Surgical Options for Enlarged Aorta & Aortic Insufficiency

[Nat__0]

  My husband is 47 w/ congenital heart defect.  He has a bicuspid aortic valve causing mild aortic insufficiency.  He's been followed by a local cardiac group.  Until last month his cardiologist said valve replacement was far into the future (if necy at all) since he was asymptomatic.  
  However, at his annual follow up this time, cardiologist didn't like what he saw on echocardiagram & ordered an aortic MRI.  MRI indicated that his aorta is about 50 mm.  Cardiologist thinks surgical consult is necessary.  He said they'd probably suggest surgery to insert a dacron tube in the aorta.  And since they'd be in doing the surgery, they'd probably replace the aortic valve now and possibly do bypass if any is needed.  
  Cardiologist said because of his age, they'd probably use a St Jude's mechanical valve.  Due to my husband's line of work, coumadin may cause compliations.  Cardiologist also mentioned Ross Procedure, but wasn't sure if it is an option due to the enlarged aorta.  
  I've read everything I could on this forum and have checked out the Ross Procedure site.  (Need other places to investigate if anyone can point me in the right direction.)
  1 - Can you explain this procedure of inserting a dacron tube into the aorta.  At first I thought cardiologist said the aorta seemed constricted.  But could that be the case if it is enlarged?  
  2 - Can you insert the tube, replace the valve (mechanical or Ross Procedure) and do possible bypass using minimally invasive vs regular surgery?
  3 - Since he's still asymptomatic, do you think surgery needs to be done this year?  (Do we need to get the surgical opinions now or can we wait til I have health insurance (summer) which will cover New York City medical centers instead of a regional one?)  Is there a risk to waiting 3 months for opinions?  
  4 - My husband's work requires lifting, carrying, hammering, etc.  Is it true he may not be able to do these activities for 3 - 6 months?  He's self-employed (sure could put a crimp in our budget).  
  5 - Would valve sparing procedure be an option?  
  6 - Are there alternatives to inserting dacron tube to eliminate or alleviate problem.  
  PS - He has hypertension also & takes medication for it.  
  Thanks in advance.  

[CCF CARDIO MD APS]

_
Dear Nat,
1) The technical explanations I will leave to the surgeon who will be performing the surgery; this forum has questions answered by cardiologists.  I can tell you that it is not unusual for the aorta to dilate just beyond a stenosis, as well, it can dilate with high blood pressure.
Once the aorta dilates to 5cm or greater, surgical correction is generally recommended in the near future since the risks of surgery are far outweighed by the risk of rupture (risk of rupture of the aorta increases with every increase in dilation, and of course rupture of the aorta is essentially incompatible with life, i.e. a death sentence.)
So it is of the utmost importance that you discuss with the surgeon exactly what the risks and benefits are of waiting.
  
So, Nat, it is not a matter of symptoms or not when the patient has a dilated aorta, rather it is a matter of how dilated is it and what are the risks of rupture.
Because the risks of surgery go up with each successive open heart surgery, it would not be justifiable to go in and replace/repair the aorta and yet not fix the valve also.
It is the surgeons decision whether or not the valve can be spared in replacing the aorta, regardless most surgeons would be reluctant to spare an already diseased valve such as your husband has.
A dilated aorta has weak walls and so the dacron graft is usually put in place of the diseased aorta, and if necessary the coronary arteries that normally come off the proximal aorta are resewn in above the graft (not in to the graft itself.)
I think your husband has a constricted valve and a dilated aorta just above the valve, ask for a picture of this since there are people that have constricted and dilated areas of the aorta.
  
99.9% of the time, patients with bicuspid aortic valves need replacement by the age 50-60yo; some need it sooner because it stenoses sooner or it leaks badly.
In young patients there are attempts being made at repair of the valve, however, with the problem with the aorta just above the valve and the fact that leaking is not the main problem, it is unlikely that your husbands valve is repairable.
  
So that leaves you with replacement and the options are a tissue or a mechanical valve.  In young patients we tend to place the mechanical valve since it can last forever (barring any complications like infection or thrombosis which are quite rare in the patient who takes good care of him/herself after the surgery.)
A tissue valve (homograft) lasts 10-12 years at best, so for a 30 yo patient that means about 4 reoperations if that is even possible (every successive surgery is more complicated and dangerous/risky to the patients life.)
  
The Ross procedure is where the tissue valve comes from the patient himself (i.e. they would use his pulmonary valve to put in the aortic position)
and then the patient gets a homograft placed in the pulmonary position.  Suffice it to say that we do not advocate this procedure, if only because the patient goes from having one valve disease to having two valve disease.  The results of this surgery are highly variable, i.e. a few centers have reported great success and others naught but problems.
  
In general it takes four to six weeks to recover from open heart surgery.  Minimally invasive surgery allows for a shorter recovery time, however this is usually done in those patients having a single bypass graft done, a single valve done, and not usually is this done when the aorta needs to be investigated and replaced.
I would think that the kind of work your husband does now (lifting and carrying) would be contraindicated now, i.e. these are activities that can increase the pressure that the dilated aorta is exposed to, thereby increasing the risk of its rupturing.  It is very important you see that you speak at least with the surgeon regarding these issues as well.
I hope this information is useful. Information provided in the heart forum is for
general purposes only. Only your physician can provided specific diagnoses and therapies.
Feel free to write back with further questions. Good luck!
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