Enlarged Arota

[usadave]

I was recently hospitalized for chest pain. It was in the center of my chest and went around the right side to my chest. I was administered nitroglycerin on the way to the hospital and after 2 sprays under my tongue the pain subsided. I had an ekg that was abnormal, but my heart is tilted so my ekg's are not always within the norm. They did a CT scan which showed a dilation of 4.2cm at the ascending thoracic aorta and the aorta at the level of the sinuses of Valsalve of 4.3 cm. The descending thoracic aorta at this level measures 2.8cm. A small amount of fluid was detected. A echo-cardiogram was ordered which confirmed the enlarged aorta above the cusp of 4.3cm and 4.2cm in the ascending part. The aortic valve was trileaflet and normal.The Pulmonic Valve was normal with some mild regurgitation. The finding was Dilated aortic root with possible small pleural effusion. They did an MRA which showed  an aortic dilation of 3.9cm at the AP extent. I was released and told I do not have an aneurysm and I can resume all normal activities and to follow-up in 6 months. I had a normal stress test, my blood pressure varies from about 116/85 to as low as 107/60, my cholesterol  My resting heart rate when lying down goes to as low as 42 bpm, they say I have non-symptomatic bradycardia. I do have neurocardio syncope which was diagnosed about 17 years ago. I was also diagnosed with sleep apena about 9 years ago. I am 48 year old male. I have read other articles and they say what I have is an aneurysm. I had a normal echocardiogram about 7 or 8 months ago that did not show this. Should I be worried?



This discussion is related to aortic aneurism and/or dilation aorta?.

[skydnsr]

On re-reading you post and my advice to you, I'm struck by the fact that you really need to get seen quickly.  What did the emergency room advise you to do from here, in terms of follow-up?  Did they refer you to anyone?  Did they even give you any advice for further care?  Please get in to be seen by someone -- a primary care doctor, anyone -- who can start a good, thorough diagnostic work-up.  You have symptoms that are troubling, and you have questions that you need answered.  With the aortic enlargement, you eventually do need to be seen by an aortic specialist, and if you can get in with that person on the front end, that is great.  It is generally optimal to get to see the most relevant expert first, rather than having to go through a lot of other doctors before you meet that person.  But you need medical attention now.  For a young, healty person to get short of breath just walking around is not normal.

[skydnsr]

Fenwen, yes, you need to seek further medical attention.  I could guess about what is going on, but I would only be guessing.  So rather than listen to the guesses of some stranger on the internet who is not even a doctor, please get yourself to a cardiologist who will work you up thoroughly.  Your symptoms are not trivial.  Okay, I will make one stab-in-the-dark guess.  Modest aortic enlargement in a young, active, otherwise healthy male is sometimes associated with a bicuspid aortic valve.  So if you can find a cardiologist who has a particular interest in the aortic valve and the aorta, you should be in good hands.  More and more, nowadays, you can find doctors' vitas on the internet and see what they say they specialize in.  If you are near a big city with a major heart center, I would try there.  Good luck, and let us know how you are doing.

[nickppatel]

To echo skydnsr, you need to find out whether those measurements were taken at the same place.  If they were, there is cause for concern and you need to be very carefully watched, preferably by an aortic surgeon.

You might consider very aggressive ARB therapy to possibly avoid the operating table.  Click on my screen name and read my many posts on the topic.

[Fenwen]

Hello,

I am a 23 year old male and I was recently taken to the ER due to numbness of both arms and face and sudden chest pressure.  I also experienced slight loss of motor control as it was difficult to do simple task like opening a water bottle.  I went to the ER and all tests were negative except for low potassium levels and on the CT scan of my chest the doctor said I had a slight elargement of my acsending aorta at 3.3cm.  I was discharged that night and it is now 2 days later.  At times I am getting a slight numbness in my left hand.  My chest feels congested and if I am walking around a bit I get fairly out of breathe.  I am a usually active 23 year old male weighing 160lbs.  So I be concered?  What should my next steps be.

