Aorta Dilation

[gael]

I am a 28 year old male  who would be considered an elite athelete in my choosen sport. ie. Gaelic Football (Quite like Aussie Rules, lees physical)

In February 2001 I underwent Open-Heart Surgery to replace my aortic valve which was leaking. The operation was a success (still slight regurgitation) with a homograph tissue valve being used. I was back playing at the top of my sport 4 months later.

This was a congenital bi-cuspid condition.
About a year ago my Cardiologist in the RVH hospital in Belfast expressed his concerns about the measurements of my aorta after a routine echo test.
His main concern however was, what way my heart would respond under peak excercise. So he organised another echo and a treadmill test.

Results of echo/treadmill

The Aorta (aortic arch) is measuring at 43mm (was also 43mm a year ago, but think it may have been approx. 38mm immediately post-op in 2001).

My exercise capacity and heart rate measurements were both perfect during the treadmill test. There was also no evidence of any arythemia.
However, my systolic Blood Pressure reached a maximun of 240/250 during the 18 minute test. (Bp does seem to be fine normally but does be higher when I get it cheched at hospital - or after I drink alcohol.

My Cardiologists Concerns

That the already dilated Aorta is being put under too much strain during intense exercise.
The impications for robust physical contact.

Is there any way back to competitive sport??
Is there anything we can do to minimise any risks??
What and how big are the risks??

[acmoore]

Frito15:  I appreciate your frustration and anger. My son was diagnosed with a bav and a 4cm dilated ascending aorta in the fall when he was 15. He was very resistant to quitting competitive sports.  He played football, hockey (hockey was his absolute love and he wanted to play highschool and college), and soccer.  We met with a cardiatric surgeon who showed my son pictures and gave him some good articles to read that are referenced above. My son had a hard time with making that change but the surgeon gave him very graphic details of what can happen.  He takes altenol now 25 mg.  and he became a referee in Hockey. Good money.  He plays intramural soccer,  and cross country running and track (so you can still letter!).  There are other sports you can play if your school offers them (tennis, golf),  or talk to your parents about clubs.  My son was offered team manager positions on both his hockey team and the football team but he declined. Every year my son and I sit down with his doctor and revisit what he can do.  He loves sports.   He helps the gym teachers as an assistant in the younger grades.  He does weight training but low weight(i hope) and high reps.   Every 6 months he has some kind of an image resolution scan...like an echo or a ct scan.  I am very proud of him for making changes and being positive, but I know it still hurts.  I think that you will be able to find some other things to do and continue to enjoy sports.  Goodluck.  Talk to your parents and your doctor.

[Frito15]

Hi.  I am eleven years old and feel that life just isn't fair.  I have a bi-cuspid aortic valve, aortic arch anomaly, and an aortic dilation.  I am just at the age where sports are so important.  I am starting middle school and am wanting to play football so badly.  I am upset, mad, frustrated and feel that it is not fair!  My parents won't let me because of the heart conditions. Would it really be that dangerous for me to try?  My cardiologist says no competitive sports, but I feel that at least other people got to try sports...I didn't even get the chance.  Right now, I dont' think ANYONE should be able to play.  Any ideas on how to accept this?

[jen006]

I was interested to read so much information in your post regarding aortic dilation, BSA, Z-scores and the like! My son (5) has mild dilation of the ascending aorta (with BAV). His z-score is 4, I believe he measures 2 standard deviations above the norm, but when adjusted for BSA the dilation falls into the 97th percentile. I had a lot of trouble understanding and relating all this info as I could not find too much online that was helpful in putting all the pieces together. You have been very helpful.

