What Diameter Aorta Requires Replacement?

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MethodAir;n861200 said:
The cardiologist also noted the relationship between heavy weightlifting and the aortic leaflet tear. It makes sense -- the valve by medical definition is 'diseased' and prone to premature wear and tear.

Furthermore, if the ascending aorta is replaced (and the bicuspid valve spared), whose to say that the valve isn't then subject to greater forces. The pressure has to go somewhere.

You could be right but I believe the medical term 'diseased' is pretty broad. I have read that a bicuspid valve is more prone to stenosis but not leaflet tear and I don't see why a graft replacement of the aorta would make the valve "subject to greater forces". The conduits today are flexible and that area is largely downstream of the valve. If anything the replacement of the aneurysm helps the valve to last longer as the valve is less likely to open further than it should.
 
The label is fitting in this context -- as we know, the bicuspid valve is defective and can degrade a lot faster. My bicuspid valve had mild stenosis. Replacing just the ascending aorta could change the way forces are distributed in the area. It's the weak link in a chain that breaks.

That said, I think if someone is sensible, and understands the risk, odds are they should be ok. I was pushing the envelope and had no idea that I had a 'bicuspid aortic valve'.
 
At 10 months out I'm lifting but they told me 60 lbs max...dunno why exactly but I am not about to do that much anyway. My aorta was at 4.7 at the time of surgery but my surgeon told me later that it was very fragile, so I think that the earlier you have aortic surgery, the better. I'm not on any meds at all save a daily 325 mg aspirin. I did develop some pvcs and pacs about a month ago but they went away on their own with no medications. It's been quite a ride. I've made my reservations for my return to scubs diving in March.
 
Well I'm already defective so....
I understand what you're saying but I haven't come across any info that says lifting weights would make a bav wear out quicker.Replacing the aorta wouldn't raise your blood pressure and as the "pipe" is now the right size for the valve you will get less turbulence than with the oversize aneurysm. Think about how a stream flows into a wider area and you get eddies. The smoother flow is considered beneficial to the valve.The aneurysm is the weak link. As for what a cardiologist has to say about it I have a lot more confidence in what a cardiac thoracic surgeon who specializes in the subject. thinks about it.
Hey Jim hows it going? Good to hear about the return to scuba diving. Hope you didn't put the shorts away for the winter going to be 74 on Thursday.
 
cldlhd;n861206 said:
The aneurysm is the weak link.

In my case, the bicuspid aortic valve was the weakest link (not the ascending aorta). The answer is certainly not black and white.
 
I agree it isn't black and white and I guess that's what I was getting at when I commented on what you wrote- " it is not able to handle the same forces as a tricuspid". Each valve is different, there's some people out here who need surgery because of a leaking or stenotic valve while others, like me, only needed it because of my aneurysm. My surgeon told me that it's likely my valve would have lasted my lifetime and never required surgery. It had trace leakage pre surgery and none post with no signs of stenosis. Most bicuspid valves look like a trileaflet where 2 flaps failed to separate but mine was what they call a sievers 0 where it looks "like it wasn't even trying to be trileaflet" in the words of my surgeon. Its 2 equally sized leaflets similar to a mechanical bileaflet valve.I'm not sure if that's a good or bad thing though. I wasn't trying to be rude and I understand erring on the side of caution but as you said it isn't black and white so blanket statements regarding what bav's can or cannot handle aren't going to apply to everyone.
 
Chris wrote: "Hey Jim hows it going? Good to hear about the return to scuba diving. Hope you didn't put the shorts away for the winter going to be 74 on Thursday."

Hi Chris...I'm doing great...hope you are too...had a CT angio in October when i met with my surgeon and everything looks fine...yea this weather is weird but I'll take it!

Happy holidays to you and the family!

Jim
 
MethodAir: I guess I was guilty of the whole black and white thing when I said " the aneurysm is the weak link", for some it's the aneurysm for others the valve and I imagine for some it's both. From what I know of hydraulics regarding pressure and flow I would think increased flow would be at least, if not more, likely to damage a susceptible leaflet than pressure. If so then any exercise that significantly raises heart rate ( cardio ) ,and therefore flow, would potentially tear a leaflet. I would think increased pressure due to heavy lifting would be more likely to rupture an aneurysm. I'm no expert just throwing some of my personal thoughts out there.
Jim: Glad to hear everything looks good on your end. I'm getting a CT angio in January so that'll be the first one since the big day, fingers crossed. Happy Holidays to you also, I have the day off going to head out and try to finish the shopping, wish me luck.
 
Hi Ultrarunner, I had a David valve sparing operation when my root measured 4.8 per MRI. Prior CT's and echo's in the preceding year had ranged from 3.8 to 4.5. Measured with a ruler in surgery it was 5.0. Healthy tricuspid aortic valve. When my surgeon told me that a 4.8 root aneurysm was surely going to expand, and at some point I was inevitably going to have to accept the risk of OHS, I didn't see any logic in waiting. If waiting meant avoiding the OHS then it might make sense to compare the risk of OHS against the risk of dissection, but why accept annual risk of sudden death if it doesn't avoid the risk of OHS? There are many older threads on this website where many of us have questioned the establishment's logic. I am glad I had mine fixed when I did.
 
