What Diameter Aorta Requires Replacement?

[AZ Don]

It's not an easy decision, and I found it odd that my surgeon so clearly put the decision in my hands when I knew so little about it. I think he favored mechanical in my case but he did not make a recommendation. I have not seen too many discussions about those with 3 choices: tissue, mechanical, or a valve sparing procedure. Of the 3 I think the valve sparing procedure may actually be the more complex one, and so it may be even more important to have a highly qualified surgeon. I did investigate how long my valve might last. The numbers I found were all over the place but the surgeon's estimate was right in the middle, so it seemed reasonable. Although some have clear preferences, the choice between tissue and mechanical is often difficult. The way I looked at it, the valve sparing procedure is similar to the tissue choice but superior because there was a chance of never needing another surgery and my understanding was that my native valve was superior to any replacement at the time. It was hard to argue with: if it ain't broke, don't fix it. So based on the data I still think I made the right choice. Course it may be that there just isn't enough data yet. I've seen one or two others that didn't get so many years after a valve sparing procedure. Mine isn't done yet, but the echo numbers have deteriorated enough that I'm doing my next follow-up with a surgeon - both for a second opinion and to get to know the surgeon (due to insurance changes I can't go back to my prior one).

 

[pellicle]

Hi

Thanks pelllicle and Don. I apologize for my valve ignorance..

No apology needed ... the reason for coming here is to displace ignorance and try to get information with which to make our decisions informed ones

I learn heaps here all the time

 

[ottagal]

Thanks pelllicle and Don. I apologize for my valve ignorance. I've been concentrating entirely on the aorta replacement so far. I made assumptions that I shouldn't have. You make a great point about the through the artery valve being smaller, As an active person, this wouldn't be a good fit. So maybe I should leave it out of my planning entirely.

Don, given your experience, perhaps opting for the valve sparing procedure may not be the best.plan. I haven't been given an estimate of how long my valve would last. All I know is the regurgitation is "Mild-Moderate" at the moment. Maybe I should just get everything done at the same time. I'm sorry you have to go through surgery again so soon.

Ultrarunner, AZ Don and others,

Thought you might find this article of interest. Dr. Tirone David is a cardiac surgeon in Toronto who actually developed the David procedure/valve sparing. This discusses the outcomes after 20 years.

You may have already seen this.

http://www.annalscts.com/article/view/1396/2011

 

[MethodAir]

In your case, you had to have surgery because of your valve, so they also did the aorta. My BAV isn't too bad yet, so the surgeon said he would do a valve sparing procedure if it doesn't get worse before the aorta surgery. Have you heard of other Canadians getting their aortas replaced

The surgical intervention point in Canada for ascending and root aneurysm may be lower when valve is bicuspid. There is probably a range that the surgeon will consider (along with other factors).

The bicuspid aortic valve is considered diseased, and inherently has performance and longevity issues, so I don't really understand the logic in sparing it (if they might be there already -- and there are high performance alternatives that reduce the risk of a re-op). A 1 in 10 chance could be considered high risk.

Also, CT scan may show a slightly larger diameter than echo.

 

[pellicle]

I love Steely Dan ... in my top 10 bands!

 

[Ultrarunner]

Me too. Music is important to me. I should probably spend more time listening to music and relaxing while I wait for the inevitable.

Like Don, I find it strange that the valve decision is entirely mine, with no recommendation from the surgeon. I 'm fairly analytical and I should be able to sort through the data, but not everyone would be.

The outcomes of valve sparing seem pretty good based on the study mentioned by ottagal. I think my surgeon, who specializes in the valve sparing surgery, suggested it was more complicated and therefore had a higher mortality risk (3% to 4%). That makes me wonder if a simpler procedure would lower the risk and tilt the odds in the direction of replacing the aorta earlier.

 

[cldlhd]

My surgeon also specializes in valve repair and while he said repair is more complicated he didn't say it was riskier. He still put it at 1 to 2%.

 

[Ultrarunner]

My surgeon also specializes in valve repair and while he said repair is more complicated he didn't say it was riskier. He still put it at 1 to 2%.

I wonder if dissection risk each year is more than 1 to 2% at an ascending aorta diameter of 4.8cm?

 

[cldlhd]

I asked ,he told me a lot would depend on what you do physically and also not everybody's arteries are the same so the way I saw it I preferred the risk of surgery, which I would need eventually, to the risk of walking around with it. Plus the scare of the surgery is focused, as in when you get close to the day of surgery the fear is more intense than the walking around with an aneurysm fear but once it's over so is the fear. Mine was measured at 4.8 but turned out to be a little larger and the post surgery report described it as thin walled so I'm glad it's done.

