Enlarged Aorta

[bob_sixsix]

37 years old, 6'6" tall, 220lbs, no history of heart problems.
I've been going through quite a few tests to rule out Marfan Syndrome. It has been 3 years of tests and I haven't recieved a definitive answer on Marfan!
My doctor at Yale Medical Center put me through fifth ECG and noticed what appeared to be a "bulge" on aortic arch. This bulge was never picked up on previous ECG's or CT scans. He wanted to get a more definitive image of bulge so MRA was ordered. MRA results:
-heart normal in size
-great vessels origin unremarkable
-aorta measured: aortic root 3.8cm,ascending aorta at level of right pulmonary artery 3.7cm,descending aorta at level of left pulmonary artery 2.2cm and descending aorta at level of diaphragmatic crus 1.5cm.
Aortic root is minimally ectatic. No evidence of aneurysmal dilatation seen in remainder of ascending aorta, aortic arch or descending thoracic aorta. No evidence of aortic dissection.

My doctor then ordered an aortogram to get a definitive image of the aortic arch.  I had that done Thursday and preliminary results:
-slightly generous proportions at end of ascending aorta.  No evidence of aneurysm or artherosclerotic disease.
The interventional cardioligist asked me if I wanted hime to "shoot coronaries" while in there, I said no.

1)CT scan measured as high as 4.5cm in ascending aorta. Why is MRA so different?
2)Is ascending aorta normally this large compared to descending?
3)Should I've had coronaries imaged?
4)Femostop used for femoral closure. Is brusing around site and base of scrotum normal?
5)Do I have Marfan?
Thank you!

[CCF-M.D.-MJM]

Hi Bob,

Sorry to about your medical concerns.  Marfan's can be a tough diagnosis to make.

1. CT scan measured as high as 4.5cm in ascending aorta. Why is MRA so different?

I can't give you a good answer for this.  They should read about the same.

2)Is ascending aorta normally this large compared to descending?
It sounds like your ascending aorta is a bit large.  They usually are not that different.

3)Should I've had coronaries imaged?
I wouldn't have.  If you ever need your aorta replaced, you will likely need to have your coronaries imaged, but you are not there yet and it is hard to say if you will ever need it replaced.

4)Femostop used for femoral closure. Is brusing around site and base of scrotum normal?
No it isn't normal to have bruising around your scrotum.  there must have been some bleeding but if it is not getting larger it should not be a concern.  It may expand a little and turn a greenish-blue color, this is normal.

5. I can't answer this one.  This is a tough questions and would require a thorough history and physical with test review, but even then it sounds like you are borderline at most.

I hope this helps and good luck.

[pbanders]

Bob, glad to see that the MRA provided you with good news. You will need to have your aorta monitored to make sure that the dilation does not progress to dangerous levels. Talk to your cardiologist about how often he wants follow-up MRA's. CT's expose you to a considerable amount of X-radiation that the MRA's avoid.

[bob_sixsix]

Thanks for your concerns and comments pbanders.

Did you have your aorta monitored with the MRI or ECG?  I not only had the MRI completed, I also had an aortogram last week.  I still have bruises from some blood loss but the procedure was fairly quick and simple.  I haven't heard back from my cardiologist as to how I will be monitored.  I am hoping it will be with the MRI because the invasive approach of the aortogram(angiogram) is not my first choice.
The interventional cardiologist who did the aortogram Thursday commented on the initial report that there were no aneurysms and no artheroscerotic disease present but that the end of the ascending aorta had "slightly generous proportions".  I have seen this "larger" measurement in this area of the aorta three years ago on a CT scan.  It doesn't appear to have gotten larger over three years but I have not received a final report for the aortogram which I assume will have measurements of this area.  Have you ever had an aortogram done for your aortic root?

Thanks again!

~Bob

[Billy!]

Bob and everyone Do you know what are normal ranges in cm for aortic root,ascending and descending thoracic aorta in average middle age men by mri/mra?What iv contrast was injected during mri/mra test and how did it feel,any allergy?Was your aorta imaging done as heart mri/mra or as chest mri/mra?Thanks

[TKK]

I've been trying to post a question for quite some time, however when I heard of this situation I just wanted to provide some feedback.  My condition is like yours, I have an enlarged Aortic valve and arch.  My valve is at 4.5 and my arch is at 5.2, I have been told that I have to have my aortic valve and part of the arch replaced.  I am 39 years old and quite active, needless to say that has come to a halt.  I hope you find out what's going on because I'm going stir crazy and I just found out my situation 3 weeks ago.

