Aorta Disease and Treatments (Drs. Eagleton & Roselli 3/5/12)
Monday, March 5, 2012 - Noon
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 aorta. Vascular surgeon, Dr. Eagleton and cardiac surgeon, Dr. Roselli answer questions about aorta disease.
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Causes of Aorta Disease
Julie7759: There is so much we don't know about aneurysms and aortic disease. What research is being done to determine cause above hypertension and genetic disorders?
Dr__Eagleton: There is a great deal of research that is currently ongoing with regards to why aneurysms form. Specifically, at the Cleveland Clinic, we have ongoing research that evaluates a variety of reasons that aneurysms form. In addition to genetics evaluation, we are also evaluating what molecular problems can exist in the destruction of the aortic wall, the repair of injury to the aortic wall, and abnormalities in the inflammatory response of the body to damage in the aortic wall. The aim of these research programs is to ultimately identify pharmacologic agents that could prevent aneurysms from degenerating, or to promote repair of the aortic wall reducing the risk of rupture.
cv123: Hello. Several people in my family have had or are currently diagnosed with aortic aneurysms/dissections. It seems that a common link between them is that they are/were all heavy smokers. Is smoking the main contributor to aneurysm development? I am not a smoker but my brother is and I'm wondering what my risks and his might be. Thank you.
Dr__Eagleton: There are several risks for the development of aortic aneurysms, and you have highlighted to two key known risk factors. The first is family history - we know that many cases of aneurismal disease run in families. We do not always know, however, the specific genetic defect in many of these cases. The second risk factor is smoking. In fact, as part of the entrance to Medicare screening exam, any male who has ever smoked more than 100 cigarettes in his lifetime, be screened for an abdominal aortic aneurysm with an ultrasound.
Screening, Diagnostic Testing and Follow-Up
vindependent11: Hello, I would like to know even if no one in your family has had an aortic dissection, can an individual still be tested for the disease? Thank you for your time.
Dr__Eagleton: There are indications for screening for aortic aneurysms but currently there are no indications for screening for aortic dissections, which is a different disease entity. Aortic dissections typically present as an emergency and is not something we would screen for. We certainly know that patients with certain underlying diseases such as Marfan Syndrome, or uncontrolled Hypertension are at increased risk for aortic dissections. Specific risk factors in the general population however, have not been readily identified.
margaretn: Brother 51 passed away with a ruptured aortic aneurysm, other brother 49 was diagnosed with the same condition and had surgery and is alive today. I currently do not have this disease and trying to get some answers. Have one main question on who should get genetic counseling/testing in our family. I have two children and one grand child. The brother that passed away has 3 children. It is highly unlikely we have Marfan's, however, the brother that passed away was over 6' and one of his daughters is 6'. The other brother is about 5'6" and I am 5'4". Thank you!
Dr__Eagleton: It certainly appears that you may have a familial predisposition for aortic aneurysm disease. I would recommend that you be evaluated by a genetic counselor. He/she would gather as much family history as possible, as well as personal clinical information, and determine what testing would be applicable to you and your family. There are, however, many familial cases of aneurysmal disease for which we do not have an identified genetic defect yet to test for yet. In addition, we would recommend that you be screened for an aortic aneurysm.
MrsBub24: I see a cardiologist...should I be seeing a vascular surgeon. My ascending aorta is just over 4.0
Dr__Eagleton: Ascending aortic aneurysms are typically repaired by cardiovascular or cardiothoracic surgeons. It is quite common, however, for cardiologists to follow these aneurysms and refer them to these surgeons when they are approaching a size that would warrant repair.
SusanK: I have a family history of Aortic Dissection. My DO has ordered an ultrasound of my aorta. Will this test be able to detect any aortic tears or aneurysms? Thank you.
Dr__Eagleton: An ultrasound is the recommended screening tool to evaluate patients for the presence of an aortic aneurysm. It will also be able to provide some information about whether an aneurysm, if present, is due to a dissection. If the ultrasound is abnormal, and depending on the size and its characteristics, another imaging tool may be used to better define the disease - such as an MRI or CT scan.
deli1999: Thanks for these clinics-- I have an Abdominal Aortic Aneurysm at 3.25 cm I was wondering is an ultrasound as good as a CT for determining the size. What Cm size will warrant an Op and what procedure is in store for me? I understand there are two types, please explain Thank You deli1999
Dr__Eagleton: An abdominal aortic aneurysm of 3.25 cm is considered a small aneurysm. The recommended screening tool for an aneurysm of this size is an ultrasound. While it does not provide as much detail as a CT scan, it also does not require the use of radiation or contrast dye. If your aneurysm increased in size, a CT scan would be recommended in order to help plan the type of repair that would be necessary. Aneurysm repair is typically recommended when an aneurysm reaches a size of 5 to 5.5 cm.
