Dilating Ascending Aorta QUESTIONS

[the art den lady]

I received my cardiologists report today. I love the Mayo! I did find out that my valve size is at .98 and my mean gradient (valve pressure) is at 55. Up from 38 a year and a half ago. Ergo . . . surgery.

Does anyone know:

a) What a dilating ascending aorta is? (The report says that even after surgery I should avoid lifting heavy weights).

b) Can they fix that when I'm getting my valve replaced?

c) I just read an article that stated, "The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention." ????????????

Do I really want to be thiiiisssss informed? Ha-ha

Thanks for any answers,
Jackie

-------------------------------------------------------

1995 - TIAs (mini strokes) started after birth of my daughter, Aspirin started.
1996 - BAV w/mild stenosis diagnosed.
2003 - PFO (hole in heart) fixed w/Amplatzer. 3 catheters up the legs.
2003 - FVL (clotting disorder) diagnosed, Coumadin started.
2/16/07 - Surgery for BAV w/severe stenosis, Mechanical Valve, Dr. Suri, Mayo Clinic.

Expect the best. Prepare for the worse.

I intend to live forever -- so far, so good.

"Life is great, life is grand. Life is like a rubber band." - Jackie Beach

 

[lynn]

My echo before surgery also said the ascending was dialated. Once surgery was done and I got the surgery report it was noted that I had an aneurysm of 4.3 and they replaced the ascending while in there. This showed in the CAT scan the day before surgery and the TEE done while I was on the table. No one said anything to me and I'm kinda glad they didn't So, yes....they most likely will replace and save you another surgery down the line

 

[MrP]

You'll make better decisions, and hopefully, live longer by being better informed. You may want to see the bicuspid foundation website if you haven't already.

www.bicuspidfoundation.com

Short answers (cooking as I write):

1) A dilating ascending aorta (aneurysmal dilatation) is an enlarged aorta between the aortic valve and the aortic arch. Avoid lifting heavy weights before and after surgery to avoid ripping the suture and to avoid possibility of another aneurysm developing later.

2) Yes, you will most likely want to get a composite aortic valve w/ Dacron graft....tissue or mechanical valve w/ graft attached as one piece.

3) Special attention to resect the aneursym before it ruptures or dissects (inner layer tears)....don't wait for the aneurysm to get too big. If the anerysm extends into the aortic arch or even close, deep hypothermia circulatory arrest (cool your blood using the heart bypass machine) before turning off the heart bypass and resecting your aneurysm. Get a good surgeon who specializes in this for best results and to minimize the time to resect the aneurysm (reduce risks associated with possible stroke during surgery).

Hope this helps.

 

[StretchL]

Hi, Jackie.

Having an aneurysm of the ascending aorta is not uncommon in those of us with BAV disease. My AA was dilatated to .5cm at the time of my surgery.

Some believe that the dilatation of the AA and the BAV arise from some genetic pathology that causes both. Others are of the mind that it's the pressure gradient across the valve that causes the AA to dilate. (Think of the pressure generated by a garden hose when you put your finger over the end of it. Some think that the dilatation is caused by the similarly increased pressure as blood leaves the heart and hits the wall of the AA.)

Dr. Stelzer corrected my aneurysm by plicating (like pleating a piece of fabric) the wall of the AA. I have a photograph of the finished repair in my files if you're interested in seeing it. I mistakenly left it off the web gallery.

I would be surprised if any surgeon would not correct the aneurysm one way or another once they're working in your chest.

Finally, I humbly suggest that you not sweat this too much. As I said, dilatation of the ascending aorta is very common in patients with bicuspid aortic valve disease.

Good luck!

 

[Magic8Ball]

You've already had good answers above, i had a 5.8 dilated ascending aorta replaced at the same time as my BAV aortic valve replacement.

Read all of the links above to come to your own conclusion, for what its worth my research told me that the only sure fix for this was to have it replaced with a dacron graft.....think of your aorta like an inner tube of a bike which has been over inflated severely to the point that its almost burst...even if someone claims they can fix it would you want to ride that bike fast and risk a blow out?

