4.8cm aneurysm on ascending aorta questions

[paulschumann]

I have a BAV at 1.3cm with mild to severe stenosis that my cardiologist wanted to watch every 6 months with an expected replacement when things started to deteriorate. did a CT scan and said they found a 4.8 cm aneurysm so I guess that means now is the time. getting a angiogram scheduled in a couple weeks and replacement soon after.

whats a 4.8cm aneurysm, is that big, is that normal for BAV? what do surgeons normaly do to fix an aneurysm that size? I'm 32 years old and in otherwise perfect health and asymptomatic with the occasional palpitation.

 

[ElectLive]

Coincidentally, I started a new thread a few days ago that have will some info relative to your questions: http://www.valvereplacement.org/forums/showthread.php?38464-Aortic-Aneurysm-stuff

Depending on a few other factors, 4.8 for quite some time was not deemed surgical, recent guidelines are starting to recommend a more proactive approach, though. But in the end, that's of course a discussion for you and a surgeon.

I was 35 in perfect health and no symptoms and had surgery a few weeks after discussing my 5.0 aneurysm with a surgeon, but do not, I repeat, do not assume it will be the same for you. Grafting an aneurysm can be fairly simple (big picture of course, nothing heart related is simple), but it does depend on exact location. Your surgeon will cover that as well as the related valve discussion.

Best wishes during this time, and however things proceed, I can assure you from experience, things can be very normal even only a few months after a combined valve replacement and aneurysm surgery.

 

[ElectLive]

I should add, too, my first reaction was: But my BAV is fine, are you kidding me, surgery?

 

[malibu82]

hey, i was 27 years old when i was diagnosed with BAV, with mild stenosis and a 4.8 ascending aortic aneurysm. they told me due to the size of the aneurysm i would need surgery some time that year, but i could chose when. they replaced my aortic valve as long as they were in there because it would need replacing in the future.

after surgery was done, i asked them how big my aneurysm really was. they said 4.2cm. kind of a bummer, if i would have known that before surgery i would have waited!!!!

 

[ElectLive]

Wow...I'd be bummed too, goodness. I'd heard of an instance or two where a patient found out there's was actually larger, and not by that much, had not heard the opposite. Was the 4.8 a CT measurement?

 

[themalteser]

Hi, I got a 4.7cm dilation, but in my root. Cardiologists repeated themselves that I should not worry at all, and that mist likely I will not need surgery for many years. Don't know whether this is because it's in my root rather than above it, as my rest of ascending part is 3.4cm.

Furthermore, they don't call mine aneurysm, but, slight dilation. And trust me, I've spoken to around 15 different cardiologists and surgeons!

 

[ken taylor]

IM a pro active person as you can tell by all my post, I see no benifit in waiting . I would look for a surgeon and get it done and move on with my life, Waiting sucks the surgery is a blessing!!

 

[camgough]

If your valve is still functioning fine, and is in good shape you should ask about a valve sparing procedure. I had this type of surgery where my bicuspid valve was saved and reimplanted after my 6.7cm ascending aneurysm was replaced with a dacron graft. My aortic root was replaced as well. This surgery is technically difficult, but has many benefits if done properly.

 

[themalteser]

Just to add, I think you should listen to what the cardiologist wants you to do, at the end, these are the professionals, if they say to monitor it, than they must have a strong case , as they can't afford to be sued or ruin their reputation! Usually, they do not operate on a 4.8cm ascending aorta, unless accompanied by a poorly functioning valve , this is because research dictates that risk of surgery is higher than risk of leaving it alone, bearing in my that there is around 2% risk in surgery, so leaving it alone is much, much lower! But, of course you already have a degree of stenosis, so might have the option to replace at this stage. Obviously, we want everything perfect, and thus, that is why you might want to replace it, if it was my way, I probably consider surgery now but, I don't think you should rush into surgery, unless your cardiologist says so. Remember that unless you have marfans, or a family history or pregnant , your risk with that size might be negligible. But, ofcourse, I can only tell you from what my cardiologist told me, and it's only my root thats dilated, these included Yacoub ( who ordered my scans) told me to carry on a normal life, tirone and Dr Craig miller.

 

[ALCapshaw2]

The 'usual' (or at least most common) trigger for surgery to correct an aortic aneurysm is 5.0 cm (sometimes 5.5 in larger bodied patients).

OTOH, for patients with BAV, some surgeons are recommending surgery sooner rather than later, partly because of the possibility of a connective tissue disorder that is often a factor with BAV and Aortic Aneurysms. It would be wise to consult with a SURGEON with considerable BAV and Aortic Aneurysm experience. As I mentioned in a previous response to one of your other threads, Dr. Sundt is the Aorta Specialist at the Mayo Clinic. (and remember, Cardiologists Diagnose Heart Valve/Aneurysm problems but Surgeons FIX them. It's time to be talking with appropriately experienced surgeons IMO.)

'AL Capshaw'

 

[ElectLive]

Usually, they do not operate on a 4.8cm ascending aorta, unless accompanied by a poorly functioning valve , this is because research dictates that risk of surgery is higher than risk of leaving it alone, bearing in my that there is around 2% risk in surgery, so leaving it alone is much, much lower!...

But, ofcourse, I can only tell you from what my cardiologist told me, and it's only my root thats dilated, these included Yacoub ( who ordered my scans) told me to carry on a normal life, tirone and Dr Craig miller.