 

[Ultrarunner]

I agree with your logic. Maybe I should be more insistent with my surgeon the next time I see him. In the mean time, I've dialed back the exercise intensity so much from what I was doing that I should be good for a while. Maybe when I get to 5.0 cm I'll be able to convince him to go ahead.

 

[cldlhd]

Nothing wrong with that thinking. I don't want it to seem like I'm trying to talk you into it in anyway but I just wanted to give my perspective and experience.It could take years to reach 5.0 or 5.5 and who knows what kind of advances could take place in the meantime.

 

[aweunited]

I thought i wold pipe up since I have some recent info on max HR recommendations. My cardiologist pre-surgery was looking for % of max, I believe he might have mentioned keeping it <100beats per minute at one point too.

Then again, due to a TON of stresses in my life my aortic root dialated from 4.5cm diameter to 5.1cm diameter. Being borderline I thought about holding off of surgery for a few years to try and manage the problem with less stress. I elected to have the surgery since I figured i would heal better being younger (32) and since we have a baby on the way soon. Post-op the Surgeon told me that my root was VERY thin, and his opinion was I would have dissected within the next year or two.

On the;e; bright note, the surgeon said he felt post-op I could recover to jogging/running/cardio again (70-75% of max HR), with light weight lifting (<half of body weight max.)

Additionally , we are pretty sure I have Marfan Syndrome 9a connective tissue disorder.) We are just waiting on the genetic test.
.

 

[Ultrarunner]

Thanks for posting. Do you remember what % of max your cardiologist recommended? I think this would be a better limit than an arbitrary number since I have a high maximum heart rate. I can't imagine staying under 100 bpm. Neither my sports cardiologist nor my surgeon offered an opinion on this.

You certainly made the right decision. Quite a few people on this forum have indicated that the actual state of their valve or aorta was worse than the scans suggested. But since my surgeon wants to wait, I'm wondering about the importance of controlling stress. I have the option of semi-retiring, so if I can get feedback suggesting work stress can put an aneurism at risk, that would make it an easy decision. Unfortunately I couldn't get much information on stress from my specialists.

 

[aweunited]

Sorry I forgot the cardiologist recommendations. for my case I believe I remember him saying 60% of estimated max ((220-32)*0.6 = 112) But I think he also said something like 130bpm max too, which would be more like 70%. Perhaps the most telling piece of advice I got was not to "strain" myself. I took that to mean no more sprint workouts after I am healed up.

Now some anecdotal evidence about stress: My aortic root was at 4.5cm on an Echo in January of this year. I then proceeded to go on a 2 month business trip away from my family, when that was done we moved the whole family 500 miles to my new job (same company,) bought a house, and got pregnant. I guess you could say I did ALL the stressful things and haven't been taking care of myself very well either. The takeaway is that when I finally followed up with a cardiologist in August, my CT scan showed that my root was then 5.1cm. For my personal case, I am sure that stress played a factor (my blood pressure seemed to be up 10 points at the cardiologist,) but I also believe that I DO have Marfan syndrome, which means I probably have weaker blood vessels anyway.

One silver lining is that I calmed waaaay down, took a beta blocker (Losartan) which lowered my BP by 15 points and took it easy from August to November. I don't think we saw any growth in the root during that period. For me I feel like it wasn't just the one stressful thing, it was all the things. So my opinion is that unless you really don't like your job, I would stick to routine. And ease back from the super hard running (sounds like you already have), and settle for long slow distance.

If you get frustrated you might try buying a cheap blood pressure monitor and checking your blood pressure DURING your runs to see what your personal correlation between Heart rate and Blood Pressure are. The reason the Surgeon told me that weight lifting is out is because studies have show that heavy weights have increased some people BP to something like 300 over 150.