I chose mechanical because of my age and had a 'Bentalls Procedure' done which replaces everything from the top of the ascending aorta through the aortic root and also the aortic valve with a one piece factory made unit....the reason i didn't go on-x was because they didn't make this one piece unit.....i didn't want the surgeon to spend his time stiching two bits together rather than stitching be back up properly...

The two main choices for fixing the ascending aorta in laymans terms are to just cool you down and then clamp the aorta and cut/replace it with the dacron graft (kinda artificial tubing).

The second is to really cool you down much further (DHCA) which is riskier but allows the surgeon to replace all of the ascending aorta (the other option leaves a little bit where the clamp was placed and this remaining bit has a chance to fail in the future)

I went DHCA, it doesn't add much to the total risk of the surgery, i was still a 98% expected success even with the DHCA but i think my long term results will be better now....

I'd question any surgeon heavily who wants to anything other than cut it out and replace it to make sure you fully understand what he's trying to do and the risks/benefits of it. It may technically work well for a bit but if you end up having surgery again just to replace the ascending aorta because the surgeon wanted to try something different on you then you will not be a happy camper.

Good luck with your research & remember its not that bad, any choice you make will be the right choice for you and the alternative of doing nothing is the only wrong choice there is....

 

[the art den lady]

Got a call from the surgeon last night and he won't be fixing the dilated ascending aorta when he's in there. He said it is a mild dilation and he'll just replace the valve at this time. However, there might be a chance for surgery from this down the line.

The # I found on the report under Mid-Ascending Aorta is 38 mm which converts to 3.8 cm. Is this the # I'm looking for? Where would I look?

One thing my first cardiologist said was never to lift over 30# even after recovery from my AVR. I'm assuming because of this dilated aorta?

Thanks for all the replies and the link MrP. I hadn't known about it.

jackie

 

[Mike C]

Some great posts with very good information

3.8 is most likely the number but I would also look for a similar number, possibly higher under aortic root.

3.8 is mildy dilated...aorta's in normal individuals expand slightly as we age, those with bicuspid aortic deaseas expand more.

true, lifting heavy weight, causes a dramatic increase in blood pressure which can make aorta expand quicker or possibly dissect. If you do not have the aorta corrected, you should most likley be on a beta blocker or similar.

It will continue to expand even with valve replacement.

your age is an important consideration, 3.8 at 30 and 3.8 at 60 are much different.

 

[Kate]

Hi!
Just to clarify - the reason for the lifting restriction is because dilated aortas occasionally tear (think about if you shove too much into a plastic garbage bag - the sides become weakened and sometimes tear). When a person lifts something heavy, their blood pressure tends to spike, increasing pressure on the walls of the aorta and the liklihood of a tear.

I don't want to scare you unnecessarily - the chances of your aorta tearing are likely very slim, but they do increase as the aorta gets bigger and, should a tear occur, it is a major medical emergency with a high chance of mortality. My guess would be that your surgeon has determined that the risks associated with surgery to fix your aorta are higher than the risk of your aorta disecting (which makes sense if your aorta is currently at 3.8cm). Most surgeon's don't like to fix aortic aneurysm's until they are 5cm, at which point the risk of dissection is around 5%.

One thing to keep in mind - the 5cm guideline may be too large for you if you are a small woman. Since the majority of people with this condition are men, it skews to their typically-larger body size. At 5 foot 3, I successfully got the Cleveland Clinic to operate on mine at 4.8cm. Hope this is helpful! Kate

 

[PJmomrunner]

The word on this issue from the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease is as follows:

3.3 Bicuspid Aortic Valve With Dilated Ascending Aorta
Class I
1 Patients with known bicuspid aortic valves should undergo an initial transthoracic echocardiogram to assess the diameters of the aortic root and ascending aorta. (Level of Evidence: B)
2 Cardiac magnetic resonance imaging or cardiac computed tomography is indicated in patients with bicuspid aortic valves when morphology of the aortic root or ascending aorta cannot be assessed accurately by echocardiography. (Level of Evidence: C)
3 Patients with bicuspid aortic valves and dilatation of the aortic root or ascending aorta (diameter greater than 4.0 cm*) should undergo serial evaluation of aortic root/ascending aorta size and morphology by echocardiography, cardiac magnetic resonance, or computed tomography on a yearly basis. (Level of Evidence: C)
4 Surgery to repair the aortic root or replace the ascending aorta is indicated in patients with bicuspid aortic valves if the diameter of the aortic root or ascending aorta is greater than 5.0 cm* or if the rate of increase in diameter is 0.5 cm per year or more. (Level of Evidence: C)
5 In patients with bicuspid valves undergoing AVR because of severe AS or AR (see Sections 3.1.7 and 3.2.3.8), repair of the aortic root or replacement of the ascending aorta is indicated if the diameter of the aortic root or ascending aorta is greater than 4.5 cm.* (Level of Evidence: C)
Class IIa
1 It is reasonable to give beta-adrenergic blocking agents to patients with bicuspid valves and dilated aortic roots (diameter greater than 4.0 cm*) who are not candidates for surgical correction and who do not have moderate to severe AR. (Level of Evidence: C)
2 Cardiac magnetic resonance imaging or cardiac computed tomography is reasonable in patients with bicuspid aortic valves when aortic root dilatation is detected by echocardiography to further quantify severity of dilatation and involvement of the ascending aorta. (Level of Evidence: B)
*Consider lower threshold values for patients of small stature of either gender.

 

[Susan BAV]

...Do I really want to be thiiiisssss informed? Ha-ha ...

I think that I know what you mean there; it's really overwhelming, isn't it... Happily, so far you've gotten some really good replies here though, Jackie.

My ascending aorta was considered by at least one surgeon to be an aneurysm and needing replaced but the surgeon I eventually chose didn't replace it and I'm happy and in agreement with his treatment for my situation.

There don't seem to be completely absolute answers (i.e., treatment) for BAV persons because of so many individual and unknown variables and probable degrees of the BAV extended disorder. Some other valve issues, like that from radiation damage, have confusing unknowns also.

Some BAV people have had everything replaced and/or reinforced and then some other unforeseen thing will come up and jeopardize their health and life. Nobody has perfect health, and everyone has some kind of restriction, sooner or later. All of us have to weigh factors, including our personal definition of "quality of life," to make the decisions reagarding our treatment. You're taking in a lot of information now which you and your surgeon will be able to discuss and weigh and then you'll make your decision and make peace with it. I have optimism for my future, whether it's longer or shorter; and I've made the best decision I can and I won't look back; I'm at peace with it.

Regarding lifting: I can't recall exactly what my cardio said about my lifting heavy things after I recovered from OHS but he did give me a warning but I occasionally lift very heavy things -- which may not be a good thing I think -- and I personally don't think lifting heavy things is a good idea for someone with the BAV disorder. Sometimes it is unavoidable though.

Oh, since I've been working on this reply, I see you have some other helpful posts also. You have lots to read! Take care!

 

[MrP]

Did you have a CT scan to measure your aorta? Echo tests provide limited visibility of your ascending aorta, although they can measure the aortic root with a reasonable degree of accuracy if you have many many measurements. A two-dimensional view, an echo measurement of the aortic root is not precise...margin of error is greater with an echo...especially a single measurement. A CT scan or MRI will give a complete view of the ascending aorta prior to surgery and more precise information regarding size of the ascending aorta. Better to know the size of the ascending aorta going into surgery.....avoid repeat operations. Insist on a CT scan if you haven't already had one....the value of 3.8cm you cite may be for the aortic root as measured by echo, and your ascending aorta could indeed be much larger.

Also keep in mind that BAV patients have larger than normal aortas, and you may be one of the lucky ones who don't ever develop significant aneurysmal dilatation.
Good luck!

 

[the art den lady]

As always, great information. Thanks so much. I'll print it out and ask more questions.

One odd thing I have right now is the top of my tongue has been numb for 3 weeks or so. They're not convinced it's TIAs. I put myself on aspirin and they said that was okay. I had stopped aspirin about 6 mths. after I started Coumadin. From what I've been reading, it sounds like the recommendation now. I'll be going in to my local doctor if it's not gone by Monday.