There are two types of repair that are currently available. Open surgical repair involves an incision in the abdomen and replacement of the aneurysm with a graft made out of prosthetic material. This is sutured to the healthy artery above and below the aneurysm. The second mode is termed "endovascular" repair. This involves repairing the aneurysm from the inside of the aorta using a graft, lined with stents, placed from an incision in the groin. The type of repair that is best is individualized for the patients - some will be better with open repair and some will be better with endovascular repair. Your surgeon will assist you in making that determination.
movshuk: I have BAV with combined AS and AR. At present, my aorta is not enlarged, with aortic size 3.2 cm in the latest echo exam. Using the Cleveland index of aortic area/height, my ratio is 4.8 (at height 1.82 m). But I am worried about the possibility of future enlargement of the aorta. Do you think that is it sufficient to check my aortic size by only annual echo exams (as I do now)? Would you recommend occasional MRI or CT scans to augment the echo exams?
Dr__Roselli: If you are a middle aged adult and you have had at least one CT or MR, that confirms that your aortic size is only 3.2 cm then it is unlikely for you to develop an aneurysm. However, it is important to understand that the most vulnerable portion of the ascending aorta (the mid portion) is often not seen well with echocardiography because of the interference from air within the trachea which lies directly behind that portion of the aorta.
speech53: Good afternoon - I have recently been diagnosed with a(n) dilation, dilitation (numerous descriptions) of 4.0 in my ascending aorta. I am 53, exercise, not overweight, etc. At this point still trying to find the right cardiologist and would like to know what criteria or experience I should "look for" in my search.
Dr__Roselli: Any board certified cardiologist should be able to provide you the proper guidance. What is important is that you establish a good relationship with him or her.
atta: Do all aortic aneurysm eventually require surgery? Should aneurysms with strong family history be monitored more frequently than every one year?
Dr__Roselli: No - not necessarily. After the initial diagnosis however, I will typically re-image patients at about 6 months until we can be reassured that the aorta diameter is relatively stable.
Bicuspid Aortic Valve and Aorta Disease
dukefan55: I am a 57yo female with a bicuspid aortic valve with moderate stenosis and an ascending aortic aneurysm of 4.4 cm,I also have mixed connective disease. Does this put me at a greater risk of dissection? Thanks for taking my question.
Dr__Roselli: Yes. By definition, people with a bicuspid aortic valve - BAV - probably have an as of yet incompletely understood connective tissue disorder that puts them at risk for aneurysm and dissection. We believe that people with a BAV and a large ascending aorta are at risk for complications (rupture or dissection) at a slightly smaller size than is typical for most degenerative aneurysms.
JAK: My 14 yr old son was thought to have marfans while at a visit for scoliosis. They did an echocardiogram and found he has a bicuspid aorta valve that has a trivial leak. the asc aorta diam is 3.0 cm. How often should he have an echo done? Should he not be playing football at all? He has been plying pick up football and basket ball w/ neighbor kids. Thank you for your help, Judy
Dr__Roselli: He should have an echo on an annual basis. He needs to be monitored very closely with regards to his blood pressure. He may participate as a 14 year old should in any activity as long as he is being monitored by a physician.
JLK: Also, based on my wife’s height (170cm) and aneurysm of 5.0x4.9 cm at the mid ascending aorta, how does your calculation work for deciding when is the time for my wife to have surgery? Is her ratio greater than 10 now? What time frame does she have before she has to have surgery?
Dr__Roselli: Based on your wife's height and a maximum aortic diameter of 5 cm, her calculated maximum aortic area to height ratio is 11.5. For patients with BAV, we recommend repair when the ratio is greater than 10, if the surgical risk is otherwise low.
