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Aortic Aneurysm stuff

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ElectLive

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I thought I’d share some random bits of information on aortic aneurysms that I’ve gathered the past year, pre and post surgery. There is a lot of great information on this site already, but some of it seems to be changing, and hopefully this will also help put a lot of odds and ends regarding aneurysms in one place.

First things first, when to operate. I’ve seen all kinds of numbers here and elsewhere, some based on diameter size alone, some based on body size formulas, some seemingly based on a given doctor’s opinion. As for me, not quite a year ago, I was told by a cardiologist that my 5.0 cm aneurysm should be closely monitored, but surgery was not immediately necessary. 5.5 cm was the trigger point. Further info: my growth rate had been rapid, and I am (well, was) bicuspid aortic valve.

My own research following that appointment, some of it here, some of it on various medical sites, seemed to indicate 5.0 cm more often than not as the recommended trigger point for bicuspid patients, basically matching Marfan’s guidelines. So, I walked into my surgeon’s office for the first time thinking it was probably time to operate. He agreed. But he emphasized further that the ACC guidelines had been recently modified (Spring 2010) and that 4.5 cm would have been my actual trigger point. He clarified this trigger point by comparing the surgical risk versus the risk of dissection/rupture, and surgery was in fact the lower risk option.

Now, here’s a link (summary article plus embedded link to the guidelines) to the 2010 guidelines: http://cardiobrief.org/2010/03/17/ahaacc-release-thoracic-aortic-disease-guidelines/ It’s over a year old, so I’m sure old news for some, but probably new to a lot of folks too.

Interestingly, if you look on page 1530, the guidelines actually indicate surgery anywhere from 4.0 to 5.0 cm in bicuspid patients, depending on several factors, and there’s a related chart. Now, don’t anyone (particularly those in the 4.0 to 5.0 range) jump to conclusions, specifics of each individual patient still factor in. But the guidelines overall are certainly shifting toward a more cautious, preventative approach.

I can’t speak to the previous state of body size formulas, and if they changed too, or already reflected this in years prior. I remember doing the Cleveland formula at the time, and it indicated that my 5.0 was at the surgery point, don’t know if 4.5 would have been too.

Other stuff… I had seen several isolated studies indicating that first degree relatives of bicuspid/aneurysm patients were significantly more susceptible to aneurysms, even if they weren’t themselves bicuspid. My surgeon agreed and recommended that parents, siblings, children all get an echo. The ACC guidelines have some information on this as well. One thing harder to conclude, though, is how often to monitor, if at all, assuming no initial aneurysm evidence. Definitely no consensus here, but in a recent Cleveland Clinic valve disease webchat, a cardiologist recommended an initial echo at early adulthood, with follow-up every 10 years or so.

For my young kids, I also asked a pediatric cardiologist both locally and at Cleveland Clinic for advice, and echoes were recommended at birth (to check for bicuspid), and then with or without bicuspid, another echo at both 5 years and after the big growth spurt (teens) to recheck for aneurysm.

What else…oh yeah, brain aneurysms. I’d seen another isolated study indicating heightened risk for brain aneurysms in bicuspid patients. A cardiologist at Cleveland Clinic indicated that they occur, but it is not adequately studied. No current guidelines recommend screening. This seems the least likely to happen, and probably not worth any worry, but thought I’d mention anyway.

Another interesting thing about aneurysms is the likely connection to sleep apnea and related conditions. Please see Duff Man’s thread for more: http://www.valvereplacement.org/forums/showthread.php?37612-Aortic-Aneurysm-and-Respiratory-Issues

Finally, there was a Cleveland Clinic webchat a few months ago that had a lot of interesting info about aneurysms too: http://my.clevelandclinic.org/heart/webchat/1207_aortic-aneurysm.aspx I’m sure a lot of people already know about these, but for those that don’t, they are a great resource and opportunity to ask questions.

And, that’s pretty much it. This is not meant to be definitive or conclusive by any means. For anyone with an aneurysm and/or facing the prospect of aneurysm surgery, please research and discuss more with your own doctors. But for general reading at least, thought it might be useful.
 
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Duff Man

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Correlation of Brain Aneurysms in Patients with a Bicuspid Aortic Valve

http://www.ncbi.nlm.nih.gov/pubmed/20439844


Obstructive sleep apnea as a potential risk factor for aortic disease.

http://www.ncbi.nlm.nih.gov/pubmed/21442254


High Correlation of Sleep Apnea in Marfan's Disease

http://www.ncbi.nlm.nih.gov/pubmed/18852161


Sleep Apnea IS Associated with Greater Thoracic Aorta Size

http://content.onlinejacc.org/cgi/content/full/52/10/885



Aortic Surgeon Symposium 2010 Videos

http://www.streamingmeeting.com/webm...2010/toc.html#

Particularly interesting is Dr. Sundt's presentation about the Bicuspid Aortic Valve:

http://www.streamingmeeting.com/webm...5-1100_f/f.htm


Matrix metalloproteinases in ascending aortic aneurysms: bicuspid versus trileaflet aortic valves.

