Tuesday, July 12, 2016 | Noon
The aorta is the largest artery in the body and is the blood vessel that carries oxygen-rich blood away from the heart to all parts of the body. An aortic aneurysm is an abnormal enlargement or bulging of the wall of the aorta. Dr. Vidyasagar Kalahasti, Director of the Marfan Clinic answers your questions about aortic aneurysm and Marfan syndrome.
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Diagnostic Testing and Follow Up
e727147: I have aneurysms that are in watching state. Is the new GE Revolution scanner something I should seek out for better pictures?
Vidyasagar_Kalahasti,_MD: All of the currently available CT scanners have excellent resolution and do not believe that you need to have additional scanning with the GE Revolution scanner.
tahuff01: I was diagnosed with hereditary hemorrhagic telangiectasia in 2004. At the time, the doctor suspected Marfan’s because I am tall and skinny. The doctor performed wingspan/height measurements and hand exams (not positive for Marfan). No family history of Marfan’s. In addition, an echocardiogram did not show a large aortic root. The doctor ruled out Marfan’s. This month, I had a MRA to rule out BAV. The MRA found a normal operating tricuspid valve, but noted: aortic root at level of sinuses of Valsalva of 3.6cm, sinotubular junction of 3.1 cm, ascending aorta of 2.8 cm, proximal aortic arch of 2.5 cm, distal aortic arch of 2.5 cm, proximal descending thoracic aorta of 2.2 cm, and descending thoracic aorta at the level of the diaphragm hiatus of 1.87 cm. I am a 43 year-old-male, ~6’3” and ~166 pounds (BSA=2.0). Given the aortic root size, should I now be concerned with Marfan’s? Would a genetic test be helpful for diagnosis? Thanks!
Vidyasagar_Kalahasti,_MD: Thanks for the question and based on the clinical information provided, I do not believe that you have Marfan syndrome, but will be happy to see you in our clinic for a second opinion along with a genetic assessment!
ralpallen: On 9/15, ultra sound found max diameter of infrarenal aorta at 3.1cm ap lesion extending at the level of mild ectasia both common iliac arteries at 1.2 max diam. lumen was 2.5 distal evidence of calcification in vessels no evidence of dissection, rupture, or fluid in images. Follow up on 6/16 showed distal aorta 3.3 ap lumen 2.5 distal all other specs too many to list; lol remained the same. I guess just keep doing ultra sounds every nine months, and should be fine if no changes occur? I am very active in gym and jogging no need to change lifestyle? A smoker for 55 yrs. quit six yrs. ago; and have had three inguinal hernias, one belly button hernia, one hiatal hernia and now one aorta aneurysm ??? That’s six basic aneurysms or weakening of muscles or vessels or arteries genetic weakness? Thanks for the explanation!
Vidyasagar_Kalahasti,_MD: Thanks for the question, and we will be happy to see you at Cleveland Clinic for further evaluation and discussion about treatment options.
hsmith: I have a family history of aortic aneurysms - should I be screened for this? How do you get screened and when is it recommended?
Vidyasagar_Kalahasti,_MD: We recommend screening with echocardiogram to assess for thoracic aneurysm and ultrasound of the abdominal aorta for abdominal aneurysm. Additional screening with MRI may be needed in specific patients. Depending on the specifics of your family history, screening recommendations can vary.
iriverman: I'm now 70 years old and just had my sixth CT scan, one every six months, to keep check on a 4.1cm ascending aortic aneurysm which has remained stable. I'm concerned about CT radiation. Is it reasonable to continue on a 6 month basis or should a MRI or Ultrasound be considered, and are these tests as good as the CT for my condition? Thank you!
Vidyasagar_Kalahasti,_MD: The frequency of CT scan/screening in your case seems too much, and I would recommend ultrasound (echocardiogram) follow-up annually, and if there is significant change in size, then consider CT scan or MRI.
gm3: I had AAA open flank type surgery in 2013 and have been advised that 50% of the patients that have AAA surgery develop an aneurysm behind a knee. Currently, I have a Bakers Cyst behind the right knee, which I am able to manage with exercise. Should I have ultra sound behind screening for knee area on annual basis to check for aneurysm? Are there other evaluation methods, besides ultra sound, that are available to check on aneurysm in the knee area?