Grace: My husband is 54 years old and has a bicuspid valve and aortic aneurysm. The size is 5.3. The valve has moderate leakage. Surgery is now recommended to fix the aneurysm and replace the valve. Could you provide me with the guidelines on when surgery should be performed on the aneurysm? I understand guidelines have just been reduced if the patient also has a bicuspid valve. Thank you. Grace
Dr__Roselli: I agree with the recommendations for surgery. When it is over 5 cm as an absolute measurement or if the max area to height ratio is greater than 10 in patients with BAV.
waleslar1: My thoracic aortic aneurysm is 4.9 at the root. My bicuspid aortic valve is leaking, but still working well. I'm 58 years old, and have no symptoms to speak of. I'm 5' 11" tall. I've heard that in the next few years surgeons will be able to replace the aortic valve using endovascular methods. Might I wait to have that done, and have the aneurysm operated on at a different time, and of course by means of open heart surgery?
Dr__Roselli: At 4.9 cm in a patient of your height, we would recommend undergoing surgical repair of your ascending aortic aneurysm. At 58 yo, with a well functioning bicuspid aortic valve, we would typically leave your aortic valve in place. If it is only leaking and not stenotic, then I would repair it. Percutaneous valve replacement is still relatively contraindicated in patients with BAV.
Growth of the Aorta Size
toeroe: re: ascending aortic aneurysm. I have an ascending aortic aneurysm that was diagnosed about 8 years ago. For years, it was stable at 4.3 cm. However, in July 2011 it was measured at 4.5 cm and last month measured between 4.6 and 4.7 cm. I've had a five-bypass CABG with two grafts failing in the first year plus six stents. No corrective surgery has been recommended thus far but I'm concerned re: growth of the aneurysm. What, in general, are the decision points that impact whether corrective surgery is performed (e.g. growth rate, overall size, aneurysm shape, etc). I have read many conflicting thoughts on this. Thank you!
Dr__Roselli: It is difficult to answer this without review of your CT scans. Often times variation in the measurements are due to variability in the measurement techniques. Regardless, the general recommendation is to repair an ascending aortic aneurysm when it is 5.5cm or greater - or - there is documented growth of greater than 5 mm in one year.
chuckarc: Hi My mom is 79 years old and was diagnosed with an ascending aortic aneurysm measured at 5.1cm. It has been stable since they found it over 1 year ago. If it grows to 5.2 is she safe to continue watching it?
Dr__Roselli: Without knowing the specifics of your mother's situation it is hard to say when I would recommend repair. But - in an older patient it is probably ok to wait until the aneurysm is greater than 5.5 cm.
RonG: I am a 63 year old male who has been diagnosed with an ascending Aortic Aneurysm through an echocardiogram. As a result, I had a CT scan done and the aneurysm measured 4.2 cm x 4.5 cm. What is the size of a “normal” aorta and at what size aneurysm do you recommend surgery? Is this always done via open heart surgery or are there less invasive types of surgery to repair an ascending aortic aneurysm? I am maintaining normal blood pressure but do recommended any other course of action to prevent it from getting larger? Thank you
Dr__Roselli: Normal aorta is typically less than 3.5 cm. depending on your age and height. Blood pressure is the most important thing you can control. You should probably not do any heavy lifting greater than 50 pounds. Most importantly, this needs to be imaged on a regular basis to assess for growth.
Vlasta: Q: What is the significance of an increasing diameter of ascending aorta (from 39mm to 43 mm over 3 years) and how does it impact the heart function? Q: Can the same process that causes widening of the aorta contribute to forming of an aneurysmal segment in the diagonal branch of LAD? Q: What is the most common cause of an increase in the size of an aorta? Can this process be reversed or stopped with medication or lifestyle changes? Q: What is the upper range of normal aorta diameter and is there a treatment protocol? Q: Can widening aorta and/or a coronary aneurysm cause shortness of breath? What effect does this have on blood pressure and the heart function over time? I realize you will be getting many questions and can only answer a few of them. Thank you.
Dr__Roselli: I would not expect you to have symptoms from either one of these problems. Because we don't fully understand all the causes of vascular aneurysm formation, it is difficult to say why you have this, but it is not unusual if you have aneurysms in one vascular bed to have them in another. Short of maintaining well controlled blood pressure, there is little else you can do to slow the progression of aneurysm formation. Growth of 3.9 - 4.3 over 3 years is not unusual or particularly dangerous.