Dan Zulu;n861367 said:
Hi Ultrarunner, I had a David valve sparing operation when my root measured 4.8 per MRI. Prior CT's and echo's in the preceding year had ranged from 3.8 to 4.5. Measured with a ruler in surgery it was 5.0. Healthy tricuspid aortic valve. When my surgeon told me that a 4.8 root aneurysm was surely going to expand, and at some point I was inevitably going to have to accept the risk of OHS, I didn't see any logic in waiting. If waiting meant avoiding the OHS then it might make sense to compare the risk of OHS against the risk of dissection, but why accept annual risk of sudden death if it doesn't avoid the risk of OHS? There are many older threads on this website where many of us have questioned the establishment's logic. I am glad I had mine fixed when I did.

Yes, it seems logical to me too. Unfortunately, my cardiologists use the Canadian guidelines (5.5 cm) and my cardiac surgeon just said the risk of the surgery was higher than the risk of dissection. He didn't give me the option of having the surgery now. I've heard so many, like you, who's actual measurement is higher than the scans indicated, so that is another reason to be proactive. My next echo is in three months, and then I see the cardiologists again. I think I'll ask to get a referral to another surgeon for a second opinion then. In the mean time, I'll just have to hope I don't dissect!
 
If I missed it I apologize but what size is your aorta according to the measurements? I guess the thinking that the risk of the surgery today is higher than the risk of dissection today so wait is logical but it doesn't factor in the mental state of the patient and how much stress they have knowing that they're walking around with an aneurysm. My surgeon was pretty open to the idea of surgery even though my aneurysm was measured at 4.8 cm at the time. He said the likelihood of dissection was relatively low as long as I stayed within my restrictions but surgery was inevitable and if I didn't want to live with the restrictions then he would do it. So I decided to get it over with. The surgeons know more than we do on the subject but they don't have a crystal ball and let's face it over the years the medical community has changed their position on many occasions. So my thinking was I wanted to ensure I had it done at the hospital and by the surgeon that I chose, plus the restrictions bothered me.
 
4.8 cm (by echo and ultrasound). I'm not overly stressed about the thought that I could dissect. And limits to aren't a problem because I wasn't given any! My limits are ones I've decided on myself after reading the feedback here and elsewhere. I continue to run and hike, but try to keep the heart rate no higher than 140. I can live with this for a year or two, if necessary. I'm also trying to reduce sources of significant stress, but that's probably something I should have been doing more of anyway.
 
Ya stress is bad regardless. Mine was measured at 4.8 but turned out to be 4.99 cm at time surgery. I was told not to lift more than 80 lbs when I had the aneurysm.
 
If waiting meant avoiding the OHS then it might make sense to compare the risk of OHS against the risk of dissection, but why accept annual risk of sudden death if it doesn't avoid the risk of OHS?

I agree with this completely. As I understand it, the intent of the guidelines is to recommend surgery only when the risk of surgery is less than the risk of dissection over 1 year. So then if the wait is more than one year the risk of dissection is greater, and after that there is still the risk of surgery. I've only seen one reasonable argument that addresses this point and I copied it below. In any case the guidelines are what they are and while not all Dr's follow them, many will.

The key to reconciling our observational studies that small aortas pose only a low risk with the IRAD observation of a substantial number of dissections occurring at small sizes lies in recognition of the “at-risk” denominator pool of patients. Our Yale studies present danger rates for patients under observation at our institution with small aortas; indeed, their risk of aortic events, although not zero, is low—too low to justify surgical intervention. For the IRAD patients with dissection, however, these were drawn from the general population at large. Whether the distribution of aortic sizes is normal or paranormal, the number of at-risk patients increases dramatically as one moves toward normal from the largest aortic sizes in the distribution curve (Fig. 14). In fact, it is likely that there are millions of patients in the U.S. with aortas between 4 and 5 cm. One could certainly cause harm by operating prophylactically on all of them. In fact, if one were to divide the numerator of observed dissections in IRAD by a denominator of millions, the observed yearly percentage rate of dissection in the small sizes would be very small. Such interpretation supports, as IRAD concluded, that we maintain our current surgical intervention criteria.
http://content.onlinejacc.org/articl...icleid=1140497
 
Mine was 3.68cm at the root and 4.16cm ascending but they left it and just changed the bicuspid valve for a mechanical.
 
I came across that too, Don. But your point makes sense. There is a risk of dissection each year and then there is still the same risk of surgery (unless, as cldhd says, there are medical advances). So even if the risk of dissection each year is lower than the risk of surgery, the cumulative risk of waiting a few years, and then doing the surgery would be higher.
 

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