Vidyasagar_Kalahasti,_MD: Thanks for the question and ultrasound screening is appropriate to look for popliteal artery aneurysm (the artery behind the knee) and if completely normal, then you may not need annual screening and can be checked in 3-5 years. The other evaluation is with a CTA of the leg arteries.
freddie78: Hello! I have Marfan syndrome, and recently my ascending aorta was 3.7 cm when measured. I am already treated with a beta blocker. How often should my aorta be checked?
Vidyasagar_Kalahasti,_MD: Thanks for the question and current guidelines recommend annual screening with echocardiogram and/or cardiac MRI or CT scan. In general echocardiogram is preferred due to advantages of not having radiation or contrast administration. However, in selected patients, cardiac MRI or CT scan is needed for better assessment of the aorta.
mariearc2015: I have an aortic aneurysm 5.3 on CT scan and 5.0 on ultrasound - which test is more accurate. How often should they be done? Thank you.
Vidyasagar_Kalahasti,_MD: CT scan is more accurate with aortic dimensions and at your current size, recommend six months follow up. You may also consider elective surgery at a center like Cleveland Clinic.
Blood Pressure Management
marfank: What is should be the goal blood pressure for patients with Marfan's syndrome and an aortic aneurysm?
Vidyasagar_Kalahasti,_MD: In general we recommend blood pressure less than 120/80 mm Hg; and heart rate of less than 60-65 bpm.
AndrewB: I am a 48-year-old man without Marfan's and with aortic root dilatation of 4.4cm, 30 year history of HTN now poorly controlled at high 140s/80s. Not very physically active at the moment but heart rate generally low 60s (when more active, HR goes to 50s). On Lisinopril 10mg, metoprolol 12.5mg, atorvastatin 10mg. I am concerned about possible weight gain (or difficulty with weight loss) on metoprolol and that even at this low dose I am feeling fatigued and slowed. I had heard that carvedilol might have fewer metabolic effects, wondering about your thoughts on choice of beta blocker.
Vidyasagar_Kalahasti,_MD: Fatigue is a common side effect described with all beta blockers including metoprolol and carvedilol. In general in patients with aortic dilation, cardio-selective beta blockers such as metoprolol and atenolol are preferred. You are currently on a very small dose and with slow increase in exercise you should be able to lose weight.
robbockscc: Related to AndrewB's question about weight gain and metoprolol... Does metoprolol slow metabolism? If so, how does it compare to atenolol?
Vidyasagar_Kalahasti,_MD: Metoprolol slows your heart rate and so some people have fatigue symptoms. Patients can have different responses to metoprolol or atenolol and sometimes switching from one to the other may help the side effects.
Marfanese: I have low blood pressure and was given lopressor to reduce pressure in chest wall. When is high blood pressure med prescribed versus Losartan or beta blocker?
Vidyasagar_Kalahasti,_MD: In patients with very low resting heart rate, losartan is preferred as it does not decrease your heart rate but does decrease your blood pressure. Additionally losartan has been studied specifically in patients with Marfan Syndrome.
AndrewB: A follow up to my question about metoprolol vs carvedilol. You said that cardio selective beta blockers (such as metoprolol) are generally recommended. Is that because they produce better outcomes for those with aortic aneurysm? Is carvedilol not a good option -- could it cause adverse effects (i.e., worsening of aneurysm)? Carvedilol was suggested as an option by my cardiologist. I had hoped it might lessen my concern about weight gain and might even provide better blood pressure control.
Vidyasagar_Kalahasti,_MD: Carvedilol may be used as an option if all the other options (atenolol and metoprolol) have non-tolerated side effects.
sheila1234: My brother passed away several years ago from sarcoidosis. What's the difference between that and Marfan's syndrome?