[skydnsr]

Dave, no.  I'm sorry, but growth from 3.5cm to 4.3cm in 7 months is not normal.  That is very fast growth.  If those measurements are both accurate and if they are both referring to the exact same place on the aorta, then you'd better start making plans for surgery.  Most cases of aortic dilation are expected to grow at a rate of about 0.1cm per year.   Yours is growing more like 0.1cm per month, if those figures are to be trusted.  

There is a lot of confusion about how to measure an aortic aneurysm accurately, so I wouldn't panic just yet.  But you do need to get an expert to look at both sets of images and settle the question of whether it has really grown that much.

I don't know about the fluid; I'm not even sure what fluid you are referring to.  The pleural effusion?  I don't know what to tell you about that.  I do know that with an aortic aneurysm that is possibly growing very fast, with the chest pain, and with the bradycardia, you need expert care.   If you want to either post or PM me your location, I might be able to direct you to a thoracic aortic center.  

Physicans who specialize in care of the aorta are fairly few in number.  They tend to be located at large regional heart centers in large cities.   You can google "thoracic aortic center" and see what you get.  I went to Dr. Joseph Coselli in Houston, and I recommend him.  I also have consulted Dr. Sharo Raissi in Los Angeles, and I recommend him also.  There  are others, not a whole lot of them, but there are others.  

If you can't go to one of the nationally known guys, then at least seek out the "local expert" in your area.   It needs to be someone who has a special interest in the aorta and preferably someone who received training at an aortic center.

Good luck.
    

[usadave]

I recently went back and got a copy of my last echo that was done about 7 months ago. It said I was borderline dilated with an Aorta measurment of 3.5cm. So a growth of 3.5 cm to 4.3 cm in 7 months is normal. Also, what about the fluid that is present?

[skydnsr]

The definition of what is an aneurysm varies among doctors.  Rule of thumb, the ascending aorta should be about the same diameter as the descending thoracic, so your own ascending aorta is definitely bigger than expected.  Usually when doctors say "dilated" or "dilatation" in reference to the aorta, they mean that it is enlarged but not to the point that they would consider it to be an aneurysm.  When they use the word aneurysm, they mean that it is enlarged to the point of being pathological.  

One definition of an aneurysm is a vessel that has a diameter 1.5 times bigger than normal, and the 4.2 measurement of your ascending does qualify, by that definition.  (The root is normally just a tad bigger than the ascending aorta in everyone, as it is in you.)  Other doctors will wait until the vessel is 2x normal to define it as an aneurysm, and yours doesn't qualify by that definition.  The definition that kenkeith found, which is that any part of the aorta that is over 4.0cm in diameter qualifies as an aneurysm might be the best one, because it will lead to close follow-up, but with all due respect to kenkeith for his research, I don't believe that it is necessarily the definition that is in widest use.  "Best" and "most popular" aren't always the same.

I'd say almost any cardiologist will recommend a "wait and watch" approach for you.  I would expect a recommendation for at least annual imaging of the aorta.  Transthoracic echo does not usually show enough of the aorta, transesophageal echo is kind of an ordeal, and CT exposes you to a lot of radiation if it is repeated many times, so expect to be sent for an MRI at least annually.  If you just started having your aorta looked at, your doctor might want you to come back in six months to make sure the dilatation, aneurysm, whatever you want to call it is not growing fast.  If and when it gets close to surgical criterion (anywhere from 4.5 to 6.0, depending on the surgeon's judgment) you might need to be monitored more frequently than annually, also.  As for activity restrictions, aortic specialist doctors usually caution people in your situation against heavy lifting, straining at stool, or anything that induces a Valsalva maneuver.  

For more information about aortic aneurysms, see www.bicuspidfoundation.com.  Good luck.

[kenkeith]

An enlarged aorta greater than 4.0cm is considered an aneursym.  There is a variation in size depending on the location of estimation and also there can be some variance if the image is at an angle.  If there is some concern it should be watched and if and when the size is greater than 5.0cm surgery will become an option to prevent a rupture. The usual procedure is watch if there is any growth, and the size does vary among individuals.