dilated aorta

[Chuck from Fort Wayne]

I am 56 years old, and had a cardiac pacemaker installed 17 years ago. I also have mild mitral valve prolapse, noticed when I was three; and aortic valve insufficiency, increasing slowly and first noticed after the pacemaker. I am 5 foot 9 inches, formerly 5' 11"; weight under 150 pounds, and exercise often, having bicycled over 150,000 miles the past 30 years. I am employed as an attorney. For a variety of reasons, I have bicycled and exercised much less this year than past years; which my wife appreciates, but I regret.
My annual echo this year indicated my aorta is dilated, 5.5 cm(?); last year it was 4.2. This is the first time my cardiologist mentioned such. He looked a bit worried. I had a CT of my chest last week, a TEE scheduled next week, and revisit my cardiologist the following week. Any comments regarding the likelihood of surgery being required; the nature of the surgery and repair done; the risks; the limitations following surgery would be welcome. My cardiologist does not want to discuss such before the other tests. The pacemaker was rushed 17 years ago; but if this is not a rush I would probably like a second examination at a facility with more experience and advanced options than my cardiologist in Fort Wayne, Indiana has available.
My pacemaker is 17 years old, but still has nearly a full charge on its battery; but I refer to it as an antique; it has few abilities other than to be set on demand, currently at a pulse of 50. So it does little, but not worth replacing yet. I hope I can get more advanced choices than I got with it.

[CCF-M.D.-MJM]

Hi Chuck,

This is a very complicated question and one that is probably worth getting a second opinion on.  I agree if you are going to potentially have an operation on your aorta, you want it done in the hands of someone that does a lot of successful surgeries.

Aortic replacements are done for several reasons.  One is absolute size -- ascending aortic measurement of 5.0 cm if you have Marfans syndrome or a bicuspid aortic valve, 5.5 cm if you do not have these disorders.  Another criteria is the rate of expansion between 0.5 cm/year to 1 cm/year.  If your measurement was correct, you would meet these criteria and qualify for an aortic replacement.  Given your age,  you would need a cardiac catheterization prior to surgery and would probably need an MRI to further define the anantomy as well.

Take this with a grain of salt though.  The first thing I would do is an MRI to evaluate whether the 5.5 cm measurement is accurate.  Depending on the degree of aortic leaking, you may need an aortic valve as well.  If this is the case, based on your age a mechanical valve is likely to be recommended which means life long coumadin.

Regarding post op limitations, it would take about 6 months or so to get back into the full swing of things and  you would be farely limited for the first 6 weeks or so.

We repair a lot of aorta's here at the Cleveland Clinic.  The intention of this web site is not to recruit patients but to provide what I think is a service.  That being said, I really trust our surgeons with the aorta.  They have a lot of experience.

Good luck and thanks for posting.

[PJmomrunner]

You don't mention where on your aorta the aneurysm is.  The criteria for operating depends on whether it's in the ascending or descending aorta.

[pbanders]

If the dilitation was discovered during an annual echo, then I'd wager it's in his ascending aorta. And at 5.2 cm, that's beyond the threshold (5.0 cm) where surgery begins to be considered. Like Chuck, I'm a cyclist who raced on and off for 30+ years, and last year, at a 5.0 cm dilitation of my ascending aorta, I had surgery to graft it. Chuck, you should discuss your options with your cardiologist.

As for post-surgery activity, my first advice to you is to ignore the horror cases you find on the web associated with those who have had aortic dissections due to aneurysm - you don't have dissection, and every case is different. In my case, I was back on my bike in 6 weeks after surgery and have been riding about 100-130 miles per week all summer. I'm 47, and I expect to live a normal, active livespan. I take a beta blocker every day. At first, it will cut your aerobic capacity (due to lower heartrates during exercise and resting), but after a while, I hardly notice it. Beta blockers are typically prescribed (for life) after such surgery to decrease peak aortic systolic pressure rise (lower max dP/dt), to reduce arterial stress - but from what I can tell, beta blockers are a pretty good drug for older people to be on, as they lower blood pressure and decrease artierial decay, and lower your risk of strokes.

You'll come through any surgery just fine. Make absolutely certain that you have a top specialist in aortic surgery do your case. You're looking for someone who has done hundreds of these operations at a major center, not someone at local hospital who has done 10 or less. Cleveland Center is a good place to start. You might also want to consider having a mini-sternotomy, where the incision is only 4 inches long and only half your sternum is split. I had this done and you can barely tell I ever had surgery, and I recovered very quickly. If you opt for this, get a surgeon who had done a LOT of these, as it slows down most surgeons at first, which increases your time on perfusion (longer time on perfusion is correlated with surgical and post-surgical complications).

[pbanders]

Oh, I see the echo was 5.5 cm, not 5.2 cm - echo is not the definitive test, the TEE should be more specific, and the CT with contrast even more accurate. What they're looking for is the extent of your aorta that's involved. If it's just in your asending aorta, then the surgery is less complicated. If your arch is involved, they need to do a more complex procedure where your body is cooled and you're taken off perfusion while they repair the arch (that's where your carotid arteries are, which need to be attached to the graft). Experienced surgeons have done many of these surgeries and can handle this situation. Another consideration is whether or not your coronary arteries need to be reimplanted into the graft. Most of these issues should be resolved after your CT and TEE data is reviewed.