[Schmoomcgoo]

No, I had no heartrate altering drugs (although I am on a beta blocker which does keep it pretty low--I don't believe I was on it yet for my first CT though).  I also didn't have nitro or any vasodilator, but I have no small vessel disease (my coronary arteries are "beautiful") and was having the CT to assess an aortic aneurysm.  For what it's worth, my dad has taken nitro for possible angina and said it did nothing (so they said it wasn't angina ***shrug***).  I'm a worrier so I understand worry, but try to think of this as life-saving, 'cuz it may well be.  How lucky we are to live in a time when people can have these non-invasive diagnostics and have OHS with survival rates in the 98%+ range!  Hey, I'm having my first MRI with contrast on June 7.  We can compare notes. :)

[dhflp]

What was your heart rate during CT ANGIO imaging since you did not receive heart rate lowering drugs? CT ANGIO technician told me that they also give nitroglycerin during imaging to expand arteries.By the way what IV contrast did they use on you and did they give you nitroglycerin with IV contrast? It's scarry because I never had taken nitroglycerin in my life.

[Schmoomcgoo]

I recieved no heartrate lowering drugs.  I cannot imagine doing a CT angio, for whatever other reason, on someone with known aortic dilation and not measuring the aorta.  Ask them to if you want to be sure; you'll have plenty of time to chat while they're getting you ready.  I'm sure everything will go fine.  Make sure you report back.  Take care.

[steveki]

Thanks so much for your insight. I am electing to treat myself for this. My solution: NO medication, I am going to drop my weight from 285 (I was 298) to 260. I am going to do it by diet, walking, cycling, and yes, lifting, but not powerlifting, 10-12 rep sets of modersate weight (for me).
its hard for the normal person to imagine the strain of lifting huge amounts of weight from the ground, Heavy squatting and so on. I have been near the top of my game for a few years now and I have been powerlifting for 14 years. I have been reading and found data to indicate 4.0 may not even be consdered dangerous in large framed males who have grown their body and heart from years of training. (maybe it is wishful thinking. I dont believe that lifting at 60% max efforts and cardio training will grow this thing anymore, and if it does, then so be it. Pbanders, i cannot live like a sad medicated piece of meat wainting to die. I know you don't. I have enough problems in my life and training has always been my therapy. if therapy kills me..well then poetic justice I should think!

Steve

[dhflp]

Do they give heart rate lowering drugs like inderal and nitroglycerin so heart rate is less than 65 bpm during CT scan imaging?It's scarry to take inderal and nitroglycerin with IV contrast (at the same time)during CT scan imaging.Is aortic root/ascending aorta diameter size measured on CT angio as is calcium score?

[Schmoomcgoo]

CT angiography is a CT with a contrast dye injected into you through an IV.  The CT machine is like a big donut with a fast moving xray camera inside the donut that whirs around taking pictures that are later stacked by a computer to make a nice 3D image.  The dye delineates the lumen (the space inside the artery)from the artery itself so that the inside and outside of the artery can be seen.  A few people react to the dye, but most don't.  When it's injected it makes a b-line for the groin and the area behind the nose; it imparts a warm sensation yonder (some say like peeing one's pan'ts--I didn't get this) and a medicinal scent in the nose.  It's not really unpleasant though.

I recommend asking for a CD copy of your CT--it's very cool to actually see one's aorta and it makes it a little less scary to understand what the experts are basing their judgments on.  Good luck!

[dhflp]

I am having CT ANGIOGRAPHY,(to check for any coronary blockages) but wander how's this test done.Do they use the same iv contrast for CT scan of ascending aorta and CT ANGIOGRAPHY?Is aortic root and ascending aorta imaged and measured during CT ANGIOGRAPHY? Any serious side effects from CT scan iv contrast?

[lance1881]

Desertrat49,
I was diagnosed with a 4.2cm ascending aortic aneurysm in January 2005.  My life fell apart after the diagnosis.  I couldn't think at work, felt depressed and just knew I was going to die at any minute.  About a month after the diagnosis I had an attack of afib and was put on Toprol.  I continued to have bouts of PVCs and PACs which I attribute to stress.  It wasn't until December of 2005, after increasing the dosage of the Toprol to 150mg daily and taking it twice a day (100mg at night and 50mg in the morning) did my PVCs and PACs stop.  I went in for a CT scan in June 2005 and January 2006, every six months.  So far the aneurysm has not grown but I go in on June 26th for another CT scan, always keeping my fingers crossed that it stays the same size.  I did have one cardiologist tell me that he felt that the size of my aorta might be in proportion to my body size (6'4" 205lbs) but does one really ever know?  Of course not, I just get to live with this hanging over my head from here on out.  You are doing the right thing in asking for a CT scan every six months until you feel comfortable that it is not continuing to grow.  Best of luck to you and remember, there is always someone out there feeling the same pain and anguish that you are feeling at any given moment.