[pbanders]

Your situation sounds similar to mine of last year, when I found out by chance that my ascending aorta was dilated to 5.0 cm. I am 46 and very active, so I know just how you feel, it's a real shocker, as there are no symptoms from this condition - until it eventually dissects, which is an extremely serious condition.

In non-Marfan's patients, dilation of the ascending aorta and/or arch of over 5.0 cm is usually the point where surgery is indicated. Your situation is more complicated than mine in that you are being told that your valve needs replacement, in my case, it did not. Because your arch is involved, there are additional complications, but great progress has been made in recent years with this surgery that minimizes complications.

I would strongly suggest that you contact a leading institution for a consultation if you haven't already. The Cleveland Clinic would be a good bet. I had my surgery done in CA and I was extremely pleased with my surgeon and my care. If you want details on my surgical experience, you can find it and contact information for me at http://members.rennlist.com/pbanders/heart.htm .

It will be a year next month since I had my surgery. I have a fully active life and in general, cannot tell I ever had the surgery. The beta blockers I'm on take a bit of the edge off of my aerobic performance, and I am not supposed to lift very heavy weights, but other than that, I'm the same as I was before. My long-term prognosis is also excellent. The odds are that you'll come out of this just fine, too.

[pbanders]

I'm due for my first follow-up MRA on 2/1, so I'll post again in the comments to this question and let you know what type of contrast was used, if any.

As for "normal" sizes, your cardiologist should be your first source for that information. In my case, a 5.0 cm dilation of my ascending aorta by CT w/contrast was sufficient to warrant surgery.

[PJmomrunner]

My situation is very similar to yours, TKK.  I am a very active and otherwise healthy 42 year old and I was diagnosed with a 4.7cm or 4.8 cm ascending aortic aneurysm about 4 weeks ago along with a moderately leaky (but not enlarged) "pseudo-bicuspid" aortic valve.  I have had a consultation with one surgeon and am in the process of setting up a consultation with a genetic counselor as well as a second opinion with a surgeon.  I too am going crazy--spending lots of time researching online and as little time as possible imagining symptoms and worrying about whether I should lift that 20lb. bucket of kitty litter.  I am still running 3 miles a day, 5 days a week.  What is your plan for surgery, TKK?

[long]

I am supposed to have thoracic aorta imaged by mri/mra but don't know how it is done. For better accuracy should person stop all aerobic exercise for at least 2-3 weeks prior mri/mra test?Are pulmonary arteries and veins also imaged and measured with thoracic aorta?Thanks

[TKK]

In response to "pbanders" and "pjmomrunner" I was told by my cardiologist and surgeon that surgery should take place soon.  That scared me to death, so I personally took my recoprds to Cleveland Clinc and I'm waiting for the Doctors to review my chart and schedule my appointment and surgery.  I was told by my local surgeon not to do any weight-lifting or running.  I guess by doing all of my research on the web I'm still a little confused as to how serious my situation really is.  From my understanding, my regurgitation on a level of 1-5 is 4.5.  Let me know your thoughts.

[PJmomrunner]

Hey, TKK, I truly DO understand how you are feeling.  My understanding is that standards for operating on the ascending aorta vary some, but not much.  Most seem to operate at either 5cm or 5.5cm, although I have seen criteria beyond both ends of that spectrum.  Valve leakiness is usually measured on a scale of one to six (I to VI, actually).  Mine is a II or III.  My understanding is that the leakier one's aortic valve is, the harder the left ventrical has to work to keep up with both the volume coming into it from the left atrium and the volume being spit back into it from the leaky valve.  This work overload causes enlargement of the ventrical which will eventually lead to heart failure if left untreated.  I believe that determining when to operate on the valve is also tied to one's symptoms--shortness of breath, dizziness, fainting.  At my level of leakiness I have no symptoms and "no significant enlargement" of the ventrical, so my surgery is driven soley by the size of my anyeurism, although both issues will be addressed at the same time.  I would welcome talking with you directly if you are interested.  It's somehow comforting to find someone else in this same little boat!  ***@****

[bob_sixsix]

