Questions re: progression of ascending aortic aneurysm

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jmo3

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Hi there, I'm 49 y/o and coming up on 3 years post AVR (ON-X mechanical) this July. All is well but I'm a little concerned about the progression of an ascending aortic aneurysm. Prior to and during surgery in 2016 my surgeon measured the aneurysm at 40mm which is below the threshold for repair or replacement. This is about the same diameter it had been since about 2007 (fluctuating between 38mm and 41mm over that time) as measured by echocardiogram. Since then I have been going in annually for echos and the number was 41mm in 2017 and has been at 43mm for the past two years. We confirmed this with a CT scan last year as I'm aware that echocardiogram isn't always precise.

My main questions are:

1. how quickly do these kinds of aneurysms typically progress after AVR?
2. anyone have any experience with a second OHS for aorta replacement years after AVR?
3. I know I shouldn't be weightlifting or lifting anything heavy in general but is it ok to do push-ups and planks?

Post-surgery my surgeon said there was a 10% chance I would need the aorta replaced at some future point so I'm still hopeful but unsure.

P.S. Thanks in advance, this forum is such a great resource!
 

Warrick

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Im in the same boat as you, my aorta was/is 41.2mm but not replaced in 2015, if u search the forum there is alot on aneurym and it has been the cause of a second surgery with a mech after a number of years for quite a few here, some after a few years, some after 20 yrs so there is no hard and fast rule for progression. I have read some individual surgeons have a cut off for repair of only 40mm if doing AVR on a bicuspid patient, so over 40mm they do a repair on the artery.

There are also varying stats for the number of BAV replacements that have or necessitate aneurym repair later in life even after AVR but from what Ive read it seems closer to 65% and the number Ive read on here would seem to suggest that number is much closer than the 10% unfortunately.
 

jmo3

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Thanks for the reply, Warrick. That percentage sounds more realistic based on what you’re saying about re-ops in this community. I’m also realizing that Cleveland Clinic has more conservative guidelines for when to replace an aorta based on height. Since I’m 5’6” they recommend replacement at 47mm as opposed to the traditional 50mm. Bummer, but I suppose it’s better to be prepared than surprised.
 

pellicle

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Hi

Hi there, I'm 49 y/o and coming up on 3 years post AVR (ON-X mechanical) this July. All is well but I'm a little concerned about the progression of an ascending aortic aneurysm.
interesting and difficult question. There is to my knowledge nothing more to do than "watch and wait"

I'll put this here in case you have not seen it, but it's a useful summary of the issues

https://www.anzsvs.org.au/patient-information/aortic-aneurysm/


Prior to and during surgery in 2016 my surgeon measured the aneurysm at 40mm which is below the threshold for repair or replacement. This is about the same diameter it had been since about 2007 (fluctuating between 38mm and 41mm over that time) as measured by echocardiogram.
...
We confirmed this with a CT scan last year as I'm aware that echocardiogram isn't always precise.
I see you know that the fluctuations are due to the inaccuracy of Echo measurements, and the difficulty of making a precise determination in that fuzzy mess.

My main questions are:

1. how quickly do these kinds of aneurysms typically progress after AVR?
my understanding is that the scar tissue from surgery can stabilise it ... however in my own case, despite 2 prior surgeries, my aneurysm developed some time after I was done with my 2nd surgery. I skipped a lot of scans (due to international living) and can only say that up to 13 years after my 2nd OHS there was no evidence of it.

2. anyone have any experience with a second OHS for aorta replacement years after AVR?
Well I do ... although my aortic aneurysm fix was my 3rd OHS.

3. I know I shouldn't be weightlifting or lifting anything heavy in general but is it ok to do push-ups and planks?
its hard to be definite, but from what I was told and what I've subsequently read that its best to consider the vascular system as a sort of hydraulic system (which it also is). The less hydraulic pressure you place on the primary outlet from the pump the better. So stuff like cycling where you aim for higher cadence spinning puts the pump rate high, but the pressure low. Stuff like power lifting does a bit of both, but more pressure.

I found that the following words in this article resonated what my surgeon told me on multiple occasions (like when I was 12, 28 and 48) about avoiding competitive sports


It is important to highlight the difference between recreational sports activity and competitive activity in which athletes undertake a hard training programme. A competitive athlete is one who participates in an organized team or individual sport, which requires systematic training and regular competition against others and places a high premium on athletic excellence and achievement.71 Competitive athletes have typically a strong inclination to push themselves to extremely high levels of exertion, often exceeding their native physical limits, sometimes for prolonged periods of time, regardless of other considerations. On the other hand, individuals participating in recreational sports engage in a range of exercise levels from modest to vigorous on either a regular or an inconsistent basis, which do not require systematic training or the pursuit of excellence, and are without the same pressure to excel against others that characterizes competitive sports.


So my view is this:
  • I do weight training, but do not "go insane", I train with lighter weights and aim for strength of body and endurance not bulking (so for instance bench pressing less than my body mass, higher rep sets)
  • Walking (as I posted recently about a challenging hill climb)
  • Cross Country skiing (which I did for a number of years but recreationally although seriously in intent)
  • moderation
Post-surgery my surgeon said there was a 10% chance I would need the aorta replaced at some future point so I'm still hopeful but unsure.
I think that's a reasonable stance.