[Schmoomcgoo]

I read this forum daily but don't get on it a lot, but I feel I can probably put your mind at ease some (or at least comiserate!).

I have a mid-ascending aortic aneurysm (not the root) of 4.5cm and a leaky bicuspid aortic valve.  I am also on the same beta blocker only I'm on the extended release version (Toprol XL).

Regarding the beta blocker:  After getting used to it (which took a while, I'm not sure how long, but maybe a month or even two) I have had no problems EXCEPT when I was sent 100mg tabs and told to split them and take them 50mg twice a day.  When I did that I had general sleepiness and dizziness when laying down or getting up.  I solved that problem by not splitting the tablet and taking 100mg at bedtime.  I believe that splitting the tablet interfered with the time-release coating to cause too much drug to be in my system shortly after taking the pill.  The drug company data comparing Toprol XL and metoprolol shows that the level of the drug is much higher in one's system for the first couple hours after taking it. (http://www.toprol-xl.com/HCP/8_Pharmacology.asp) I suspect you are not tolerating those initial surges of drug very well.  You might try taking your nightime dose right at bedtime and your morning dose at least 12 hours later.  That way you are asleep when the nightime dose is at its highest and (hopefully) fully awake and at a point when the nightime dosage is lowest in your sytem when you take the daytime dose.  Failing that, ask about Toprol XL (which I know is more expensive...).  I take twice your dose with no problems (I'm 5' 10", 170 lbs., BTW)

As for the aneurysm rechecks:  I was diagnosed in November of 2004.  I had an initial TEE followed by a CT at 3 months (at my request) another at 6 months and a third at 1 year.  Now I am on yearly re-checks.  I agree that this is an awful diagnosis to have hanging over one's head.  It's pretty much driving me nuts!  You are absolutely right--we are not all the same.  BUT...there are a lot more of us than you might think and most of us do seem to be pretty stable.  I recommend you go to www.valvereplacement.com where you can meet and talk to a lot of people in our situation and gain some assurance from other patients (no medical professionals).

Good luck!

PBANDERS and to all who get on here often....Please answer some questions I have since I never can get on here with the DOCTORS. I was diagnosed with a 4.2 aortic root aneurysm last June 27. Went on Beta Blocker (Metoprolol) 25 mg 2xdaily last July. I do not like the way they make me feel. If I sit down for any length of time, I doze off. I do not have the energy nor the stamina I once had. Sometimes when I lay down my head will feel like it is spinning slightly. Most of the time I feel like I just got up from a LONG NAP. Noticed that my Cholesterol went up as well. Read that that is one of the side effects as well. I had an echo on Jan 2 to check on aneurysm..NO CHANGE...so the doctor here at Mayo had his nurse call me and tell me to come back in 1 YEAR...IS this the STANDARD for doctors if an aneurysm has not changed in 6 months following the initial diagnosis????? I would hope I could always be checked every 6 MONTHS.. We are all lumped into one bunch as far as statistics go and WE ARE NOT ALL THE SAME. I am trying to find another cardiologist here in Jacksonville, FL since I am not feeling secure with my cardio doc here at MAYO CLINIC. Took him ONE MONTH to call me back after I requested that he call me after this last echo. He also told me to direct any other questions or concerns to the family practitioner that I see at Mayo as well for my yearly physicals. She told me that she has never dealt with anyone with this diagnosis. Did not make me feel secure at all upon hearing that. I was wondering if most insurance companies will only pay for ONE ECHO each year with this diagnosis???????? Seems to me a lot could happen in one year. SURE WOULD APPRECIATE ALL OF YOU PASSING ON WHAT YOUR DOCTORS HAVE TOLD YOU if what they have told you pertains to what I am asking on here. I was also wondering how many people never progress....I am keeping my fingers crossed that I might be one of those...Anything to get my mind off all the negative things that I think about with this condition. THANK YOU ALL OF YOU....Christine.......Hope everyone is feeling well...This is not an easy condition mentally to live with.