Aorta Surgery - Cardiac
tommydnj: Is there a minimum diam. that determines surgery is necessary?
Dr__Eagleton: This is a difficult question to provide an answer to specifically. There are recommended sizes at which aortic aneurysms should be repaired. These will vary based on the location of the aneurysm (ascending aorta, descending aorta, or abdominal aorta) as well as associated disease that may increase the risk of rupture (such as Loeys-Dietz Syndrome).
BeBe7: What types of procedures are available to repair an ascending thoracic aneurysm that does not involve the aortic arch or valve and what are the benefits and risks of each.
Dr__Roselli: The standard of care for an isolated ascending aneurysm is open repair with an interposition graft. I perform this operation through a minimally invasive incision for most patients. Some patients with unusual patterns of aneurysm and high risk for conventional repair may be treated with an endovascular stent graft but that procedure is still considered investigational. Your risks of ascending aortic aneurysm repair are determined by your overall health and the surgical team doing the procedure. Last year at the Cleveland Clinic, the mortality for ascending and arch aneurysm repairs was less than 0.5%.
witter123: What are the procedure options to repair/replace an ascending aorta aneurysm reop?
Dr__Roselli: See BeBe7
JLK: My wife is 51 years old, 5’7” tall (170 cm), with bicuspid valve, moderate stenosis (1.12 sq cm), and 5.0 cm mid-ascending aortic aneurysm. Current CT scan shows 4.0x2.9 cm at the sinuses of Valsalva, 3.8x3.3 cm at the proximal ascending thoracic aorta, 5.0x4.9 cm at the mid ascending aorta, 4.0x4.0 cm at the distal-ascending aorta, 2.2 cm at the mid transverse arch, 2.3 cm, at the proximal descending aorta; 1.9 cm at the mid descending aorta; 1.9 cm at the diaphragmatic hiatus. In 2007 when the aneurysm was discovered it was 4.7 cm. She has severe allergies to metal (including titanium), plastic, medication & anesthesia allergies, and also reaction to clothing containing Dacron. How many patients with a situation like my wife have been treated at Cleveland Clinic, and what are our options for having repair of her aneurysm and valve? We are highly concerned about her having reaction to a replacement valve and aortic graft. Do you perform allergy patch tests prior to surgery?
Dr__Roselli: All of those allergies certainly requires some additional attention. If someone has the allergies that you describe for your wife then yes - we do perform allergy testing preoperatively. However, given her unique situation, one good option for addressing her aneurysm and aortic valve would be the use of a homograft (human cadaver aorta and valve). This way, the only prosthetic material used in her would be the suture material, which we can test for as well.
greatscott73: I was diagnosed with an ascending aortic aneurysm last Sept. Size is 4.3mm. What are the pros and cons (if any) of having this surgically repaired before it gets to 5.0 or larger? It’s a bit un-nerving living with a time bomb in your chest all the time.
Dr__Roselli: I would not call a 4.3 ascending aortic aneurysm a time bomb. And I say that being someone who believes that ascending aneurysm disease should be treated aggressively. The only patients who we would consider replacing the aorta at that small size are patients who have another indication for surgery or who have Loeys Dietz Syndrome. We would not necessary wait to 5 cm if you were found to have a bicuspid aortic valve - see previous discussion of maximum aortic area to height ratio.
Sept14: How do the short and long term risks compare for aortic valve replacement with a separate ascending aorta graft versus aortic valve replacement and repair of all of the ascending aorta, including the aortic root? For someone with a bicuspid aortic valve and an ascending aorta aneurysm, is the additional risk to replace the aortic root ever considered the best long term solution - in other words, how likely is later development of an aneurysm of the aortic root if left alone?
Dr__Roselli: That is a good question. At this point we don't have definitive data to answer it completely. However, it is important for the surgeon to assess the aortic root at the time of the ascending repair because there are variations in the pattern of aortic involvement in patients would be BAV. In other words, in some patients a total root replacement is the right thing to do and in others, we leave the root alone completely and yet in others - we may do a partial repair of one sinus of the aortic root.
Angela: Do all aortic aneurysms eventually require surgery? Is the pulmonary artery normally approximately the same size/diameter as the thoracic aortic section? What options are there for reinforcement and/or replacement of a section of the thoracic aorta due to aneurysm?