I did not realize until your posts just how different size in the root really is. On page 1516 of the 2010 guidelines (linked in my other thread, see my first post above), there's a chart of average sizes. The root can be up to 1 cm larger normally, so that seems to explain very well the recommendations you've been given. 15 doctors...hard to argue with that!

But, the ascending aorta is definitely different, and the presence of BAV generally increases risk, as the last post indicated. I further agree with the last post that surgeon input is vital. It must be in the job description, I guess, cardiologists seem to be prone more often than not to recommend delaying surgery as much as possible, even sometimes against established guidelines.

Back to your comments, though, to my knowledge, the risk of postponing surgery is actually higher. This can be dissection, rupture, and/or death. For my situation, I was told a 5% risk to do nothing vs a 2% risk for surgery. Again, all should be confirmed with a surgeon, but here's a link with more, including a yearly complication rate chart by dilation/aneurysm size: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861012/

Of course, like so many other things in all of our medical lives, there are no absolutes here either. Some aneurysms rupture below 5 cm, some hold firm even above 6 cm (pull out a ruler, and picture that!) Probably the worst part is that you can be symptom free up until rupture.

 

[themalteser]

Ah, I understand, I always get confused as aortic root is part of the ascending aorta, but, perhaps cardiologists have different criterias on each. Thanks for that information.

 

[themalteser]

Sorry, may I ask what were your measurements Electlive please?

 

[ElectLive]

I wouldn't have known either...if your posts hadn't inspired me to look. Good for all to know.

I was 5.0 on echo and CT. (I need to create a signature with this on it, I know, just haven't gotten around to it yet) I can't remember my average (non-aneurysm) size, have it buried in pre-surgery files somewhere. I had rapid growth too, though, so I'm a little non-typical in that regard. Many I know hover at the same size for quite some time.

 

[Gail in Ca]

When my ascending aortic aneurysm was discovered in '89, it was already at 6. At that time, my 1st surgeon felt it was ok to wait the 6 weeks I waited for my surgery. He wanted a certain anethesiologist, etc. When he got in there, and began to deal with my aorta, it fell apart in his hands. I guess that's why they are more willing to do surgery now when the measurement is less, due to people like me with connective tissue issues. One must remember it's not just the size, but the condition of the aorta, which, apparently isn't readily seen on tests.

 

[Julian]

One must remember it's not just the size, but the condition of the aorta, which, apparently isn't readily seen on tests.

This is so true! Anything tissue in the body including valves. How many times have I read about peoples valves looked bad but not critical on an echo and once they got opened up the valve looked like a piece of chewed bubble gum. You never really know how bad it is until they get you open.

 

[themalteser]

Sorry Gail in ca and Julian, I don't really understand your point. Gail, your aorta seemed enormous, I guess even a non expert would have said the same things that the surgeon said to you, also, have you 'shopped around' fora second opinion? The other thing is that back in 1989, technology was just a baby, of course 6 cm would have been less riskier then surgery, now a days, surgery is safer and therefore less riskier, which in turn they can operate at a smaller sizes. In future it could be that surgery is so safe that they will operate as soon as it's a millimetre above the normal! Not because of connective tissue issues. BAV is not a connective tissue problem, but just a small stupid defect' A car without a side mirror, will still function!

Julian, where did you get the bubble gum idea from? So you think that I go to all this expensive machine tests, just for a surgeon to open me up at the end, and tell me oh, by the way, all those tests you've done are absolutely useless, your valve was infact a bubble gum!!! Come on, is this seriously getting to scary tales or what??

 

[Gail in Ca]

Yes, in '89 my surgery was a bit unusual. My surgeon met with all the surgeons, sort of a round table and discussed my case. It was just aortic valve leaking due to the ascending aortic aneurysm, but then, it was not seen much. Especially in someone who did not have Marfan's Syndrome. I guess most people would've kicked the bucket. I might've, too, as my symptoms told my surgeon nothing. (only weakness in my legs starting 6 wks after my baby was born, whenever I picked her up out of the crib, the car seat, etc. Also, if I picked up heavy grocery bags it would happen). I had already seen 5 doctors about my symptoms over a period of 2.5yrs. Finally, I changed to a new PCP, and she sent me to a cardio she knew. He saw the aneurysm on the echo that the previous doctor who read it missed.
My surgeon was surprised that my aorta fell apart in his hands. He wasn't expecting that. He was going to wrap the aorta around the graft, but had to cut it out completely and sew in the graft. It didn't involve the coronary arteries. All that and I was his second surgery of the day! He told me he only had a quadruple bypass before mine! Like it was a tonselectemy.
Scary stuff? You bet! Thankfully I didn't know all this until after the surgery was done.

 

[ccummins]

Mine was at 5 when I had surgery at age 37. I also had no symptoms but they had been monitoring my aorta. As soon as it hit 5 they said it was time. I chose to leave my BAV alone which I am glad I did. They automatically wanted to replace my valve until I started asking questions. I realize it is a personal decision, but I was not ready for an artificial valve so young. And when I asked if my valve would last longer than an animal valve, they agreed it would. Well, why they ever suggested that i repair it with an animal valve is beyond me. It was a no brainer. Over two years later and my last checkup my cardio said my lil BAV would hopefully last decades. And again, this is just me, my thinking is that by then, it will not be OHS to fix it.

 

[zztimeout]

I am 41 and have BAV and my aorta was 51mm. I had valve sparing and aorta root replacement on 19th May with a
**** load of dramas as you can read in my signature below. Surgeon said if I don't have it done I will head butt the concrete in the future. I had no symptoms prior to the big day. The day before the operation I wad laying pavers in my back yard.