[pbanders]

At 4.5 cm, you may want to consider prophylactic surgery to fix your aneurysm. Given your valve disease, you could probably justify it. I know JUST HOW YOU FEEL - I would NOT want this thing hanging over my head, I'd want to get it behind me and get on with my life.

If you want to talk with a surgeon about it, give mine a call. His name is Vincent Gaudiani, his office is in Redwood City, CA (650-366-0225). He and Craig Miller of Stanford are two of the best for this type of surgery on the West Coast. Cleveland Clinic also has an excellent reputation.

When shopping for a surgeon, you want someone who has done hundreds of these cases, not one or two. You also want someone who works very efficiently, to keep you on perfusion for as little time as possible. Gaudiani did a mini-sternotomy on me, I only have a nearly-invisible 4" scar. I was on perfusion for only 25 minutes. Get the best. I've heard that Craig Miller is just as good.

[Avel]

Here is the link to an article from a group in Saarbrucken,Germany regarding two soccer players with bicuspid aortic valve disease (BAVD).

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16598593&query_hl=3&itool=pubmed_docsum

It is not easy to come up with answers regarding exercise and BAVD, as the above paper from Germany mentions. Since many of those with BAVD are very athletic, there is tremendous interest in this topic. Those who may have an undetected aneurysm are extremely vulnerable. There was an example in the press in 2005, when it was reported that Fred Hoiberg, who was playing professional basketball with the Minnesota Timberwolves at the time, was found to have an aortic aneurysm. Reports also mentioned that he had a known bicuspid aortic valve. It is amazing that his aneurysmal aorta held together under such duress.

There is general agreement that lifting heavy weights is forbidden for those with aneurysms - the August 2005 issue of Scientific American has an article on aneurysms which includes a section called "A Warning for Weight Lifters" - the text is accompanied by a picture of a young weight lifter, and the scar on his chest from surgery on his dissected aorta is clearly visible.

Today there is greater recognition that Bicuspid Aortic Valve Disease is not the simple condition that it may have appeared to be - and its dangerous association with aortic aneurysm and dissection is gaining greater awareness. We don't know how many lives are lost - sudden deaths perhaps considered a massive heart attack may actually be from aortic dissection/rupture. Without autopsies, there is no way to know for sure.

The Bicuspid Aortic Foundation's website at www.bicuspidfoundation.com  may be helpful. The Foundation will observe September as awareness month for thoracic aortic aneurym and dissection (TAAD).

Best wishes,
Avel

[pbanders]

Your problems with metoprolol are common. I'm still a LOT more sleepy than I used to be, I take 50 mg in the morning and 25 mg at night. You could try the time-release version (Toprol XL), or a different BB. Personally, I just am accepting it and tolerating it. I also stopped caffeine at the same time as I went on it, so it's been a double-whammy.

Typical growth rates for aneurysms are very slow. Get a copy of the Sept. '05 Scientific American, there's a good article on aortic aneuryms in it. They quote a rate of 0.12 cm per year. Yearly checkups after an initial 6 month scan to rule out rapid expansion are just fine.

Personally, I'd get a cardiologist who is experienced with aortic disease. My cardio is extremely experienced with them, and my surgeon has written a dozen articles on the subject, and has performed over 8,000 cardiac procedures. This condition is complex and requires expert care.

If you have not had a CT with contrast I would insist on one. Echo is not definitive in diagnosing aneurysms. You need to have your entire thoracic aorta imaged and assessed.

Be glad your condition was detected. Most aren't and progress asymptomatically to a disasterous dissection or rupture. I think your situation is more difficult than mine. When mine was discovered, I was already at 5.0 cm, the threshold for surgery. I had my operation in a month and didn't have to wait for years for the aneurysm to progress to the threshold for surgery. In your case, I would strongly suggest that you not let this rule your life - within prudent restrictions, do what you want. While being under 5.0 cm is not risk-free, the risks are quite low (as long as there isn't a family history of dissection). Don't let your aneurysm stop you.