Vidyasagar_Kalahasti,_MD: Sarcoidosis is an autoimmune disease and Marfan's Syndrome is a genetic disease. Both of these diseases have quite varied manifestations.
Library_Lady: Can a person with Marfan Syndrome have overall few symptoms in other systems but have more aortic related symptoms?
Vidyasagar_Kalahasti,_MD: Marfan Syndrome can affect bones, including spine, hips and can have chronic pain. There are reports of lung involvement also in Marfan patients. Aortic dissection is the most serious complication with potential morbidity and mortality.
Library_Lady: How quickly can the aorta dilate? I've heard that a significant increase in size can take place in even a few months.
Vidyasagar_Kalahasti,_MD: It depends on the underlying disease that causes the aortic dilation. Patients with genetic aortic syndromes and previous dissection can have rapid growth of aorta and need frequent monitoring.
robbockscc: Are there any recommended dietary considerations for teenage Marfan patients?
Vidyasagar_Kalahasti,_MD: No specific dietary recommendations have been described at this time by the National Marfan Foundation apart from general recommendations for healthy eating.
luckyglen: I have been diagnosed with Marfan five years ago after an aortic dissection. I had an aortic aneurysm three years later in which the first graft was infected and had to be replaced. Now with a TEE, I have "severe aortic regurgitation" of 65% and the replaced aortic valve has failed. Should there be any restrictions on me? I am a 67-year-old woman.
Vidyasagar_Kalahasti,_MD: We would recommend evaluation at Cleveland Clinic to discuss further treatment of severe aortic regurgitation such as elective surgery with excellent outcomes. We would still recommend to continue daily symptom-limited exercise and follow up.
kathyl: If my dad has Marfans, what is my chance of getting Marfans? I am wondering what type of testing I should have. I am married and also thinking of starting a family in a couple years. What is the chance that my kids can have this also? My dad did not find out he had it until he was 30. Is that common?
Vidyasagar_Kalahasti,_MD: There is a 50% chance of children being affected with Marfans if one of the parents is diagnosed with Marfans. It is not uncommon that the diagnosis is delayed until age 30 like in your father. We recommend further evaluation including genetic counseling at a center like ours.
robbockscc: In a 16-year-old Marfan patient with aortic dilation and mild valve regurgitation, is it reasonable to pursue a valve-sparing aortic root replacement?
Vidyasagar_Kalahasti,_MD: If there is no significant aortic regurgitation, the valve sparing aortic root replacement is preferred to avoid the risks of having a prosthetic valve. Cleveland Clinic has excellent outcomes with valve sparing heart surgery.
Aortic Valve Disease
lookingforinfo: A 13-year-old has been diagnosed with trivial aortic regurgitation. The heart is structurally normal. Aortic valve is normal. No murmur, no syndrome, no disease, nothing abnormal is present. The child has no restrictions and follow up is in two years. Can she outgrow this problem? Can this be her "normal" and nothing further will develop. From what I am finding, this is rare in children. There is no family history of heart disease or syndromes. This was found because the child complained of a feeling in her chest. EKG and echo ruled out that the feeling she was describing was not related to the aortic regurgitation. The aortic regurgitation was found only because an echo was done. Her heart is structurally normal. No bicuspid valve. She plays competitive sports and lifts weights. Her doctor thinks this may resolve spontaneously. Is that possible or can this be her physiologic make up.
Vidyasagar_Kalahasti,_MD: Thanks for the question and trivial aortic valve regurgitation can be seen on highly sensitive echocardiographic testing and may resolve spontaneously. We usually recommend follow-up evaluation with echocardiogram in 5-10 years or sooner if she notices any problems such as shortness of breath. There are no restrictions to any of her activities including competitive sports or lifting weights.
lookingforinfo: Follow to my earlier question about the 13-year-old with trivial AR. If the heart is structurally normal do you expect this to progress? Patient grew from 5'7" to 5'8" inches in a year. Patient is now 14 years old and entering high school. How common is this found in kids especially athletic kids who train and lift weights. Thank you. Is this physiology vs pathological? It shows in four different views on echo.