I have been going through tests to rule out Marfan Syndrome for three years now and still do not have a definitive answer.  I have had 2 CT scans, 6 echocardiograms(at rest and stress), a 24 hour holter, nucleur stress test and just last week an aortogram(angiogram).
The MRA and then the aortogram were ordered by my doctor because he noticed what appeared to be a "bulge" on my aortic arch.  The MRA did not confirm the bulge and neither did the aortogram.  Both tests did note that the end of the ascending aorta, which I assume is the beginning of the aortic arch, was slightly larger than average.  I am hoping once my doctor reviews the aortogram images that he will say the "slightly larger" area is due to my height and weight which is far above average too.  I am 37 years old, 6'6" tall and weigh 220lb.  The results from the 2 CT scans that I have had gave measurements around 4.5cm in the area of the end of the ascending aorta.  The MRA and aortogram did not record a measurement above 3.7 cm in this area.  The aortic root was 3.8cm which has remained this size over the past three years from ECG's, CT scans and the MRA.  My doctor explained to me that the CT scan is not an accurate means of measuring the ascending aorta because the ascending aorta comes off of the heart at an angle unlike the descending aorta which runs axially through the body.  The CT scan captures images that are perpendicular "slices" of the aorta.  Imagine cutting off your neck and look straight down into the aorta.  This would cause an elliptical shape/measurement of the ascending aorta which would result in a larger measurement.  I, like pbanders, am a design engineer and have been over analyzing this too.  I will keep you posted on the final results of my aortogram.  Sorry if I was so long-winded here.

Good luck.

~Bob

[pbanders]

In my case, I had an initial echo, followed by a CT with contrast. My surgeon said the film was fine, but he would have preferred a 3D reconstruction of my aorta, apparently this is available from some imaging centers (my cardio ordered my imaging, before I had my surgeon selected).

Regardless, he has done over 6000 procedures, and after an initial look at my film, said, "yup, you need surgery". He showed me normal films and mine, once I knew what I was looking at, it was obvious that my aorta was abnormal.

If you're going to have surgery, here are a few things to know and think about. I had the least complicated type of this surgery, only my ascending aorta was involved. My aortic valve was fine and my coronaries did not need reimplantation into the graft, and my arch was not involved. Valve replacement complicates the procedure and depending on the valve used, may require anticoagulants (lifelong) after surgery. Reimplantation of the coronaries requires additional time on the pump. If your arch is involved, it used to be that they would lower your body temperature and stop the pump while they did the arch - but according to my perfusionist friend, they now use two perfusion machines and keep blood flowing to your brain while they work on the arch. Ask your surgeon for details, how this is done is way out of my area of knowledge.

The graft they use is collagen impregnated Dacron. Over time, your body integrates this graft very much like natural tissue. From what I can tell, the graft does not degrade with time and unless something else happens (or a valve is involved, which may wear out over time), the graft is permanent and you don't need it replaced.

The type of sternotomy you get depends on the skills and experience of your surgeon. My surgeon has done a mini-sternonotmy on this procedure for many years and can do the procedure as fast as someone who does a full sternotomy. The mini-sternotomy only involves the top half of your sternum, and is less difficult to recover from. My scar is nearly invisible. However, I would only have a surgeon who does these all the time do it, because until they're proficient, it slows down the procedure, increasing time spent on pump (which is highly correlated with surgical and post-surgical complications).

As far as complications, I had some bleeding and had to get four units of blood. I was told prior to surgery that I would likely not need blood - guess they were wrong. As far as pain goes, I had some Percoset (sp?) initially, but after I was discharged, I used Tylenol only, it wasn't that bad.

I was back to physical activity immediately, walking several miles within a day or so of discharge. I was back on my bicycle at about 5-6 weeks. It's likely your cardiologist will put you on beta blockers. I hated them initially (cold feet/hands, etc.) but you get used to them. They take the top end off of your aerobic performance, but after a while, you get used to that, too. I do pretty much everything I used to do before the surgery, except for lifting heavy weights. I lift most stuff, I just don't do anything that makes me really strain.

Be careful and stay away from all the aneurysm/dissection horror stories on the web. You're young, healthy, and have caught the condition before dissection, and are likely to recover quickly and resume your life as before. I spent a lot of time on the web scaring the **** out of myself and I know now that it didn't do me any good. Contact me through the link I provided above if you have any questions.

One last thing to note - I am not a doctor and anything I said here is only my own experience and may not entirely apply to your case. Find a cardiologist and surgeon you trust and pass everything by them, and trust their advice.