As for post-surgery, in my case, I have no complaints. I raced bikes for years before surgery, I still ride a lot and at a high level. I did a solo ride this morning of 20 miles with 1,000 feet of climbing, and averaged 18.5 mph. I finished the ride by mixing it up with two domestic D3 pros who were probably younger than 25. Not bad for a 48 year old guy who's had his chest cracked and is take a drug (metoprolol) that cuts your aerobic capacity by 10-15%, huh?

Best of luck with your treatement.

[pbanders]

Lance, don't let this thing rule your life. Get the article I referenced earlier. At 4.2 cm, your risk of dissection is extremely low. Do what you want, don't let this stop you.

You also said:

"I did have one cardiologist tell me that he felt that the size of my aorta might be in proportion to my body size (6'4" 205lbs) but does one really ever know?"

Actually, a good cardiologist knows very well. There are extensive statistics available on aortic dimensions that are correlated to body surface area (BSA). Your cardiologist should be able to tell you for your BSA and aortic root dimension EXACTLY where your dimension sits on the normal distribution, in terms of numbers of standard deviations from norm, your "Z-score". I would be very surprised if at your size that a dimension of 4.2 cm is at least 2+ standard deviations from norm. Don't trust me, get your facts from a doctor. If your cardiologist can't give you this information, get a new cardiologist.

If you want to see a graph of aortic root dimensions across a large population of people, get your doctor to access Medline and get a copy of this article, "Aortic root dilatation among young competitive athletes: Echocardiographic screening of 1929 athletes between 15 and 34 years of age". Figure one shows a graph of aortic root dimensions vs. a wide range of BSA. Even for the most extreme BSA of 2.6 m^2, the maximum aortic root dimension at 1 standard deviation from normal was less than 4.0 cm, and the average at this BSA was about 3.3 cm.

[desertrat49]

PBANDERS and to all who get on here often....Please answer some questions I have since I never can get on here with the DOCTORS.  I was diagnosed with a 4.2 aortic root aneurysm last June 27.  Went on Beta Blocker (Metoprolol) 25 mg 2xdaily last July.  I do not like the way they make me feel.  If I sit down for any length of time, I doze off.  I do not have the energy nor the stamina I once had.  Sometimes when I lay down my head will feel like it is spinning slightly.  Most of the time I feel like I just got up from a LONG NAP.  Noticed that my Cholesterol went up as well.  Read that that is one of the side effects as well.  I had an echo on Jan 2 to check on aneurysm..NO CHANGE...so the doctor here at Mayo had his nurse call me and tell me to come back in 1 YEAR...IS this the STANDARD for doctors if an aneurysm has not changed in 6 months following the initial diagnosis????? I would hope I could always be checked every 6 MONTHS.. We are all lumped into one bunch as far as statistics go and WE ARE NOT ALL THE SAME.  I am trying to find another cardiologist here in Jacksonville, FL since I am not feeling secure with my cardio doc here at MAYO CLINIC.  Took him ONE MONTH to call me back after I requested that he call me after this last echo.  He also told me to direct any other questions or concerns to the family practitioner that I see at Mayo as well for my yearly physicals.  She told me that she has never dealt with anyone with this diagnosis. Did not make me feel secure at all upon hearing that.  I was wondering if most insurance companies will only pay for ONE ECHO each year with this diagnosis????????  Seems to me a lot could happen in one year.  SURE WOULD APPRECIATE ALL OF YOU PASSING ON WHAT YOUR DOCTORS HAVE TOLD YOU if what they have told you pertains to what I am asking on here.  I was also wondering how many people never progress....I am keeping my fingers crossed that I might be one of those...Anything to get my mind off all the negative things that I think about with this condition.  THANK YOU ALL OF YOU....Christine.......Hope everyone is feeling well...This is not an easy condition mentally to live with.

[pbanders]

Steveki, you're right, there is variability with what is a normal aortic dimension with body size. However, this is common knowledge for a cardiologist, so I'm sure she's factored that in when doing the calculations for you. Dilation is NOT reverseable - as you said, this is your new reality. I asked exactly the same questions when I was diagnosed. Get your CT, it's much more definitive in determining the size and extent of your dilation (I'm assuming you were initially diagnosed with echo).