http://www.ncbi.nlm.nih.gov/pubmed/15652949
 
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hetmarie

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Interesting how the guidelines have changed over the years. My father and I were diagnosed in the 80s with symptoms of Marfan's Syndrome. They told me as an adult that until my ascending aorta aneurysm was 5.5 or larger, not to worry about it. For 12 years running, my aneurysm measured 4.8. No worries, right? I didn't plan on the diagnosis changing as far as what I had. Last year they did some new testing and determined I have Loeys-Dietz Syndrome instead. They did an MRA and determined my aneurysm was actually 5.3. When I met with the surgeon he told me that in LDS patients, they recommend surgery on aneurysms that are 4.0 cm because of how week the tissues are. (When he opened me up, instead of just replacing my aorta where the aneurysm was, he went all the way up to my neck because of how weak the tissues are and he didn't want to have to come back in 7 to 10 years to fix the rest.) He also told me that guidelines had changed and even if they had still thought I had Marfan's, they would have recommended surgery at 5.0.
 

Keith

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This is some great information! Last year my aortic root had expanded to 4.8 cm and my cardio wanted to just check it in a year. This year it was "over" 5.0 cm (I don't know how much over) measured by echo and he decided it was time to go ahead with surgery. Interestingly, a follow-up CT scan showed it at about the same size as the previous year (4.8 cm). I'm scheduled for a heart cath tomorrow and to hopefully meet with the surgeon. Does anyone know if aortic aneurysms can vary in size in a week's time? Could this explain why the CT showed it smaller, or is it likely that the echo was just less accurate?
 

Lynlw

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This is some great information! Last year my aortic root had expanded to 4.8 cm and my cardio wanted to just check it in a year. This year it was "over" 5.0 cm (I don't know how much over) measured by echo and he decided it was time to go ahead with surgery. Interestingly, a follow-up CT scan showed it at about the same size as the previous year (4.8 cm). I'm scheduled for a heart cath tomorrow and to hopefully meet with the surgeon. Does anyone know if aortic aneurysms can vary in size in a week's time? Could this explain why the CT showed it smaller, or is it likely that the echo was just less accurate?
Hi Keith, a CT scan is more accurate than echos. Echos pretty much rely on the techs measurements and even a slightly different angle can give slightly different measurements.
 

normofthenorth

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Good stuff, folks! One thing I recall from the previous discussion of the formulas that incorporate body size, is that they were VERY different from each other! They'd all produce similar (identical?) results for people of average size, but would diverge strongly toward both extremes of body size. IIRC, one maybe varied with height, and one with weight, or maybe height squared. (Weight probably varies proportionally to height raised to the ~2.5 power on average -- i.e., between squared and cubed. Sorry, non-math-geeks!)
 

hetmarie

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@ Keith, echos can vary from the machine to the tech using the machine. That's why it's good if you can get them done at the same clinic/hospital by the same person every year. There can be shadows that some are including in the measurement and that's why the size can vary. CT Scans are better than echos and MRIs are more accurate than either. Good luck to you!
 

ElectLive

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The relative accuracy of Echo, CT, and MRI is discussed in pretty good detail in the Cleveland Clinic webchat (link in original post above). It seems to be most influenced by location. As is noted, though, aneurysms rarely shrink.

I had an ascending aortic aneurysm, where an echo is most reliable, and in fact, my echo and CT showed identical size. However, it was as if the echo was thrown away after I had the CT done, every thing my surgeon showed me, he used the CT from that point forward, similar to a point made in the webchat.
 

Keith

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I finally met with my surgeon and he said pretty much the same thing: the guidelines for aortic aneurysms in BAV patients is lower than for others and is getting lower all the time. Mine is only around 4.7 or 4.8 and I've already got a surgery date for next month. I thing the attitude is that it is not an emergency at that point, but the risk is less to go ahead and replace it.
 

normofthenorth

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But the guidelines overall are certainly shifting toward a more cautious, preventative approach.
Maybe it's just me, but I'm struck by the language. In most discussions of surgery, taking a "conservative" or "cautious" approach means avoiding or delaying surgery as long as possible. (E.g., getting treated conservatively for an Achilles-tendon rupture means no cutting, just a boot or a series of casts. If the schedule is fast and aggressive enough, it actually works very well, statistically.)

What's happened here is that the surgery has become so reliable, so low-mortality, and so "routine" -- to the practitioners, NOT the patients! -- and the alternatives without surgery are so bleak and risky, that going under the knife sooner can reasonably labeled the "cautious approach"! :)
 

ElectLive

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Keith - Even though I agreed my surgery was the right medical decision, I will say it still felt a little strange strolling into the surgical waiting room the morning of completely symptom free. But the key thing with aneurysms of course is that emergency status can be instantaneous, at any random size for any given patient. Just on this forum, I can think right off hand of a rupture at 4.7 for one, but stability at 6.7 for another. Almost hard to believe.

I had around a month to get ready, too. It's not easy, but I was able to find time to research, get prepared, then relax with family the last few days. Best wishes.
 

ElectLive

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Norm - You're exactly right, and I recognized the irony when I wrote those words. As posted just above, I think it's the unpredictability of dissection and rupture that drives it, and does in fact make surgery more "cautious", so to speak. Add in the outcomes of dissection or worse rupture, and it's more than enough to make everyone nervous, including symptom free patients.
 
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