 

[Ultrarunner]

I did plan to buy a blood pressure monitor suitable for use while exercising. But my surgeon said not to bother since he couldn't give me any guidelines on a safe blood pressure or heart rate anyway. So I just decided to make my own guidelines from feedback on this forum and other reading. I've stopped racing, interval and tempo running and reduced my normal run pace from 4:30 minute kilometres to 5:00. I've also stopped long runs, based on some who were told to limit distance. I guess I don't really need to run long since I'm no,longer training for races. I do miss the days when I could roll out of bed and run 50 miles of I wanted. ;-)

Thanks for mentioning your experience with stress. I think anecdotal evidence is all that is available so I'm trying to read as much as possible. I can't imagine my aorta growing as quickly as yours, since I only have BAV, not Marfans. But the surgeon did say that if it started to grow rapidly he would schedule the surgery. I'm in the financial services industry and stress can be extreme when I have to deal with client emotions during a downturn. I've been wanting to scale back my business and maybe I'm just looking for an excuse to do so.

 

[cldlhd]

Sorry I forgot the cardiologist recommendations. for my case I believe I remember him saying 60% of estimated max ((220-32)*0.6 = 112) But I think he also said something like 130bpm max too, which would be more like 70%. Perhaps the most telling piece of advice I got was not to "strain" myself. I took that to mean no more sprint workouts after I am healed up.

Now some anecdotal evidence about stress: My aortic root was at 4.5cm on an Echo in January of this year. I then proceeded to go on a 2 month business trip away from my family, when that was done we moved the whole family 500 miles to my new job (same company,) bought a house, and got pregnant. I guess you could say I did ALL the stressful things and haven't been taking care of myself very well either. The takeaway is that when I finally followed up with a cardiologist in August, my CT scan showed that my root was then 5.1cm. For my personal case, I am sure that stress played a factor (my blood pressure seemed to be up 10 points at the cardiologist,) but I also believe that I DO have Marfan syndrome, which means I probably have weaker blood vessels anyway.

One silver lining is that I calmed waaaay down, took a beta blocker (Losartan) which lowered my BP by 15 points and took it easy from August to November. I don't think we saw any growth in the root during that period. For me I feel like it wasn't just the one stressful thing, it was all the things. So my opinion is that unless you really don't like your job, I would stick to routine. And ease back from the super hard running (sounds like you already have), and settle for long slow distance.

If you get frustrated you might try buying a cheap blood pressure monitor and checking your blood pressure DURING your runs to see what your personal correlation between Heart rate and Blood Pressure are. The reason the Surgeon told me that weight lifting is out is because studies have show that heavy weights have increased some people BP to something like 300 over 150.

I wonder if the suspected Marfans plays into the somewhat restricted heart rate or its just come surgeons/cardiologists are more conservative than others. I have bav not marfans but my surgeon told me at 3 months post surgery I had no restrictions at all.

 

[aweunited]

I am sure it does have something to do with the Marfan. From what I understood from the post surgical report, the removed aortic tissue showed a lot of wear and tear. Kind of like rusty pipes or something. Soooo, we will try and keep my blood pressure from getting too high while exercising. The big thing is no heavy weights (>half my body weight) since that seems to drive BP up a lot.

I am really looking forward to getting back to some running and hiking once I work my way through cardiac rehab. Here is to hoping my hearts electrical system plays along.

 

[Brynn]

I was recently shocked to learn my ascending aorta is 5.1,cm. I have a BAV, have had coarc repair twice, once at age 4 and again 46. I also have a small VSD, with moderate regurgitation. I think I should mention this change in size of dilation is significant, it was 2.2 in 2011. I am 58 and am a petite woman. I am very fit and active, and have had no issues, except that I do have frequent arrhythmia's. My new cardiologist feels this number for aorta might not be accurate as echo showed it to be 4.8, still significant change in my opinion. She wants to wait 6 months to repeat CT with contrast. I'm not sure this is prudent. Any input would be appreciated.

 

[AZ Don]

It's my understanding that a quick change in size is a criteria for surgery. I'm not sure what is considered quick, but typical growth is 1 to 2 mm per year. Your change is clearly not typical. If your coarc repair was also due to aneurysm then I think that makes the case for surgery stronger. I would get a 2nd opinion from a good cardio thoracic surgeon

 

[Ultrarunner]

I would second what Don said Brynn. My aorta has grown by 1mm per year for the past eight years. My surgeon said if that rate increased significantly, he would operate. You've not only had a very rapid growth rate, but in absolute terms you would qualify for surgery. The CT scan result is more reliable than the echo measurement, so I'm surprised he would say what he did. But even if the 4.8 cm number were correct, you would be a candidate for aorta replacement based on the calculator that takes body size into account. At 4.8 cm and 5' 11" I'm right on the line where surgery would prevent 95% of dissections. You are likely larger than 4.8 cm and shorter than me, so you would be well above that line. Get a surgeon's opinion.