Aortic Aneurysm
Stefan: I have an ascending aortic aneurysm for past 20 years--I am age 75 good health overall.... exercise regularly.... Weight is not obese---6 ft. 1 inch weight 215 lbs. Size is 5 centimeters been 5 centimeters for 15 years. Do you recommend I have a repair done--if so, what types of repair are available? I live in Sarasota Fl.
Eric Roselli, MD: Difficult to say without knowing you personally and reviewing your images - however, the fact that it has been stable for so long suggests that the current plan of watchful waiting is a reasonable one. I would add that it is important to know how they are measuring your aorta. If it has only been followed by echo it may be underestimating the size. It needs to be followed by CT scan or MRI.
annam64: Does a 40mm mild ectasia of ascending aorta with mild tricuspid valve regurgitation need follow up sooner than one year? If so, best testing method? I’m on Synthroid (hypothyroid) and Spironolactone (hypertension and hyperaldosteronism), and have recently been diagnosed with primary and secondary lymphedema. Lymphoscintigraphy last year showed central blockage, then lymphangiogram said slowed/abnormal flow. The ectasia was found on echocardiogram and CR, following cardiac stress test where my systolic BP dropped. Left heart catheterization showed no stenosis or blockage. Imdur was prescribed but is intolerable, causing severe headache and vomiting.
Eric Roselli, MD: No - you do not need more follow up with 40mm mild ectasia of ascending aorta with mild tricuspid valve regurgitation.
Pghgirl: Is there a connection between a bicuspid aortic valve and an aortic aneurysm and are aneurysms familial?
Eric Roselli, MD: Close to 2% of the population is born with an incompletely formed aortic valve which we generally call a bicuspid valve because it looks like 2 cusps instead of three. In about 1/2 of the people who are born with a bicuspid aortic valve are prone to have an aneurysm of the first part of their aorta - root or ascending or first part of arch or a combination of these segments. The aortic valve and the first part of the aorta are derived from similar cell lines embryologically. Amazingly our heart and our aorta is pretty much completely formed in the first trimester of our development.
Jlecmy: I was diagnosed with an ascending aorta aneurysm measuring 4.5 cm in October 2017 and 6 months later was still the same size and now I am to wait a year till they look at it again, maybe I am just being impatient but I would really like to know why and how I got it and what I need to do to keep it from rupturing .I was told it could rupture at 5cm and I would only live 3 minutes and then just wait. Wait for what ?I am a 69 yr. old female -5’ 4” tall and weigh 145 lbs. and I would just like to have a second opinion, do you agree with the diagnosis?
Eric Roselli, MD: Yes – once your aorta has shown to be stable, I would also recommend follow up in a year – it probably took a long time for your aorta to get to 4.5 cm and will probably take a long time before it gets big enough to consider repair at 5 cm or greater.
DwTr5352: I am 89, no heart trouble or meds, good health. In thoracic MRI for spine, found had ascending aortic aneurysm 3.8 adjacent to aortic valve. Have been checked by cardiologist and specialty surgeon.
Eric Roselli, MD: 3.8 is not considered a large aneurysm – Regular follow up is recommended
DwTr5352: I am 89, good health, no heart problems or heart meds. On Thoracic MRI for spine, an aortic aneurysm was accidentally found, 3.8 size, adjacent to aortic valve. Have been checked by cardiologist and aneurysm surgeon. Both say do nothing, check each year. Do you advise coming to Cleveland Clinic for an evaluation? I would rather avoid surgery because of my age. Thank you.
Eric Roselli, MD: We would be happy to see you but are not worried about a 3.8 size aneurysm
Ammashelley17: Two years ago I was diagnosed with a 4.5 cm thoracic aortic aneurysm in the ascending aorta. They found it by accident doing a CAT scan for a pneumonia. They sent me to a surgeon who recommended we scanned every six months to follow the progress. Five scans later it is 4.8 cm. I have other heart issues, including bicuspid aortic valve. My mother had thoracic/bad. I am wondering why 5 cm is the magic number for repair considering my other health issues. It’s been very difficult to adjust to living with, I have to say it’s on my mind every day. And yet my new cardiologist is the one who said considering we’re learning about the bicuspid which we should’ve already known about, none of my other doctors has pursued that before. He said we should probably push up the timeline and I will know the 25th. I’m just wondering I think I was not getting the best medical advice and I have changed cardiologist and will be changing surgeons. Is five always the magic number is my question?
