Ask The Heart Doctor: Women's Heart Health - Part 4 - Aortic Dilation, Aneurysm & Dissection

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Leslie Cho, MD:

Welcome everyone to a session on Ask Your Heart Doctor. Today our focus is on women and heart disease and we're joined by our surgeon as well as our cardiologist colleagues, and we're going to go around and introduce ourselves first. My name is Leslie Cho. I'm the Director of Women's Cardiovascular Center at the Cleveland Clinic.

Donna Kimmaliardjuk, MD, FRCSC:

I'm Dr. Donna Kimmaliardjuk, and I'm a cardiac surgeon with a special interest in focus on coronary artery disease and bypass grafting.

Christine Jellis, MD, PhD, MBA:

I'm Christine Jellis, I'm an imaging cardiologist with a special interest in advanced imaging.

Leslie Cho, MD:

Okay, so I'm going to ask a question about aorta here. We've heard a lot about aortic aneurysms recently because many famous people have had aortic dissections. Christine, tell us what aortic aneurysm is. When should you be concerned, and do women have different cutoffs for when they should go to surgery?

Christine Jellis, MD, PhD, MBA:

It's a great question, and I think there's often a lot of anxiety when people hear that they have a dilated aorta. I classify this in different ways, so I would view someone with a mildly dilated or ectatic, sometimes you'll hear the term used, mildly dilated aorta, as being not so much of a concern. When someone steps into the more moderate level of enlargement, then we want to make sure we're being very vigilant about watching them to make sure that they don't develop severe aortic enlargement, which is what we term an aneurysm. And I think that it’s important that we use the right terminology. The cutoffs for aortic enlargement are again relatively specific to the general population, including men. So often when I'm reading scans, we'll use 3.8 centimeters as the upper limit of normal and then 5.0 centimeters as our cutoff for an aneurysm. It has to be acknowledged though that it's very different if you are a little gymnast, as we're all intrigued by the Olympics, versus if you're a seven foot tall basketball player.

And so it's important we take that into consideration because particularly for petite women, they may actually need to consider surgery slightly smaller than that 5.0 centimeters. Or for people who've got inherited connective tissue diseases, sometimes we'll operate on them sooner. So what we often do is look at the cross-sectional area and divide that by the height of the person. And that can give us another threshold where we can think about timing for surgery. With a level of 10 or greater than 10 from that calculation being a cut point when we should consider surgery in more petite people. Our Chair, Dr. Svensson has been a proponent of the use of that ratio, and I know we continue to use that as a valuable tool, so something definitely worth considering. And I think being able to talk through this with your cardiologist and your heart surgeon is really important, so that we make sure that people with dilated aortas are reassured and in surveillance programs because what we don't want is to miss ongoing enlargement.

Donna Kimmaliardjuk, MD, FRCSC:

And potential dissection. That's how we meet, unfortunately, a lot of patients with undiagnosed aneurysms.

Leslie Cho, MD:

There's a lot of data about women doing worse with aortic dissections. They have worse outcomes, somewhere along three to five-fold worse mortality compared to men, in some of the registry studies. There is a lot of data about women having delayed interventions. Maybe you can speak on that.

Donna Kimmaliardjuk, MD, FRCSC:

Yes, and so you're absolutely right, there is that data. Part of it comes to this delayed diagnosis because we do tend to use these cutoffs in terms of size measurements, and that's still what really guides us surgeons as to when to intervene on an aneurysm. Again, because remember, as I mentioned earlier with surgery, everything is a risk-benefit ratio. And these surgeries can be very big surgeries that can come with significant risks. So we want to make sure we're doing the right surgery, for the right person, for the right diagnosis, at the right time. But when we use these certain cutoffs, they're usually based on studies, done mostly on men, who tend to be taller and larger than women.

So unfortunately, yes, we're learning now that we perhaps need to adjust that intervention for women. And like any other disease process, I think if you present at a more advanced stage of that disease, it's going to be harder. It's going to be a harder surgery, it's going to be harder recovery, and you're more likely to be at risk for complications. A lot of research that still is being done and needs to be put out there, and even for us as surgeons all around North America, to be updated on in terms of when we should be really thinking about intervening so that we prevent things like dissections happening.

Announcer:

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