Personally, I'd get a second opinion, and get evaluated at a specialty center such as the Cleveland Clinic. I suspect they'll tell you the same thing, though - you should stop heavy weightlifting. The reason is that duing maximum effort lifts, your systolic BP can exceed 300, which causes high stress on your ascending aorta and leads to further dilation and risk of dissection or rupture.

You should go on your beta blocker. It takes some getting used to, but personally I cannot tell I'm taking it now that I've adjusted to it. It can take 6 months or more. They want you to take it because it changes the way your heart beats so that that the highest peak pressure during systole is reduced, which reduces aortic stresses. You will have a lower HR while on the beta blocker, and probably fewer PVC's and other irregular beats. Your VO2max will be reduced to some extent, but I don't even notice it any more. Negative symptoms that go away after starting up with beta blockers are cold hands/feet and sleeplessness, and vivid dreams.

If you have to stop weightlifting, you'll adjust better if you use it as a chance to shift your athletic interests elsewhere. Aerobic exercise such as running, cycling, and swimming do not produce the peak arterial pressures that weightlifting does, as you don't close your glottis during hard efforts. There's no reason you can't continue to be very fit and active.

You'll likely require regular monitoring to determine if your dilation is progressing. If at some time in the future you need surgery, be happy that you live now and not 25 years ago, when the techniques were cruder and the risks much higher. You're one of the lucky ones who knows you have a problem and are getting it monitored - the vast majority of people with aortic dilation never know they have a problem until they dissect, which is an extremely serious and often fatal result. Good luck and hope things turn out well for you.

[steveki]

Pbanders:
Im 33 and a long time weightlifter, low bodyfat, about 6'2 285.
I had been having chest pains and skipped beats and skipped beats with pain, i went to a cardio for the full workup.

My bp was a little high resting 130/90 and a little high on the stress test..this runs in my family. My circulation was very good which ruled out heart disease,
but my echo showed my aorta was dilated to 4.0....high normal was 3.7

She is recommending a ct scan to look at the aorta, since i am built bigger there may be error, it could be bigger or smaller.

I guess my years of hard training and borderline bp brought this on.
I left the cardio yesterday and she gave me toprol xl (which im scared to start taking) and told me no lifting at all until i get the ct scan (thats if the insurance approves it) if it is indeed 4.0 im not allowed to lift ever again. This is devastating on me for many reasons, one is that lifting has always been a sort of therapy for me as well as an excellent stress outlet.
Im still getting the skipped beats with pain which scre me the most (she said it cannot be my aorta)
There were alot of things i didnt ask her since i was very numb, but my main question to you is do you know if this dilation is at all reversable? or is this the new reality for the rest of my life?  Thanks

[pbanders]

Tough questions. "What are the risks?" - the risk is that due to the combination of your bicuspid aortic valve (since replaced), your high BP during intense aerobic activity, the impact of contact in your sport, and your dilated aorta, that you're at risk of an aortic dissection or rupture.

You should consider being evaluated by experts in aortic conditions, perhaps by the Cleveland Clinic. Most cardiologists and surgeons would err on the safe side and tell you that your competitive sports days are over - but there may be other options available. Are you currently taking a beta blocker?

I've found it is very difficult to find good information on athletic activity AFTER aortic surgery. I'm 48 and had a 5.0 cm aneurysm of my ascending aorta grafted in Feb 2004. I was a very active cyclist and former racer prior to my surgery. I have resumed a fairly intense exercise schedule since surgery, and there have been no issues (no changes on two yearly MRA's, echos, or ECG's). I know of two other people with similar histories to mine who have both resumed heavy aerobic exercise since surgery. I do NOT do any heavy weight lifting or exercises that cause me to close my glottis, nor do I participate in an "impact" type of sport.

[Cleveland Clinic]

gael,

Its impossible to make recommendations without full evaluating you. Overall, I would be somewhat concerned with you participating in competitive sports with any significant degree of aortic disease because the high mortality and morbidity associated with aortic rupture.

good luck