Eric Roselli, MD: 5 is not a magic number it is only a guideline. We wish we could measure something else like a bio marker on a blood test to help guide us in the decision making and we are working on that but for now we have to use the size of your aorta as the guide. We have recent data from the CC demonstrating that the max aortic area as measured by CT scan divided by your height in cm may be a better guide to help us decide when to operate. .Specifically when that ratio is greater than 10 given your family history it may be reasonable to operate if it can be done very safely.
Mariaf: About 10 years ago a hole was found between the two chambers of heart. It was too early...or nothing to do about it?! In 2015 an upper aortic aneurysm of 4.2 was found. When doing MRI and Cat Scans it has varied in size: 4.2, 4.4, 4.3 and this years' echocardiogram 4.0 with no ischemia. Why is it varying? Different readings? Which tests and with what frequency should I do them?? I just got a regular cardiologist in a small clinic/hospital and would like to be seen in Cleveland...I imagine there is a long wait?!
Eric Roselli, MD: With any of these tests – there is a margin of error of 0.2 cm. We would be happy to see you in Cleveland.
jeremiah3891: Hello Drs. Parodi and Roselli, Thank you in advance for your professional feedback:
1) Generally, at this current moment, what is the best surgical option for a person with BAVD (mild to moderate regurgitation) and Thoracic Aortic Dilation of 4.5 at the Aortic Root as per a recent MRA (echo shows no change year over year and has value closer to 4.0)? Otherwise, no other serious cardiac or other health issues.
2) Given info in 1), would flying domestically or internationally be a risk factor?
3) Would moderate cardio exercise, pushups, sit ups, pull ups, stretching and general resistance training using body weight be problematic or accelerate progression of BAVD or Aortic dilation?
Thank you, Jeremy
Eric Roselli, MD: Standard recommendation is watchful waiting with annual imaging. Most of the aerobic activities you described are okay but I would limit lifting to less than 1/2 your body weight so push-ups and sit-ups are okay but pull-ups not so great. Flying in a pressurized cabin is safe for your aorta and valve.
Coldmiller: I am a 47 year old male, height 5’10” and weight 240. Had a CT scan with contrast done in November of last year and below are the results:
Coronary arterial atherosclerosis calcification is visualized (calcium scoring test score of 204)
Aortic root at the level of the aortic valve is borderline enlarged with a diameter of 4.3cm. Remaining thoracic aorta is normal.
Ascending is 3.5cm
Aortic arch is 3.0cm
Descending is 2.7cm
So, how bad is this and how much should I worry! Been trying to read up on it and am just getting confused by it all! Cardiologist that I had seen told me to not lift anything .....Absolutely nothing not even a gallon of milk!!! Now, I am just paranoid about this whole situation thinking that some small thing I lift or do is going to take me out. Should I get on ARBs?
Eric Roselli, MD: I would recommend you see an aorta specialist to discuss this further. A root of 4.3 cm is big enough to warrant follow up imaging but nowhere close to needing an operation At 5'10" 240 lbs I want you to be active and lose some weight. It is probably fine for you to lift up to 50-60 lbs and not worry too much about it.
nickninggao: I am a 44 man who was recently diagnosed with an aortic root aneurysm as an incidental finding on a CTA. The size was 4.9/5.0 cm as stated on the radiology report, although a cardiologist who read the images measured 4.7 cm. My aorta is otherwise normal with tricuspid valve an no other symptoms. My father in his mid-70s had a recent type b aortic dissection and a few years ago he had an abdominal aneurysm that was stented. We are not aware of any other family members who have aortic disease, although my grandfather did die of sudden cardiac arrest in his mid-70s.
Would you typically advise watchful monitoring or intervene surgically in this type of a scenario? In advising client a client to do just wait and watch, do you have stats on what percentage in the 4.5-5.0 cm ascending aortic aneurysm range actually progressed to a complication of rupture or dissection?