[Jjc2005]

Hey Chuck
I am another person who went through the surgery, just six months ago.   I am a just turned 60 female.  They discovered my dilated aorta after my sister's death from the dissection of her aorta.  She was the third person in our family (a paternal Aunt and a paternal cousin) to suffer from this.  With my family history, the surgeon I found, suggested surgery even though I was only at 4.5 cm.  

While I am not a cyclist, I was walking briskly every day for about 80 minutes.  I recovered quickly and within two to three weeks I was back walking about two miles.  My college friends and I had planned a ten day get-together before my surgery and it was planned for four weeks after my surgery.  I participated 100%.  I still feel good and I am happy I had the surgery.  

My surgeon trained at the Cleveland Clinic and consulted with them.  Find someone who has done lots of these surgeries and talk to him/her.

Oh, all my first cousins are getting their aorta's checked.  So far two more dilations have been found.

[Dave 1652]

Don't freak out yet.  Possibly, if you are athletic, your muscular, slightly enlarged heart is causing your echo results to be inaccurate.  For TEN years, my husband's echoes AND TEE's measured his aortic root at 4.7.  Once, it was measured at 5.2.

When he has an MRA with contrast or MRI, it always measures at 4.0.  And, we have the pictures to prove it!

[PikaPika88]

My friend told me her dad had a pig's aorta put in.  It works beautifully.  Is that a joke or real?

[pbanders]

If that's true, then that's a new one for me. What would be the advantage? The Dacron grafts that are used now are stronger than human aorta tissue, and gain an epithelial layer of cells over time, they almost look like human tissue.

[tickertock]

I think your friend is probably talking about the aortic valve and not an aorta artery graft that is replaced because of an aneursym.

[Chuck from Fort Wayne]

Thank you for your comments. I spoke to my cardiologist on the phone today. The chest CT done indicated my aorta at only 4.8; so for the moment there is no plan to do any surgery. I will still have the TEE done this Friday, and will see my cardiologist the following week, or talk further on the phone. He will probably have CT's and TEE's done annually on me.
My wife and I are relieved. He does want me to cease any isometric exercise, such as using heavy resistance on my Bowflex machine; but my bicycling should be a good exercise, particularly if I am careful to spin small gears and not push big gears.

[pbanders]

You might consider getting a second opinion from Cleveland Clinic. I know that while your aortic diameter is still under the threshold for surgery, the rate of increase (whether its to 4.8 cm or more, coming from 4.2 cm a year ago) still exceeds the rate that the doc here quoted for concern. At a minimum, I'd want another TEE or CT in 6 months to make sure it as stabilized.

I don't mean to be alarmist - it's just that I found that there is a very wide range of opinions on what course of action to take. I have no idea of what the level of experience your cardiologist has with ascending aortic aneurysm, but I do know that the Cleveland Clinic doctors are extremely experienced in this area.

[clavus]

Chuck: Let me tell you what I did. I am  a doctor in my early 50's from a smaller town in Indiana. I did not know I had a bicuspid valve and labile hypertension until both were discovered in May. I had been running and weightlifting(a common theme on aorticdissection.com) for years. This had allowed an ascending thoracic aneurysm of 4.8 or 4.9 cm to develop (only slight enlargement May to October.) Seven days ago in Ann Arbor Dr. G. Michael Deeb modified my bicuspid valve and put in a dacron graft. I feel pretty good already. You have gotten great advice from the doctor that first replied and especially pbanders.I went for aneurysm surgery sooner than later because 1)I had symptoms that were angina-like (these pains and pangs are underdiscussed/underappreciated by even aorta specialists.)Amen for beta-blockers which you should rush to get on 2)I was too far from an aortic surgeon if I ruptured or dissected 3)the bicuspid muscle defect is like that in Maarfan's Syndrome and the threshold for surgery is being lowered at some centers 4)I trust super-experienced surgeons more than my own ability to restrain my activity. Your own personality matters. By the way, I found out 2 weeks ago that my great uncle made it to almost 70 with a very large aneurysm before Mayo Clinic fixed him in the 1960's.Regarding my aortic valve modification vs. mechanical or biological valves, we did it because he could (and we don't like coumadin.)My case was presented at a meeting Saturday and I am sure most of the surgeons thought they had a better idea. It is a constantly changing topic making it hard to research online.In 15 years I'll give 'em a stem cell and grow me a new one. Then they'll put it in through my groin vein.

[pbanders]

Interesting story. My surgeon was Dr. Vincent Gaudiani, Redwood City, CA. Dr. Gaudiani told me something similar to your comment, that in the near future, that even ascending aortic aneurysms would be repaired endovacularly. I've seen what they do for AAA's with the endovascular graft and it's amazing.

Personally, I was really glad they way my case presented.  I went to my doc with PVC's, they did an echo, found my aneurysm, and a month later I had surgery. Because it happened so fast, I never had much time to dwell on it, and worry that I'd dissect before it was fixed. I was also told that the longer I waited, the more the chance was that my aortic valve develop problems, or that my arch would become involved. My advice to all out there who are nearing the surgical threshold is to go ahead and get the work done.

[gem12]

Please visit www.bicuspidfoundation.com
The information and support is extensive.

[BLUEBOY]

The measurement of my aorta by sonnegram was 5.6.  By MRI
the measurment  was 5.  What do these differences mean.?  I am a 51
year old male with long time high blood pressure. Any cardiologist out there? Thanks.

[Lisasal]

A related discussion, Reasons for aortic dilation was started.