Dr__Roselli: No. Many aneurysms never grow large enough to cause complications or warrant surgical intervention. Yes the pulmonary artery is typically the same size of the aorta.
xinxin: I am 63 years old female with moderate to severe mitral valve stenosis (pressure area 1.17^2cm), and moderate aortic valve regurgitation. I feel tired and shortness of breath sometime. I wonder how soon I need a surgery. Do I need to replace both valves at the same time, and what is the risk to replace the two valves? Who is (are) the most experienced surgeon(s) to do both valves at CC? For finding a surgeon at CC, do I pick one myself or CC choose one for me? Thanks a lot!
Dr__Roselli: All of the adult cardiac surgeons at Cleveland Clinic frequently perform multivalve surgery. I cannot recommend timing for surgery for you without more detail. If we have an indication to operate and another valve has moderate dysfunction addressing both of them is typically indicated. You can contact my office directly if you want further evaluation.
atta: What is the mortality rate for aortic surgery to repair aneurysms and if there is a strong family history of dissections at what point in size of aneurysm, vs. pulmonary artery size, is surgery recommended?
Dr__Roselli: For elective aorta surgery on the proximal aorta at the Cleveland Clinic, risk of mortality is consistently less than 1 %. In patients with a family history of aneurysm or dissection, we tend to lower the threshold of when to intervene. I am not familiar of any data correlating pulmonary artery size to aorta size to assist in the decision making process.
Sadiegrey: my son 54 had emergency surgery for aorta aneurysm 6 yrs ago & now has the artificial valve and on metoprolol and coumadin for life. His surgeon says it will probably have to be replaced soon as it is enlarging again....they do cat scans yearly and last 2 @ 6 mos apart. The surgery they had to crack open chest and he woke up on ventilator. He does have Marfans and his surgeon sent tissue samples to a diagnostic lab that confirmed the gene and family tested. One 24 yr son already died with dissecting aorta aneurysm. Question would my son be eligible for the more non invasive David procedure surgery at Weston, FL...Son lives in Apopka Fl. He is dreading the upcoming surgery to replace this valve. Thank you
Dr. Roselli: No, he is not a candidate for the David procedure if he already had his valve replaced. It sounds as though he may need more surgery on his aorta which is not unusual if he has Marfan’s. However, it is important that patients with Marfan’s are seen at a center with a lot of experience treating this problem. If he wishes to have his records reviewed here in Cleveland, feel free to contact my office. I am very sorry to hear about your other son.
Becca: Would you recommend a follow-up of a patient with fibromuscular dysplasia or renal arteries who also has a widening ascending aorta (43mm), an aneurysmal segment on a diagonal branch of LAD artery and an elevated left ventricular end diastolic pressure at 22mmHg? Who should do the follow-up if one is needed, a vascular surgeon or a cardiologist? How often should the patient be monitored? What tests would be the best to use?
Dr. Roselli: Becca, your problems are complex. I think it would be important to follow-up with both a vascular surgeon and a cardiologist. If you would like to be seen in Cleveland, I would recommend you see Heather Gornik, a cardiologist who specializes in peripheral vascular disease and FMD (she is a world expert in the latter).
Idahoan: i am a 49 year old male, generally health and fit. I was diagnosed with an ascending aortic aneurysm 6 years ago, and it has now expanded enough (to 5.05 cm) to create enough concern to consider surgery within months to a very few years. The aortic valve is tricuspid, and has only minor leakage, so can be spared, but the aneurysm extends to (though not into) the aortic arch. The surgeon handling my case indicates that the impingement on the arch means that the surgery will need to be hypothermic, and that that carries substantial risk of serious complications. My question is this: Can you outline the current state of thinking about the risks and benefits of hypothermic surgery versus other methods of repairing this sort of aneurysm? I have read a bit about cerebral perfusion as an alternative to hypothermic arrest, but the results of all methods seem rather mixed. Thank you for any insight you can provide
Dr. Roselli: The results of arch surgery and the various methods of brain protection vary by patient and most importantly by the surgical teams’ experience. At Cleveland Clinic in 2011 we performed more that 400 elective operations on the proximal aorta and arch and the stroke rate was less than 2% and the mortality rate was 0.4%. In young patients who have an expected survival of >20years, we are generally more aggressive about resecting all of the abnormal aorta if we think you are healthy enough for us to do so safely so as to save you from a later operation. If you wish, I would be happy to review your records.