Eric Roselli, MD: It is not uncommon for there to be some deviation in measurement at aortic root level because the root is not a natural cylinder shape and there is a lot of motion in that area. So it is difficult to image and difficult to measure. With your father's history and root involvement of your aneurysm, I would recommend you be seen by a clinical geneticist and unless you have some of the more aggressive forms of genetic conditions, watchful waiting is reasonable. We have some data that suggests for patients between 4.5 and 5 cm there is a 65% chance of an event within a 10 year period of time.
nickninggao: Is an aortic root aneurysm in of itself dangerous if the other parts of the ascending and descending aorta are normal, and tricuspid and asymptotic? Is it because of the fear that a rupture or dissection of the root could cause more extensive tearing of the other parts of the aorta?
Eric Roselli, MD: Yes - we worry more about patients whose aneurysm involves the root because this pattern of aneurysm tends to be more often associated with some genetically triggered cause and may be at risk for dissection at a smaller size.
davidlyon89: I would also like to ask could my ascending aortic root of 3.8 cm- 4.1 cm be causing me to have any symptoms. I have been having tingling pain around my left shoulder blade with pressure in the middle of my upper back, light headed for the last 2.5 months. Pressure at sternum. All of my cardiac work up has come back normal. Also, my ascending root by echo was at 3.8cm 12 years ago and now is 3.8cm CT -4.2 echo. In that 12 years I did cross fit for several years then weight training and high intensity interval training, sprints. I never really maxed out but my sets would go to failure around the 10-12th rep. working out is my passion and therapy. I am also a physical therapist in the home health setting and I lift heavy patients sometimes. Now that I’m 34 and have read more on aortic aneurysms I have quit working out and afraid to even sneeze. My cardiologist suggest only cardio for exercise. I am actually getting depressed about this and my wife thinks the symptoms are anxiety related
Eric Roselli, MD: Keep working out. You should not have symptoms from your aorta at 3.8 cm, which could be considered to be at upper limits of normal.
abeleenFL: I have Marfan syndrome over the years I have had scans on my aorta close to the heart - but never anywhere else. Last week my new doc did a CT and found that my abdominal aorta has an aneurysm of 6.0. 1. I am now seeing a vascular surgeon next week. 2. What should be part of a regular scan for marfan?
Ezequiel Parodi, MD: We need to make sure you have CT of abdomen and pelvis. That is a large aneurysm, especially in an aneurysm patient that needs to be repaired soon. CT scan is important. Other scans include 2D echos looking at ascending aorta in most of these patients and followed by a cardiologist.
kbaughma: How often should patients with Marfan be checked for additional aneurysms after having the ascending aorta repaired? Are CT scans best or can that be done with ultrasounds?
Eric Roselli, MD: annually. Yes - CT scans are best. MRI is also very good. Ultrasounds are only good for a few segments of the vascular tree.
kbaughma: I had 2 dissections repaired in the ascending aorta in 2006 (and valve replacement). What are my chances of having more dissections in other sections of my aorta? The geneticist could not rule in or rule out Marfan's disease, but thought it was some kind of connective tissue disease.
Ezequiel Parodi, MD: This would be higher than the normal population. Like patients with Marfan, you should have continuing surveillance.
JoseM: If I want my mom to come to Cleveland Clinic for an appointment for an aorta aneurysm - AAA second opinion - can she have tests locally and bring scans or is it better to have testing done at CC?
Ezequiel Parodi, MD: I would recommend bringing all images including CDs. This can be reviewed and if adequate we will not get new images. If we have concerns that they do not include the chest, abdomen and pelvis or they are not good quality, we will re-image while they are here in clinic.
Exercise – Activity
LarryfromLV: I have been an active person my whole life. Basketball in college, tennis, golf, running after college until April when I had my AAA operated on. Since that time I cannot get any clear cut information about how to exercise - what i can and cannot do. I am feeling very depressed as my doctor is reluctant to let me get back to exercise. Help give me guidelines.
Ezequiel Parodi, MD: Depression is very common after such a big surgery. What is very important is to begin being active again and exercising. You need to be patient because it is a long recovery and can take 6 months after an open repair. At 4 months if everything has repaired well you should not have any restrictions. We would recommend you see your surgeon to make sure he/she does not have any specific restrictions for you.
