Why wait for surgery on aneurysm and BAV if mortality risk is low?

[HopefulHeart]

I've repeatedly read advice from Cardios and surgeons, both in my home city as well as from well-known high volume heart surgery centers such as Cleveland Clinic, that states you should wait until 5.0 cm or 5.5 cm in aortic diameter before surgical repair is recommended. Yet most hospitals, especially top surgical centers such as Mayo and CC, state that the mortality risk is very low with these surgeries and most patients go on to lead normal lives after surgery. well, if the surgery is that safe with those good outcomes ( I know there are still risks involved as with any surgery) and the patient does not have additional conditions that would make the surgery more risky, why wait until 5.0 or 5.5 cm? I know heart surgery is a big deal and it's not something you'd want to happily run towards doing, but it seems the risks of waiting and letting an aneurysm get larger and possibly be aggravated by other things such as age, decline in health, etc are far greater. I don't understand this position that surgeons and cardios are taking. What do you all think?

 

[dornole]

Well, I've always assumed that during the waiting period, they believe the risk of mortality from the aneurysm is "even lower." When that's not true any more, time to operate. You also have the potential benefit of additional progress in surgical techniques, imaging and technology by waiting.

 

[cldlhd]

I agree with Dornole about the risk assessment but I didn't wait i requested surgery and mine was measured at either 4.7 is 4.8.

 

[Ultrarunner]

I've wondered the same thing. My surgeon says the mortality risk of surgery is 4%, which is higher than the risk of dissection. I'm at 4.7-4.8 cm currently. But the fact that there is a significant dissection risk in waiting a few years and then still having the surgery risk makes me wonder if that makes sense. Also, I have a very active lifestyle (I climb over 5,000' a day), which should be taken into account. But my thoughts don't really matter, I don't have the option of electing for earlier surgery anyway, since I'm in Canada.

 

[cldlhd]

I've wondered the same thing. My surgeon says the mortality risk of surgery is 4%, which is higher than the risk of dissection. I'm at 4.7-4.8 cm currently. But the fact that there is a significant dissection risk in waiting a few years and then still having the surgery risk makes me wonder if that makes sense. Also, I have a very active lifestyle (I climb over 5,000' a day), which should be taken into account. But my thoughts don't really matter, I don't have the option of electing for earlier surgery anyway, since I'm in Canada.

I had my surgery at the same measurements you have. It turned out when the surgeon measured the aneurysm it was 4.99 cm. I agree with your opinion that lifestyle should factor in. I factored it in and my surgeon agreed, he said I was on the cusp of needing surgery but if I didn't want to deal with the restrictions or thought I might overdue it then surgery would make sense. He quoted the risk of surgery at 1 to 2%. I imagine with private insurance in the U.S. they have a threshold and anything under it and they won't pay for the surgery. I believe the decision can be affected by the surgeons opinion though.

 

[epstns]

Well, it is all driven by the statistics. If your odds of death are less without treatment than they would be on the OR table, no surgery yet. Once the scales tip and your odds of death without treatment are greater than your odds of death during or from surgery, it is time to schedule the OR.

I'm sure it is that way with valve replacement, so why would it be any different with aortic root repairs added? The stats may be different, but the logic remains.