Best Wishes
 
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pellicle

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...if u search the forum there is alot on aneurym and it has been the cause of a second surgery with a mech after a number of years for quite a few here
interestingly I would anticipate that it would may well require the replacement of any prosthetic valve, however I don't seem to recall it being associated with bio-prosthetics.

I would wonder if that's due to one or more of the following:
  • mostly they are placed in older people
  • perhaps they are replaced so frequently in younger recipients that it just gets included in the "service shedule"
  • the older people who were BAV may not have the expression of the gene that causes the degradation of the aortic arterial tissue
interesting question tho
 

Gordo60

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3. I know I shouldn't be weightlifting or lifting anything heavy in general but is it ok to do push-ups and planks?
Planks and pushups may potentially be worse than sensible weight training (as opposed to heavy “lifting”). There’s often an isometric component to planks and a tendency to hold one’s breath both of which are a concern. Slow reps / static holds raise blood pressure a lot more than moderate speed repetitions. Depending on one’s strength even push ups can be problematic in that it could require to much straining and unlike weight trying you can’t control the weight applied. The beauty of weight training unlike body weight exercises is that you can choose safe lighter weights to start with then “gradually” increase reps / weight over time.


Taken from another post (see below). My current weight training (not heavy lifting) strategy to minimise raising blood pressure / stress on the aneurysm is:

1. Dumbbells only, a barbell using both arms introduces a greater sticking / straining point.
2. Most exercises are single leg / arm to halve the weight load on the body
3. Mostly isolation exercises, big compound exercises impact blood pressure much more so
4. Repetitions no less than 15 - 20
5. No breath holding, breathe smoothly during reps
6. Stop short of any straining, don’t try to force out any final reps

This thread might interest you:

 

Gordo60

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So stuff like cycling where you aim for higher cadence spinning puts the pump rate high
Hi @ @pellicle, do you have any information sources on this please?

In the case of aneurysms I’ve often seen it mentioned that those affected should avoid raising their heart rate to higher levels which I thought would be the case with spin cycling?

However this article I think is quite balanced with input from highly experienced aortic surgeon Allan Stewart:

 

DDT77

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My main questions are:
1. how quickly do these kinds of aneurysms typically progress after AVR?
2. anyone have any experience with a second OHS for aorta replacement years after AVR?
3. I know I shouldn't be weightlifting or lifting anything heavy in general but is it ok to do push-ups and planks?
Ross Procedure: 1998, AVR+AAR: 2017 (ON-X + graft).
My echo numbers on Aortic Root were also 40-43 mm over a number of years, ascending measurement showed up at some point at 50 mm :(. After latest OHS, surgeon recommended NO pushups, due to spike in blood pressure during these types of exercises. Limit of 50 lbs also is prudent. Don't want to damage suturing (fatigue loading over hopefully billion load cycles). As physics (pressure vessel) is same prior to and after surgery for these vessels, I would try to avoid such exercises requiring application of 'Law of Laplace'. Less pressure --> less stress on artery wall --> less dilation! I would believe that use of some beta blocker would also be prudent to reduce pressure and resultant wall stress.
 

Superbob

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Fascinating discussions. I am dealing with an ascending aortic aneurysm variously measured at 5.3 cm to 5.6 cm and am heading day after tomorrow to a surgeon consultation. Over the past two years, I became enthusiastically involved in a senior exercise class that featured a good deal of planking. Could it be I exacerbated the aneurysm with that kind of exercise? I suppose it would be naive to suppose it might shrink a little with my retreating from that kind of exercise, but could I perhaps stabilize it by just walking and swimming, no push-up-type or heavy weight stuff? (*I have read somewhere that 6.0 cm is when rupture risk is especially high. I had been stable at 5.0 for many years.
 

pellicle

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Hi @ @pellicle, do you have any information sources on this please?
to be clear I was meaning before the aneurysm was considered "watch list" material, as the person I was responding to did not seem to have anything notable in diameter. I myself was "discovered" at 5.6cm (or the like) and was told to not "strain" but high HR was considered OK. At the time I was doing a lot of "nordic pole walking" barefoot down at the beach, so I asked both my cardiologist and my surgeon.

My "source" is personal communication with my surgeon and cardiologist. After surgery I specifically enquired about exersize (meaning I enquired about specifics) and my surgeon said when questioned directly that if cycling I got my HR to 178 that was OK with him. That team has got me to here from 5 years old and so lets just say "I trust them".

I understand it if this is not satisfactory.

I saw over 170 on my recent walk up the rock face and have also seen that in XC skiing numbers of times.

But again, I don't have an aneurysm now (although they were curious about where the graft ended and I started as apparently that was enlarged, but hasn't changed.

I've not heard of high HR (without other complications such as arterial obstructions) causing excessive pressure on the vascular system, but I have heard that the compression of the largest muscle group (the quads) in conjunction to pressurising the lungs (spongy mass) does send BP through the roof. This is why I mentioned hydraulics.