EJER: How often can I safely have CT scans? I am concerned about radiation.
Ezequiel Parodi, MD: Of course we want to minimize the radiation exposure with imaging - but this is the best way to follow aneurysms and repair them electively. Depending on size and location of aneurysms, generally follow up is 6 months to a year. Small aneurysms of the abdominal aorta can be followed with ultrasounds as well.
EJER: Is it generally safe to lift 20-pound weights six months after aortic aneurysm repair surgery (assuming that there were no complications)?
Ezequiel Parodi, MD: Yes - definitely.
paz: with AAA, are there any particular exercises we should avoid, such as core exercises? Or any that you'd recommend that may be helpful?
Ezequiel Parodi, MD: The goal would be to avoid heavy weight lifting and to avoid exercise that peaks your heart rate and blood pressure. We recommend biking, walking, swimming, aerobic exercise.
Pthibault; Is there a max HR while exercising for a 68YO male w/ thoracic AAA of 4.4?
Eric Roselli, MD: Difficult to say with certainty – without knowing how your heart rate affects your blood pressure. Probably between 120-140 bpm
Bijon: I dissected my aorta in January 2017 and had surgery to repair a Debakey1. I now am told that I currently have a residual Debakey 3b.Any physical activities I should avoid? Any specific symptoms that I should be alarmed about re further dissection
Eric Roselli, MD: The first thing is you are being followed regularly by an aortic specialist, including cross sectional imaging, ie. CT or MRI. Secondly, it is important to keep blood pressure (BP) well controlled. One of the aspects of good BP control is to avoid heavy lifting. Typically that means you should not lift more than 1/2 your body weight and some people would restrict you further depending on what your aorta looks like. When you lift heavy things your BP can go very high.
fotojake: My 83-yr-old mother had a recent aortic dissection and successful surgery. Her heart doctor recommended I get an echocardiogram. The results of it show an aortic root with a dilation of 4.1 cm. I'm a 59-yr-old male, 6'4" and 165 lbs. At one point it was thought that I may have Marfan's, but never confirmed and doesn't run in my family; that was 23 years ago and an echo back then showed my aortic wall to be "upper limits of normal." I wish I still had that echo in my med files from back then, but I do not. My concern is my lifestyle: I ride a mountain bike, run regularly and watch my diet. Should I back off on the exercise? I was told to come back in one year for another echo. Thank-you.
Eric Roselli, MD: 4.1 is not that big but a repeat echo in a year makes sense. It may make sense to get a CT scan or MRI to look at more of your aorta - in the meantime an active lifestyle consisting of aerobic activity is not contraindicated.
nickninggao: With an aortic root aneurysm around 4.7-5.0cm would you recommend playing competitive full court pickup basketball? Or should that be restricted?
Eric Roselli, MD: You need to ask your doctor who knows your precise details of your medical condition but I don't think an aortic root of 4.7 cm should be a reason to stop playing basketball. Having said that, we don't have any very good data to drive recommendations about acceptable activity levels. Most of these recommendations are made on theoretical concerns.
Abdominal Aorta Surgery
honeybee: AAA-6.4cm and also 6.0 in the ascending - How is that managed at Cleveland Clinic? Who should I contact? Is that major surgery with an incision down the whole chest/belly? Does one surgeon do it all? How do I start?
Ezequiel Parodi, MD: Both aneurysms meet criteria for repair. This patient should meet both CT surgery and vascular surgery for evaluation. It will be two different surgeries. The one done by cardiothoracic surgery is done in the chest by a CT surgeon. The one by vascular surgery can be done open with an incision in the abdomen or endovascular depending on the anatomy. Contact us online through a web appointment contact or call our phone line to get started.
Thoracic Aorta Surgery
mariaf: Confirming: An upper aortic aneurysm needs to be repaired through open chest surgery, correct?
Ezequiel Parodi, MD: If it is ascending and on the arch - yes - if descending after the arch we have options such as stent grafts.
paz: are endo repairs like a stent? What is the "stent" material and how is it attached to and seal off the interior aorta wall? Same for the open repair, is it like a sheath? What is material? How attached?