Becca: At what size would a dilated aorta need repair? My ascending aorta is 43mm. Is there a way to predict the growth rate? What is the normal diameter of ascending aorta?
Dr. Roselli: 43mm is not a very large aneurysm. Typically it would be closer to 5cm before we consider an operation but that is not the only deciding factor. They typically grow about 1mm per year.
Clara: If all major arteries have stents - 6 in all. I have had open heart surgery with grafts. They have not had stents put in yet. I seem to be getting stents every year. Will this lead to open heart surgery again if I keep getting blockages?
Dr. Roselli: Yes, if you have had previous bypasses or stents you are not cured of your disease and need to continue optimal medical therapy: no smoking, weight loss by eating right, exercise, blood pressure and cholesterol control, daily aspirin, etc.
Aorta Surgery – Abdominal
dpersson: I have AAA that measured 4.7 cm 9 months ago. I will have an ultrasound in 3 months to check its status. I have excellent (unmedicated) blood pressure and have non obstructive coronary artery disease. I am 60 years old and otherwise am good health. I have been told that once the AAA is 5.5 they would recommend surgical repair. Does this sound appropriate and does the surgery have to be a graft or is a stent a possibility?
Dr__Eagleton: The treatment plan you have outlined closely follows recommended guidelines. Typically, aneurysms that are greater than 4.5 cm are monitored every 6 to 12 months for growth with either an ultrasound or CT scan. Repair is recommended when the aneurysm is approximately 5.5 cm. Surgery may be recommended sooner if the aneurysms is considered to be rapidly growing. There are two types of repairs available: conventional open surgical repair (replacement of the aneurysm with a graft through an abdominal incision) and endovascular repair (using a stent graft to treat the aneurysm from the inside of the aorta through incisions in the groin). Not all patients are candidates for endovascular repair, and the long-term outcomes for this procedure are not as well documented as with open repair. The type of repair will be variable from patient to patient, and your surgeon should counsel you on the risks and benefits of each for your specific clinical situation.
Endovascular Stent Graft
gm3: What is the long term performance projection for a Gore Medical Excluder Stent and what is the replacement procedure should problems materialize?
Dr__Eagleton: Unlike open conventional surgery, we do not have long-term data available for most endovascular grafts. We do know, however, that more patients that have undergone endovascular repair will require a secondary procedure at some point in their life (compared to open surgery). This is true regardless of the brand of stent graft (or endograft) that was initially used. Typically these interventions are performed in a minimally invasive setting (ie. through a needle puncture in an artery using catheters and wires, as opposed to major surgery). It is rare that an entire endograft would require replacement, but it can occur. The exact procedure that needs to be performed depends on the reason that the graft failed. Procedures can include excision of the graft with surgical replacement of the aorta, or relining of the stent graft with a second device. Again, however, this is not typical.
blarco: Is endoscopic vascular surgery possible for ascending aortic aneurysm? (currently at 4.1cm)
Dr__Eagleton: Endovascular surgery for ascending aortic aneurysms is possible, but it is rare. Currently endovascular surgery for ascending aortic aneurysms are reserved for very specific clinical scenarios as part of a research program.
gm3: What is long term performance of gel foam used to stop an endoleak type II with aneurysm sac enlargement that was used when transarterial sax embolization failed?
Dr__Eagleton: This is a difficult question to answer. There are a variety of materials that are used to occlude a type 2 endoleak and include gel foam, metal coils, and glue. The exact type of agent used depends on the specific clinical scenario (what exactly is being attempted to be blocked off). The results are not specific to gel foam, but more on the success at blocking off the endoleak.
Recovery after Aorta Surgery
greatscott73: What is a typical recovery time after repair of an ascending aortic aneurysm?
Dr__Roselli: Hospital stay is typically 5 - 10 days - it takes 6 weeks for the wounds to fully heal. And - it may take 2 - 3 months before you recover your endurance.
Aortic Valve Surgery
Mattkonet: I AM AGE 86, HAD 4 WAY BY PASS 10 YRS AGO. I HAVE AORTIC STENOSIS. .07 SQ CM AND I AM ONE OF JEHOVAH'S WITNESSES. NO NOTICABLE SYMPTOMS. WOULD MINIMALLY INVASIVE VALVE REPLACEMENT WORK FOR ME?