Vidyasagar_Kalahasti,_MD: It is possible that this trivial aortic regurgitation may not progress but I recommend follow up echocardiogram in three - five years.
lookingforinfo: In addition to my earlier question, what has to happen to make this trivial AR progress? Can it resolve with a normal heart structure? The heart is normally structured with no evidence of disease. What would cause this to happen?
Vidyasagar_Kalahasti,_MD: Trivial Aortic Regurgitation is not of clinical concern and may resolve with treatment of an aortic aneurysm.
Marfanese: What size aortic root aneurysm is too large to repair? Is 4.9 cm on the high end?
Vidyasagar_Kalahasti,_MD: At Cleveland Clinic, there is no aortic root aneurysm that is too large to repair. 4.9 cm is at the lower end of the disease spectrum.
chester32: I currently have a 4.5 cm aortic root aneurysm that narrows to approx. 3 cm at the brachiocephalic artery. I am being tested for Marfans, Ehlers Danlos, etc. I suffered an internal carotid artery dissection three years ago and there remains a "chronic dissection flap" although my arteries are patent. It is also believed I may have FMD due to the beading and tortuousity of my carotids/vetebrals and renal arteries. I also have a small aneurysm in one kidney and a 1.1 cm aneurysm of the superior mesenteric artery. Is it possible for me to undergo open heart surgery after having a carotid dissection? Or would I be considered high risk for stroke when put on the bypass machine due to the condition of my arteries in my brain? Is Marfan's associated with other type of aneurysms in other arterial beds other than the aorta? Thanks so much for your response and dedication to saving lives and committing your time to this forum.
Vidyasagar_Kalahasti,_MD: It is possible to have open heart surgery after having a carotid dissection. Your condition may also be due to possible Loeys Dietz Syndrome, and we will be happy to evaluate you at Cleveland Clinic along with consultation in genetics. Marfan is usually not associated with aneurysms in other arterial beds.
Library_Lady: Can problems with the aorta lead to fatigue?
Vidyasagar_Kalahasti,_MD: Usually not. In general, patients may have side effects of fatigue from medications such as beta blockers that are commonly used in patients with aortic aneurysm or dilation.
genodoc: What is the long term future of AI with small aneurysm of ascending aorta re: minimally invasive repair??
Vidyasagar_Kalahasti,_MD: We can do minimally invasive repair of ascending aortic aneurysms with excellent long-term outcomes.
kjg48: My 19-year-old son has a bicuspid aorta and an aortic aneurysm at the root. The valve continues to function quite well with minimal blockage and very little leak. During his last bi-annual visit to monitor his aneurysm and valve, it was determines to reduce his visit to once a year based on his height being unchanged over the last two years(6'3" @ 165 pounds), and his aortic growth being considered stable over the same time period, with a max diameter of approximately 4.6 cm. His cardiologist still restricts him from heavy lifting/straining or long distance running, he has been cleared for competitive recreational volleyball, no training. Does this seem to be a safe recommendation and what would you see as the next points of action?
Vidyasagar_Kalahasti,_MD: These recommendations seem appropriate based on his testing and stability of the aortic dimensions. It is possible he may have slow growth of the aortic root aneurysm requiring surgery. If he needs aortic root aneurysm surgery, we recommend coming to Cleveland Clinic due to our excellent surgical outcomes. In general, if the bicuspid valve is functioning normally we do not replace at the time of aortic root surgery. We have performed bicuspid aortic valve repair in select patients.
Library_Lady: How does caffeine affect, or not affect, aortic health?
Vidyasagar_Kalahasti,_MD: In some patients, caffeine may increase heart rate and blood pressure and indirectly affect aortic size.
JD0708: Do you ever wrap an ascending aortic aneurysm?