[pbanders]

Bob, you might want your cardiologist to look at this article on Medline, "Aortic Root Dilatation Among Young Competitive Athletes: Echocardiographic Screening of 1929 Athletes Between 15 and 34 Years of Age". Figure 1 of the article the relationship between body surface area (BSA, indicator of physical size) and aortic root dimensions for the study group. The figure provides a way of determining if for a particular BSA value, a person's aortic root dimension is within the range of normal dimensions. For example, for a BSA of 2.1 m^2, the 95% confidence limits were about 2.5 to 3.5 cm.

Of the study group of 1929 athletes, 7 of them had readings of aortic root dimensions that were clearly off the norm (0.04%), with dimensions of 4.2 to about 5.8 cm. These were people that were identified as needing additonal followup and treatment.

[pbanders]

Sorry, make that 0.4% of the group showed significant aortic root dilation.

[TKK]

I was curious what has changed since your data is based upon an old reference.  What concerns me is when an aneurysm is mixed with a severe leaking(regurgitation)valve.  Please comment

[pbanders]

The reference is from the year 2000. It's "1,929 athletes", not "Athletes from 1929". Sorry for any confusion, that's the way the title of the article is written.

[bob_sixsix]

When I started going through the plethora of cardio tests that I listed earlier my BSA was 2.48m^2.  I lost about 20lbs since so I'm sure it's a little lower.  My aortic root has been measured about 8 times with different tests: ECG,CT scan, MRA and now aortogram.  All of the tests have repeated a measurement of 3.8cm.  I am not too concerned that I have a problem in this area.  I am more concerned that in the area at the "end" of the ascending aorta where it transforms to the aortic arch.  This area seems to have inconsistent results.  I have had the echocardiograms measure around 4.0cm, the MRA measure 3.7cm, the CT scan measure 4.4cm.  I have not received measurements back from the aortogram but the initial report read that "there is no evidence of aneurysms or atherosclerotic disease."  It did say "slightly generous proportions at end of ascending aorta."  When they say "end of ascending aorta" they are referring to the transition of the ascending aorta and the aortic arch.  I'm curious to see what the measurements will be in this area from this aortogram.  Supposedly, the aortogram gives the most definitive images so I will trust this over the other tests.
I just read the post from CCF-MD from "Billy's" on the aorta thread and the doc claims that anything over 4.0cm is considered an aneurysm.  This doesn't make sense with his information on aorta size to BSA ratio.  Is there a "cut-off" of 4.0cm regardless of the person's height and weight?  A little confusing.  I will run all these questions by my cardiologist.  I was corrected the other day when I called him a cardiologist to a member of the cardiac catheter lab.  He explained that my doctor is not a cardiologist he is a thoracic surgeon, chief thoracic surgeon actually, at Yale.  He is one of the best around and I will trust him totally.
Thanks for the info pbanders.  Let me know what you think about this BSA to aorta size ratio in the latest post.

~Bob

[pbanders]

Regarding your MRA questions, I had one yesterday. Yes, they use contrast, it's gadolinium, it's nowhere near as problematic as iodine is with CT. I didn't feel any heat or burning sensation when it was injected, as opposed to iodine, which makes you feel warm all over. While it's cramped, noisy, and somewhat unpleasant, MRA beats getting a big ionizing radiation dose, a la CT.

[bob_sixsix]

pbanders,

Did you get results back from the MRA?  How often do you have your dacron implant monitored?
I received results from my doctor on the aortogram and he told me everything looked perfectly normal.  He had no explanation for the "shadow" that appeared during the echocardiogram which led me to have the MRA and the aortogram.  He told me to schedule an appointment in two years for an echocardiogram and enjoy life.
That "burning" or "flushing" feeling you described during the CT scan is slightly more intense during an aortogram.  They explained to me that patients who have undergone angiograms describe it as "peeing your pants".  The warm feeling starts from your chest and ends around your femoral arteries.  I am still bruised up for the procedure but I am glad I had it done.

Take it easy and thanks again for your information on this matter.

~Bob

[pbanders]

Bob, glad to hear your aortogram looked normal, nothing better than good news. My MRA turned out fine. I'm getting yearly MRA's now, but that may increase to longer intervals if they keep looking OK.

[Billy!]

Are these athletes who have aortic root diameter over 4 cm candidates for surgery or is the size of aortic root in the range of 4 to 4.5 cm normal for them and not pathology? Is it possible for a normal middle age man whose BSA is 2.1 to have aortic root (measured in greatest diameter by mra) in the ranges of 4 to 4.5 cm and yet not have any evidence of aortic root enlargement(ecstasia) or dilatation?If yes how and in this instance at what size would aortic root be considered pathology?Does anyone know what would normal(mean) limits be of aortic arch in a normal middle age men?