Dr__Roselli: Yes potentially. There are several other anatomic and physiologic requirements that need to be met before telling you that you can have the transcatheter aortic valve replacement (TAVR). If you wish to be assessed for this, please contact my office.
clara: I had the aortic valve replaced with a pig's valve 2006. I have started having SOB and chest pressure that has become severe in the last month. Is there a possibility that the replaced valve may have a problem?
Dr__Roselli: You should have your valve assessed on a yearly basis with echo if you have a prosthetic valve. With porcine valves, sometimes they fail suddenly which may explain more acute change in symptoms. You should contact your cardiologist to have this evaluated soon.
cv123: Hello. I have a two part question. First, what are the main differences between an open chest invasive aortic valve surgery and a less invasive procedure? And second, what are the major factors that are used to determine which procedure is best for a given patient?
Dr__Roselli: There is not exact definition for less invasive - it describes a spectrum, of treatment options. The least invasive approach at this time (TAVR) has not been proven to be as durable as the more conventional surgical options. For isolated aortic valve surgery, nearly all patients are candidates for a minimally invasive approach. The specific type of mini invasive approach depends a lot on your vascular anatomy and the experience of the surgical team.
Exercise and Activity
movshuk: May regular aerobic exercise be a risk factor for increased aortic size in patients with BAV? If not, which exercise intensity (in relation to the maximum heart rate) would you recommend?
Dr__Roselli: How much exercise you can do with aortic valve disease is dependent upon a few things.
- The severity of valve dysfunction may limit you and you need to speak with your cardiologist in more detail about this.
- 30 - 50% of patients with BAV also have associated aortic disease, which may put them at risk for developing an ascending aortic aneurysm.
If you have an ascending aortic aneurysm, you are allowed to participate in aerobic activities but general recommendations are to not exceed a heart rate of 160 beats per minute and to limit heavy lifting to less than 30 - 50 pounds. These are general guidelines and there is no hard evidence to direct us in these recommendations.
choicewords77: Is there any added danger to one diagnosed with an aortic aneurysm measuring 4.2. traveling via airplane? Second (related) question: for same individual would flying or driving be preferred on a trip from Ohio to Florida. Thank you for doing these chats. We have so many questions regarding the diagnosis of the aneurysm.
Dr__Eagleton: An aneurysm of 4.2 cm would not be a contraindication to flying, and I certainly would consider doing that if traveling to Cleveland from Florida.
movshuk: Do you exercise? If yes, how often?
Dr__Eagleton: I exercise 5 to 6 days per week for approximately 30 minutes each time. This is a mix of aerobic and resistance training. In addition, I try to take the stairs when possible. A mix of healthy eating and regular exercise are important for maintaining a healthy body.
Julie7759: What physical restrictions are there after a person has recovered from ascending aortic aneurysm repair?
Dr__Roselli: Immediately post op, patients are told not to lift more than 10 pounds or drive for 6 weeks. Once you have fully recovered and completed cardiac rehabilitation, you may be able to resume all normal activities, unless you have active aortic disease elsewhere.
Celiac Artery Aneurysm
vvl: At what size should surgical intervention be recommended for a celiac artery and superior mesenteric artery aneurysm? Is it the same for fusiform or saccular aneurysms?
Dr__Eagleton: Unlike diseases of the aorta, we don't have as much information about the natural history of celiac artery or superior mesenteric artery aneurysms to know if there is a certain size at which they are more likely to rupture. Many, but not all, will require surgery. This decision is often based on why the aneurysms occurred, their specific location in the blood vessel, and the patient’s risk factors for the type of surgery that would be required to repair that aneurysm. Saccular and fusiform aneurysms tend to develop for different reasons, and we think they may have a higher risk for rupture. Given this, we are often more aggressive with approaching saccular aneurysms.
vvl: If the celiac artery has a dissection where stenting is not possible, should surgery be recommended?
Dr__Eagleton: We do not typically intervene on dissections involving the celiac artery unless there is an associated complication. These complications include the development of an aneurysm, or if the dissection is significantly interfering with the blood flow in the celiac artery. Isolated dissection of the celiac artery is not common, and rarely requires intervention in the absence of an aneurysm. If one of the complications is present, then an intervention would be recommended. If this could not be repaired with a stent, then conventional surgery may be warranted.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.
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