5.0 cm surgical threshold for Aortic Root Aneurysms

[NavyMatt]

I am a 34yo male, with BAV and ascending aortic root aneurysm of 5.2 cm (at root- it gets smaller quickly as you go up the aorta).  Have been watching 18 months (MRI/CT/TEE) with no change in measurements.

I am debating surgery, and have mixed opinions from doctors on whether to have it now, or watch and wait.

Despite many visits to CT surgeons, I still have not gotten solid answers to several questions, relating to the 5.0 cm standard above which surgery is recommended.

1) Where in the anatomy is the 5.0 cm applicable?  Is it applicable to the root (which is normally larger than the ascending aorta?).  Some doctors have indicated that the 5.0 cm standard is applied 1.0 cm above the sinuses; others have said it's applicable anywhere in the ascending aorta.

For me, it makes a difference, and is important.  I'm about 4.5 cm above the root, narrowing even more towards the arch.

2) Did any of the studies, from which the 5.0 cm standard is derived, take into account age and/or related conditions?  For instance, are a 35 year old and a 70 year old, with the same measurement, at equal chances of dissection?

I do know that sometimes I've seen BAVs "lower" the threshold by .5 cm or so.  But what about Hypertension (I have normal BP)?  I have seen in a couple of the studies I've glanced through that Hypertension is very common amongst those actually dissecting.  Does my normal BP change the surgical threshhold?

Something about a one-size-fits-all 5.0 cm standard seems off, to me, and so I'm looking for more data.

I appreciate any help that experts might give on these questions.  Thanks much, and hope this helps others, too.


This discussion is related to Enlarged aortic root and bicuspic aortic valve.

[kenkeith]

...Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater...

Although many articles have described techniques for resection of thoracic aortic aneurysms, limited information on the natural history of this disorder is available to aid in defining criteria for surgical intervention.

It is recommend 5.5 cm as an acceptable size for elective resection of ascending aortic aneurysms, because resection can be performed with relatively low mortality. For aneurysms of the descending aorta, in which perioperative complications are greater and the median size at the time of complication is larger, we recommend intervention at 6.5 cm.

For BAC sometimes aorta surgery can be performed and the aorta valve is saved.  That is a consideration that should be taken into account as untreated aorta aneurysm can damage the valve if left untreated.  

If age is a consideration then the option for surgery woiuld favor the younger aged individuals with a greater lifetime expectations and a higher survivor rate. I don't know what role pb has for any progression of measurement, but it certainly implies the overall general health is favorable and that may indicate better recovery.

[NavyMatt]

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[NavyMatt]

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[NavyMatt]

This is an update for anyone reading this post and curious as to my outcome:

I ended up having the surgery.  

I basically got to what seemed like the end of the road with researching my questions as to the "spec" at which surgery should be performed for a aneurysm of the aortic root in a BAV. I had many questions as to how the 5.0cm spec was derived, and how it might be adjusted for several factors. I got to a point where the best experts (I found several I was convinced were tops) basically admitted "we really just don't know".  They (very willingly) conceded that the 5.0 cm number is very arbitrary and has little real data supporting it.  There is is very skewed sample population since most people who find themselves with large aneurysms get a surgery- no one wants to be the one to contribute data for the "authoritative" point at which rupture occurs.  

My local cardiologist, who helped a lot in researching, basically summed it up and said "okay, so let's say maybe it's really 5.5 or 6  and you're not there yet.  But we know you're way out of normal and therefore you still have abormally high risk.  What are you waiting for?  Why not just do it and buy down your risk"?  To this, I had ready answers- there's risk to the surgery, there's the lifestyle impact downstream if I get a mechanical valve, etc.

What ended up tipping the balance in favor of surgery for me was the advise I got at Mass General Hospital from the CT surgeons.  They were much more upbeat on the chances of success of valve-sparing- they told me I had a 95%+ chance of success of doing a valve sparing procedure (Previously I'd been told 50-50).  This mattered a lot- I really didn't want a valve replacement.  They also took a harsher view of the anatomy of my aneurysm, and thought- more on the basis of direct comparison with features they've seen in their patients, than on a "size" factor.  So both sides of the equation seemed to tilt more towards getting surgery.  They also thought my aortic regurgitation was more severe than others had assessed, and thought they might tighten that up to boot.

And, true to their word, they did succeed in a valve sparing procedure (graft replacement of the ascending aorta with dacron tube.  They also did replacement of the non-coronary sinus of Valsalva which was very enlarged). (They "tightened" my valve but don't think it did much on my aortic insufficiency factor).  Of course, this is open-heart surgery.   I had a very quick recovery in the hospital- out in five days, and was really ready to go in about 3 (I wanted to get out of there!).  I was surprised how much I was up and about really from day 2, and at discharge I was really fully up and about on my own.  

I did have some very bothersome PVC's which started about 4 weeks post-surgery and continued for a month or so.  But those largely subsided on their own, not sure what was up with that.  

I'm now six-months post surgery, and except for the scar, you really wouldn't know I had surgery.  I'm back running, working out.  No push ups yet, probably not for a while.  I still feel the weakness in the sternum- although not sure if that' physical or mental.

[kenkeith]

A quote from my answer to you. "For BAC sometimes aorta surgery can be performed and the aorta valve is saved.  That is a consideration that should be taken into account as untreated aorta aneurysm can damage the valve if left untreated".  

It is good news your valve was saved.  Did saving the valve have a role to not wait too long?  I have read an aortic aneurysm as large as 15 cm without dissection!

[benny212]

Wow, How unreal.  Very weird.  Matt, I feel as if you and I have lived an identical life in terms of our aneurysms.  I had the same experience with researching, rationalizing, and trying to rule out everything.  I too am nervous about not being the same after the surgery, and wonder how long I would actually live with the aneurysm.  I think to myself, perhaps I would never need the surgery.  The problem like you said though is the downside if we are wrong -- no second chance -- we're dead.  I hate having choices like this, but since I have two children, and another on the way, I'm having it done.  I have looked at all of the potential procedures, and have also decided on "valve" sparing procedure.  Originally I was looking at the Ross procedure, and am so glad that I did more diligence and researched until I was blue in the face.  It was all worth it.

Now though -- I'm scared ******** about having the surgery.  I believe I'm going to have it done on November 2nd.  I'm terrified.  Probably way more than the average person.  Normally I'm tough as nails, but hospitals, needles etc really get me crazy.