Has anyone had an odd back pain in the same spot? For me, it's about a hands length down from my left shoulder and a hands width in from my spine. It was only severly painful about 3 times this year. Even massage doesn't help. But the 'knot' always seems to be tender. The first cardiologist said it had nothing to do w/my heart condition. ???

jackie

 

[MrP]

I had a back pain in the same location that came and went for about a year before sugery. Also had sharp chest pain. About a month or two before surgery, I also had an intermittent cough for no apparent reason...up until the night before surgery. All these symptoms went away after surgery.

 

[aussigal]

If 3.8cm is the # for your AA and you arent a really petite little lady then I would feel OK about leaving good enough alone. I have read that up to 3.5cm is OK for a normal sized aorta so you would definately qualify as being mildy dialated. I would reckon the surgeon will have a look at it while he is in there just to make sure.

 

[Magic8Ball]

Has anyone had an odd back pain in the same spot? For me, it's about a hands length down from my left shoulder and a hands width in from my spine. It was only severly painful about 3 times this year. Even massage doesn't help. But the 'knot' always seems to be tender. The first cardiologist said it had nothing to do w/my heart condition. ???

jackie

I have exactly this on the left hand side, had it occasionally for as long as i can remember, never associated it with the heart condition....it feels like a long muscle pops out from behind the shoulder blade and sits on top of it...you can hear it 'shlop' as you massage it from side to side...

Its really painfull when it hits and affects arm strength..

As for your ascending aorta, being a BAV i have read that a .1cm growth per year is considered average so you could have 12 years before it reaches 5cm or it could tear early.

If you choose to go tissue valve this may be worth the risk as you could need opening up again around that time for a new valve anyway.

If you are going mechanical then i don't see the point of leaving an obviously faulty bit of tissue in there...for a good surgeon the complication of doing that at the same time as the valve isn't that much greater..

Ask another surgeon before you committ.

Regards.

 

[the art den lady]

I haven't had a CT scan. I used to have chest pains until I stopped lifting heavy weights. I'm not a small gal, so maybe that's why my surgeon feels safe in waiting.

I was wondering about after the surgery in the ICU. Should I have my husband and daughter stay overnight or should they just go back to the motel and wait for a call? Wasn't sure how that was done.

 

[MrP]

If you haven't had a CT scan or MRI, your surgeon has no idea what size your ascending aorta really is. As stated above, and echocardiogram will not provide visibility of the ascending aorta. And without a CT scan or MRI, one cannot compare ascending aorta size with descending aorta size to know whether or not there's mild dilatation or aneurysmal dilatation. Seems to me like your surgeon and cardiologist are not doing their jobs. Where are you having sugery, and how much experience with BAV does your surgeon have? Has he/she performed a hundred or a thousand valve + aneurysm resections?

 

[Phyllis]

I was wondering about after the surgery in the ICU. Should I have my husband and daughter stay overnight or should they just go back to the motel and wait for a call? Wasn't sure how that was done.

I stayed with Dick in ICU until about 7:30 PM and then went back to the hotel. He wasn't off the vent yet and the ICU nurse offered to get me a cot if I wanted to stay, but I decided that I needed a good night's sleep (well, semi-good ) so that I could be there for him first thing in the morning. She assured me that I could call any time during the night to see how he was doing.

 

[csutherland]

Regarding whether or not to spend the night at the hospital, for what it's worth here's what I did: One of our adult daughters & I were able to secure a room at an "in-house" hotel of sorts. It was very large and nice, quite reasonable in price (very important in our case), and only a walk across a catwalk to get there. We were less than 5 minutes away, didn't have to leave the bldg and get out in the cold, and felt secure in the knowledge that there were 2 or 3 nurses hovering over him.

It just depends on your temperament. Some wives wouldn't dream of leaving the waiting room, but this worked well for us. I would've given more thought to leaving the building, however.

 

[Magic8Ball]

Again, personal choice....i went in on the sunday, kissed the wife goodbye and she left.

I had the surgery on the monday, they called her to say it was ok.

I saw her on the Tuesday.

I wanted to be calm going into surgery, not emotional, and i didn't want my wife/family sitting around uncomfortable and stressed out when there was nothing they could do. Not to say they were not stressed at home but at least they could comfort each other in familiar surroundings.

Of course, the hospital was only 50minutes from my house so it wasn't like we were in another city and in a hotel.

Regards.