Vidyasagar_Kalahasti,_MD: Some of the surgeons in United Kingdom have performed wrap repair in patients with Marfan, and it is not being done in the US. In general, we replace the ascending aortic aneurysm with a graft.
gm3: I had AAA open surgery three years ago. Currently, I have a tooth that had root canal done 20 years ago and it has become infected. Re-treatment for tooth scheduled next week with Endodontics doctor. During the next seven days is there a possibility that the infected tooth area could pass on the infection to my aorta graft? I take four caps of Amoxicillin, (500 mg), an hour before every dental visit; however, I am concerned about graft infection during the seven days before I can secure the re-treatment program.
Vidyasagar_Kalahasti,_MD: The risk of infection is likely low with treatment at your current recommendation with amoxicillin. I would discuss with the dentist to see if you need to be on longer duration of antibiotics.
gm3: Thanks for answer to tooth infection issue related to aorta graft. Does the risk of infection to the graft via invasive procedures or body infections make it necessary to always have to take antibiotics to protect the aorta graft. Currently at the three year mark with no graft issues to date?
Vidyasagar_Kalahasti,_MD: Yes - you will need lifelong antibiotic prophylaxis prior to dental cleaning.
Exercise and Activity
runningheart: Can I still exercise if I have an aortic aneurysm? Should I be limiting my exercises or are there any that are specifically recommended? Thank you!
Vidyasagar_Kalahasti,_MD: Patients with aortic aneurysm can still exercise, but heart rate would need to be monitored and kept below 70-75% of the age predicted maximal heart rate. Depending on the size of the aneurysm, sometimes, we recommend lower heart rate target. In general, we recommend not to lift heavy weights in patients with aortic aneurysm. We give specific recommendations on an individual basis. In some cases we have used exercise stress test to determine heart rate and blood pressure targets.
rjmaki: Hello. I am a 56-year-old male with a mid-ascending aorta that was measured at 4.4 cm three weeks ago. I am a very active and specialize in time trial bike racing. I typically race/workout (40-60 minutes) with heart rate in the 150-160 bpm range for training and racing. I have been told to keep my HR in the 80% of max range by my cardiologist. Can I ride safely in the 80% range for 2-3 hour rides? Will I ever (after surgery to correct) be able to ride at these high HR levels (150-160 bpm)? What other activities should I avoid? XC skiing, downhill skiing, swimming, bowling, golf??? Thank you
Vidyasagar_Kalahasti,_MD: You would benefit from a consultation in our Sports Cardiology Center. They work with patients such as yourself who want to train safely with cardiovascular disease.
robbockscc: Aside from "standard" risks, are there are any Marfan-related concerns for a 16-year-old jumping/bouncing on a trampoline?
Vidyasagar_Kalahasti,_MD: If he does not have aortic disease or dilation, the risks should be low for jumping on the trampoline (unless he falls off).
robbockscc: Aside from "standard" risks like falling off or collision, are there are any concerns for a 16-year-old Marfan patient with an aortic dilation jumping/bouncing on a trampoline? Does playing on a trampoline put undue stress on the aorta?
Vidyasagar_Kalahasti,_MD: I am not aware of any specific concerns described in the literature about trampoline and stress on the aorta. If there is significant concern then it would be safe to avoid this activity.
robbockscc: In a 12-year-old Marfan patient, what would be a typical impact of moderate-to-severe pectus excavatum on exertion levels and endurance for activities like swimming, hiking, biking? Does pectus excavatum typically present any additional health risk for those types of moderate activities? Would increased endurance be a reasonable expected outcome from corrective surgery?
Vidyasagar_Kalahasti,_MD: This is a difficult question to answer. I recommend seeing a pediatric Marfan specialist, such as Dr. Ken Zahka at Cleveland Clinic to discuss your concerns about pectus, activity and the need for surgical correction.
ghostfive: I have a family history of death from aortic aneurysm due to Marfan syndrome. My aorta is currently about 4.0 cm. I have read that aortic aneurysm surgery is done with the aorta is at 5.0 cm. I am worried because my family members died before their aortas reached that size. Should I have my aortic surgery done before it reaches this size?
Vidyasagar_Kalahasti,_MD: Thanks for the question, and I can understand your concern to the family history of death from aortic aneurysm! The current guidelines recommend elective aortic surgery at 5.0 cm, and we will be happy to evaluate to determine if elective surgery is appropriate at smaller dimensions than 5.0 cm.