PS:
your cited article shows a woman running up stairs, which would be much higher pressures on the quads than spinning, further it says:
"there have been no studies on the risk of aortic aneurysm dissection in people who engage in high intensity interval training"

and then discusses proper warm up ... which I would always do, and its probably best to mention that in an obvious way than assume you shouldn't just "go at it hard" (who would?)

then in BOLD it says:
"In short, a person whose aortic aneyrysm is less than 5cm can safely do high intensity interval training - but the following criteria must be met: The patient must also have a tri-leaflet aortic valve; must not have a connective tissue disorder and must not be experiencing symptoms from the aortic aneurysm!"

at that time I was using somebody elses tri-leaflet aortic valve
 
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pellicle

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.. Could it be I exacerbated the aneurysm with that kind of exercise?
its possible, but I wouldn't punish yourself over any health decisions you made. I could have done my aneurysm "no help" by towing sleds when XC Skiing (among other things).

It is what it is and I'd argue that the other health benefits may have been better.

(PS I don't plank but that probably means nothing)
 

Gordo60

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planking. Could it be I exacerbated the aneurysm with that kind of exercise?
Most of my knowledge has come from personal research. I’m certainly no expert in such things.

No one really knows from what I’ve read. Probably not. However the risk seems to be higher if there’s straining involved / one holds their breath / it’s a longer count “static” hold. Essentially anything that causes blood pressure to rise significantly.

I’d guess that if the plank was performed for a number of repetitions, with no straining, no breath holding and a minimal static / isometric hold when at the top of the move it would likely be ok.

I’ve been told by my cardio and read that once the aneurysm is above 5.0 mm it pays to be extra careful.

But once the aneurysm is repaired as long as blood pressure is kept under control whether during normal living, aerobic or resistance training it’s probably unlikely any of this will result in an aneurysm progressing any faster than what’s genetically programmed into the aorta. Of course maintaining a healthy heart lifestyle in general is important. My cardio regularly reminds me of that as he says otherwise I could die from common heart related issues before the aneurysm ever finishes me off.
 

Agian

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Hi Superbob, I've been reading about your journey.

There are so many exercises to choose from. I go for long walks and lift very light weights. I do this everyday. Under the fat, which I'm intending to lose, I'm quite muscular. I've gone from a fit young man to a middle aged 'vet fokker'.
I see no need to strain. I haven't done a push up or sit up for years... too lazy. We all age together :)

Keep being super.

All the best.
 
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Gail in Ca

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When my aneurysm was discovered in '89, my doctor said it was at 6cm. I had surgery and my aorta fell apart in his hands when he was just going to open it, add a graft and close over it. I read my surgeon's notes recently and my aneurysm was actually at 7cm when he got in there. I suppose the echo's and scans are better now, but can they determine how the aortic tissue is? Whether it is ready to dissect or not?
Anyway, I had the whole thing redone in '09, (valve in graft this time), due to BE, and all is going well.
 

Keithl

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Hi there, I'm 49 y/o and coming up on 3 years post AVR (ON-X mechanical) this July. All is well but I'm a little concerned about the progression of an ascending aortic aneurysm. Prior to and during surgery in 2016 my surgeon measured the aneurysm at 40mm which is below the threshold for repair or replacement. This is about the same diameter it had been since about 2007 (fluctuating between 38mm and 41mm over that time) as measured by echocardiogram. Since then I have been going in annually for echos and the number was 41mm in 2017 and has been at 43mm for the past two years. We confirmed this with a CT scan last year as I'm aware that echocardiogram isn't always precise.

My main questions are:

1. how quickly do these kinds of aneurysms typically progress after AVR?
2. anyone have any experience with a second OHS for aorta replacement years after AVR?
3. I know I shouldn't be weightlifting or lifting anything heavy in general but is it ok to do push-ups and planks?

Post-surgery my surgeon said there was a 10% chance I would need the aorta replaced at some future point so I'm still hopeful but unsure.

P.S. Thanks in advance, this forum is such a great resource!

I am rather shocked as when my valve and aneurysm were diagnosed in 2007 I was told they watch both and when they go in for either they will do both. This year aneurism hit 5.1 so they did both. No way I wanted 2 different surgeries. Going through this once is more than enough for me.
 

AZ Don

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Hi jmo3, As I recall, I've read that aneurysms tend to grow at about 1mm per year but that until they reach a size of about 47mm, growth is not inevitable, and that after such size it generally is. I should add that there are anecdotal reports of Losartan slowing aneurysm growth. Can't recall seeing any reference to the impact of AVR on aneurysm growth.

I'm in the opposite situation as you. I had an aortic aneurysm repair that spared my well functioning BAV, which is now moderately leaking. So watching and waiting to see if someday that will need to be replaced. It has been stable for several years now.
 

Keithl

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I was on Losartan and tend to believe it helped as my growth was very slow u til this last year. I still,was prepared to do both regardless if either needed to get replaced, no way I am doing this again.
 
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