[pbanders]

Billy, you should post your questions to the doctor or talk with your cardiologist and/or surgeon. I'm an engineer, so any interpretations of the data in the paper that I make are from my experience with statistical information.

I have access to the full-text version of the paper. Figure 1 shows a statistical plot of aortic root dimension vs. body surface area for all 1,929 athletes in the study. The large sample size implies that the distribution would represent the general population statistics quite well, with the qualifier that the study group are all athletes and are all Japanese. The data show a main distribution of 1,922 points and 7 clear outliers, with the outliers ranging from 4.2 cm to 5.8 cm. The range of BSA covered is from about 1.35 to 2.6 m^2. All readings over 4.0 cm are clearly outliers for any BSA. The mean of the distribution does not exceed 3.3 cm for even the largest BSA's in the study. The 95% confidence limit does not exceed 3.7 cm even for a BSA of 2.6 m^2.

The authors state, "Regardless of the phenotype, the clinical diagnosis of aortic dilation was based solely on morphologic analysis of the aorta, and dilation was suspected when the aortic root dimension was more than 40 mm".

Hope this information is useful to you.

[Billy!]

If in this study the 95% confidence limits are 2.5 to 3.5 cm for a person whose BSA is 2.1 m^2.At what number  in the above study does ectasia enlargement starts and ends and than at what number does aneurysmal dilatation starts? Bob, How did you monitor your aorta by ECG?Which ECG leads usually show up aortic root abnormality.Was the "shadow" that appeared during echo measured?

[bob_sixsix]

The ECG was my mistake of calling an echocardiogram and ECG - sorry for the confusion.

As far as the "shadow" - I never asked or my doctor never gave me a measurement for the "shadow".  He did look into it more closely by ordering the MRA and then the aortogram.  Neither of these tests showed this "shadow".  My doctor, actually surgeon, is the Chief of Thoracic Surgery at Yale Medical Center in New Haven.  He really is one of the best around for aortic complications.  He explained that many other medical centers contact his facility for advice and data concerning the aorta.
I work for a medical company that produces medical instruments for surgery and I get out to different medical centers to see a variety of procedures.  I met this surgeon and watched him perform heart valve replacements and ascending aortic graft procedures.  I really do trust him and his diagnosis.

As I posted earlier - My doctor explained that the CT scan w/contrast is not exactly the best method of measuring the ascending aorta.  It is good for aortic root and the descending aorta measurements because these areas of the aorta run axially through your body.  The images captured from the CT scan, if you can imagine, are "slices".  These slices are as if you were to, excuse the graphic visual, cut-off your head and look down into your body cavity.  Therefore the aortic root and the descending aorta will give you an accurate measurement because you are "looking" straight through them.  The ascending aorta and the aortic arch are not situated axially through the body and will give you an "elliptical" type cross section which will produce an inaccurate measurement.
My doctor explained that they don't only look at the size of the aorta they also monitor the expansion rate of the area in question.  The aorta normally does and will expand over time.  Your doctor should monitor the expansion rate as well as the condition of the aorta.  If it is not expanding at an abnormal rate (I am not sure on the expansion rate value) then it might not be a problem.
One thing that I have found working in this field is that no two bodies are the same.  There is so much variation from person to person that each case should be treated on an individual basis.
My aortic root measured 3.8cm three years ago and it still measures 3.8cm.  The ascending aorta at the beginning of the aortic arch has measured around 4.0cm for that same time period.  My doctor didn't have an explanation for that "shadow" that was seen on the echocardiogram but feels confident that there isn't a problem after the aortogram, which does give the most definitive images/measurements.  He told me to schedule an echocardiogram in two years and to get back to playing basketball and enjoying life.

What exactly is your diagnosis?  What are your physical characteristics?  How old are you?

[chem77]

I was recently diagnosed with an Aortic aneurisym at 4.5 cm with a leaky valve. I am very athletic 35 years old and over the past 3-4 months have been experiencing quite a bit of pain starting in the front upper part of my chest and radiating around the back, get tired very easily. Monday and I am having a stress test and being sent straight to the thoracic surgeon. Do you think they will operate on me...the diagnosis has been confirmed by a CT scan and echo. Thanks for any advice.

[PPK222]

A related discussion, Advice Please was started.

[DOTTIER]

A related discussion, Bi-iliac distal aortic disease was started.