GregMS: My physician has been monitoring my ascending aortic ectasia the size of which has remained unchanged at 5.2 cm for the last six years. I have a CT done annually. Have there been studies done which would indicate the odds that the aneurysm will remain stable with this period of extended stability? I have asked two of my physicians if I should have it repaired now instead of waiting. (I am 73) The response has always been "no!" Your views?
Vidyasagar_Kalahasti,_MD: Based on the stability of growth, there is reason to not have surgery at this time. On the other hand, it would be worthwhile to be evaluated at a center such as Cleveland Clinic, who have excellent outcomes with elective surgery, to determine if you would benefit from surgery at this time. It depends on many factors not just the size alone.
davidecooke: I've been diagnosed with a thoracoabdominal aortic aneurism and have an operation booked to fix later this month. I'm 29 years old and have Marfan's Syndrome. My questions is: assuming a positive result from this operation, what can I expect as I grow older and how can I prepare for it?
Vidyasagar_Kalahasti,_MD: We wish you best with the surgery. Patients with Marfan's Syndrome need lifelong follow up even after repair. The entire aorta is vulnerable for dissection. Close follow up with treatment of blood pressure with medications such as beta blockers and losartan is the best strategy to prevent aortic complications.
goldman_w: As of this past May, I now have my entire aorta either replaced or covered with Dacron and I have had my aortic root and valve repaired. I recently had both iliac arteries done and I am having a lot of back pain since the surgery and I'm still worn out all the time. Like I said, I’m now six weeks post-surgery. Is this something I can hope will get better in the next few weeks or is this a symptom of having four AAA surgeries that is not going to get better.
Vidyasagar_Kalahasti,_MD: You are still early after your most recent surgery and expect that there should be improvement in your symptoms of back pain and fatigue. At six weeks, you should be having a follow up appointment with your doctor. It is important to discuss your symptoms with him and perhaps enroll in cardiac rehabilitation.
Marfanese: I am scheduled to have surgery with Dr. Svensson this year. I am very afraid of it. Are there any health psychologists at Cleveland that may be able to help me prepare mentally?
Vidyasagar_Kalahasti,_MD: Yes - we do have psychologists at Cleveland Clinic to help cope with surgery if requested. We have a lot of patient support for our patients both with guided imagery as well as support groups such as Mended Hearts. See Support Groups & Organizations. And see the heart surgery tab on this page to see step by step what you will expect as a patient here for heart surgery.
weistart: I have an aortic abdominal aneurysm that measures 5.3. It has remained fairly stable for the last year and a half. It is located both above and below the kidney arteries. As I understand, a special stent would need to be made to fit my profile. My question is what is the percent of loss of function from the kidney can I expect after placing a stent.
Vidyasagar_Kalahasti,_MD: We would recommend you see a vascular surgeon at Cleveland Clinic for discussion of all treatment options. View our treatment outcomes.
graceC: my father had emergency open repair of thoracic aorta his ascending aorta was replaced with graft and an endograph in thoracic aorta. In 5/19/2015, and 4/2016 he had another stent (2) put abdominal aorta for AAA. Now both stents are leaking. Thoracic one has type 1 leak with a 6.8 aneurysm nearby. Abdominal one has type 2 leak. Is this common? Or should i seek out 2nd opinion. Also, his other organs including the heart seem to be functioning well... what can be the cause of such severe dissection/aneurysm??
Vidyasagar_Kalahasti,_MD: We would recommend a second opinion for your father in the Department of Cardiovascular Surgery. We have expertise in the treatment of endoleak after endovascular stent. The cause of dissection/aneurysm in your father's case is difficult to answer without more detailed evaluation.
anaheimk: Is there any current research or developments on the treatment of Marfan Syndrome you know of?
Vidyasagar_Kalahasti,_MD: Current research is focused on additive therapy of losartan and beta blockers compared to either treatment alone to decrease aortic dilation. Multiple international clinical trials are ongoing and results are awaited.
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