Eric Roselli, MD: Endovascular repair of the aorta is performed with a stent graft. There are both components to the device- graft material (Fabric often made of polyester or Gore-Tex) and the stent which is a metal spring like structure that holds the graft in place made from stainless steel or more often a nickel titanium alloy. The stent is a way of holding the graft in place when it is delivered from a remote location when suturing the graft is not possible.
Marfanista: Are beta blockers or ACE inhibitors commonly prescribed after aortic root and ascending. Aorta replacement with graft? Why? What types of risks are there if you take no meds such as these after surgery?
Eric Roselli, MD: beta blocker are typically prescribed after most cardio aortic operations and good blood pressure and afterload reduction is important for people with aortic disease - so it is not uncommon to see thing.
tigerpaw: my dad had AA surgery and had a graft placed - now graft migrated and has endoleak - can that be repaired with an endovascular procedure too?
Ezequiel Parodi, MD: Every time that everyone has a failed endograft with a proximal endoleak - there are two ways to repair - with open surgery and explant of the graft but there are also endovascular options for people who are at high risk. There are certain stent grafts (some commercially available and some part of clinical trials) that could be used in this instance. We would need to review images to see what would be the best approach for your father.
paz: for AAA, what is your criteria for endo versus open repair?
Ezequiel Parodi, MD: This decision is based on age, overall health and anatomy.
paz: for AAA, what are advantages/disadvantages of endo versus open repair?
Ezequiel Parodi, MD: Advantage of open repair is durability. Disadvantage is longer recovery. May not be an option for all patients if they have multiple co-morbidities. Advantage of endovascular is quick recovery, shorter length of stay. Disadvantage requires yearly surveillance with CT scan or Ultrasound and possibility of device failure over time.
sunnyday: If I have had a David procedure in the past - and now I have an aortic aneurysm that is being watched at the curve - can this be done without surgery? With the stent procedure?
Ezequiel Parodi, MD: If you are asking after the arch - there are some devices in clinical trials that could potentially fix this but they have very strict anatomic criteria - you would need to be evaluated.
Aud: I have aortic stenosis. I receive an echocardiogram every six months. In May 2017 my echo showed my aorta was narrowed enough that I was scheduled to undergo an angiogram. It was determined, although severely narrowed, it was not time for OHS. It's been over a year with no change. What size does the aortic valve need to be narrowed to, to receive the go ahead for OHS?
Eric Roselli, MD: The decision to proceed with aortic valve surgery is based on many factors. But one of the most consistent requirements is that the valve is severely stenotic. Other determinants include associated symptoms, changes in the shape or function of the heart. Your cardiologist would be best to determine this. We would be happy to see you here.
PistolPete: I had a bicuspid Aortic Valve replaced in Y2011 age 69 with a tissue valve. If I stay healthy a replacement is in my future. What is the success rate of a second tissue valve for a healthy patient and is there an age factor? I am not fond of the TAVR choice.
Eric Roselli, MD: if you undergo re-replacement at a high volume experienced center and you remain healthy, the risk of reoperation is exceptionally low - there is no age limit.
rwatson4850: Hello, I have severe aortic stenosis as well as liver cirrhosis and slated for a TAVR procedure in October. The plan is to place the catheter through my upper left chest. Dye through my right arm and a filter through the groin. The valve itself will be metal but with an organic pig part used as the valve. I have ascites due to liver disease and the artery is deep in my groin so some reluctance to place the valve through there. Of course this does not disclose info from the angiogram and echocardiograms I did but does this sound like a good approach so far? Thanks.
Eric Roselli, MD: Your situation sounds familiar – the combination of both problems increases your risk for conventional repair. It is great that we now have TAVR available for these situations. Delivering the device from an alternate access approach is very common and can be done just as safe as from the groin
Cutty1938: I've had aorta valve replacement with a bovine valve in January 2018. At times I can feel and hear my heartbeat. How common is this and will it eventually go away? I made a miraculous recovery and back to doing normal activities.
Eric Roselli, MD: Yes this is very common. Usually becomes less apparent with time
bow@newstart: Does a valve replacement for me with a moderate aortic stenosis become a possible remedy for better quality of life?
Eric Roselli, MD: If you have moderate stenosis it is unlikely you are having symptoms from it.
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