AZ Don
Well-known member
The point of this post is to consider what activity restrictions are appropriate, if any, following full recovery from thoracic aneurysm repair surgery. Some Dr’s advise restrictions comparable for those with an active aneurysm and some advise no restrictions at all. There seems to be very little research and evidence in this area. In short, it appears to me that for those that have had an aneurysm, there is some small risk of having another. The risk is likely higher for those with a connective tissue disorder or bicuspid aortic valve. As such I think the choice is to accept some basic restrictions such as limitations on weight lifting and avoiding extreme exercise, or to accept that such activities may pose a small enough risk that minimal to no limitations are necessary. There are respected Dr’s supporting either choice and moderate aerobic exercise is universally recommended. I found it particularly interesting that the Cleveland Clinic has apparently altered their guidance over the past few years, and seems to be saying the risks are lower than they used to say, and this is based on a study of their patients.
I have a bicuspid aortic valve and the quote from the AHAJournal below supports what my Cardiologist told me: “We have to assume that your arteries were formed with material that is weaker than that in a typical person”. So it seems that my risk for a subsequent aneurysm is higher than for those w/o a bicuspid valve or connective tissue disorder. Aside from the info below, I’ve found very little specifics. General recommendations post-op include to stop smoking, control blood pressure, eat a heart healthy diet (limited cholesterol and fat) and exercise regularly.
My own Dr’s have weighed in on the conservative side, with my surgeon suggesting that I keep my heart rate below 120. This was guidance for after full recovery! Before surgery that was just a flight or two of stairs, or a mild hill on my bike! My cardiologist also advised only light to moderate exercise and to avoid weight lifting. While I found their guidance overly restrictive I have no ambitions to engage in competitive athletics and I plan to accept some level of limitations on exercise once I have fully recovered.
Following are some relevant quotes and links that I found. In response to my query to the Cleveland Clinic, I was provided this text taken from a 2007 webchat:
http://my.clevelandclinic.org/heart/webchat/aorta071107.aspx
cyclejoe: I am a 40 year old athletic man who had surgery on a dilated aortic root and 5 cm ascending aneurysm. Had a graft placed. I am cycling again after a great recovery. Do I have any restrictions? Can I do light weight lifting? Do I need to worry about the aneurysm returning? How long does this surgery last?
Speaker_-_Dr__Svensson: If you had a successful repair, cycling is fine as long as your aortic valve is working well. I would not recommend weight lifting unless it is light aerobic exercise.
The risk of the aneurysm returning is about 1 in 20 but it is very dependent on why you originally needed the repair. If you had a bicuspid aortic valve or Marfan's syndrome, the risk is increased. The new tube graft that you had inserted will stretch by at 10% but will otherwise not wear out. However, the aorta adjacent to the new tube graft may enlarge over a long period. Therefore, you need yearly or two yearly follow up.
(So in 2007, Dr Svensson recommended avoiding weight lifting, but in the webchats that I could access, all 2010 or more recent, he essentially said that no restrictions were necessary
From Cleveland Clinic webchats:
http://my.clevelandclinic.org/heart/...-aneurysm.aspx
edg202: What is the probability of a second ascending aortic aneurysm developing several years after a first occurrence was successfully resected?
Dr__Svensson: That is very dependent on what the original indication for surgery was. As mentioned above, if you had a successful resection in association with a bicuspid valve, the risk is only 2 % in the next 10 years.
If the reason was aortic dissection, then the risk goes up to about 10%.
Dr__Svensson: To answer your questions:
• What is the probability of another one from showing up in another location - It is very unlikely. (re. an individual with a current aneurysm)
milessusan: My son had a thoracic aortic aneurysm (8.5cm) that was repaired last year at the Clinic. His surgeon said that it is likely that sometime over the course of his lifetime that he will have another aneurysm. He has been tested for Marfan Syndrome and other genetic disorders, but everything came back "negative". He does have other "symptoms" that would indicate he has some sort of connective tissue disorder. Do you think aneurysm recurrence is likely? Also, he still takes atenolol....will he have to remain on this med indefinitely?
Dr__Svensson: The risk of recurrence is dependent on blood pressures and whether dissection was present.
GARY: I had an expanding aorta replaced above the heart. What are the chances of an aneurism (sp) happening elsewhere along the aorta? GARY
Dr__Svensson: Gary, the chances are very small that you will have an aneurysm in another place on the aorta.
Shawnee: In 2004, I had surgery to replace my aortic root and ascending aorta replaced with a graft and remodel and reimplantation of my aortic valve (modified David procedure). What is the expected need for reoperation?
Dr__Svensson: At Cleveland Clinic, the freedom from reoperation at 10 years is 95 percent.
Shawnee: Following my 2004 surgery to replace my aortic root and ascending aorta, I have remained very active. This includes bicycle racing (32 races this season). I often see max heart rates of 183-187, with averages of 168-174. My BP is well controlled w/o medications. Is there any data regarding high performance athletics following surgery? Also, I have been a bit frustrated with the lack of "exacting” post surgical care. Other than imaging, are there other suggestions, (meds etc.)?
Dr__Svensson: I have a couple NBA players doing well after David root repairs; so exercise is not an issue. Yearly echoes and MRI would be fine. You should speak to your cardiologist about your concerns or we would be happy to provide you with a second opinion at Cleveland Clinic.
rkunglaub2: I was diagnosed with an ascending aorta aneurysm of 4.7 cm last fall. I an a very active athlete age 64. What are your recommendations for exercise, running biking swimming--heart rate limits and time limits? If I have surgery, are there any exercise limitations?
Dr__Hammer: Keep your HR at 80% of you max heart rate.
Dr__Roselli: Avoid heavy lifting as a general rule not more than 1/2 your body weight. I have had many patients return to competitive athletics after surgery.
Blumen: Does a 2.2 cm rt iliac aneurysm and a 4.8 cm ascending aortic aneurysm indicate possible additional aneurysms? And is the rt. common iliac aneurysm a concern? Thank you.
Dr__Roselli: Yes aneurysms in multiple locations are suggestive of a connective tissue disorder or at least a propensity for aneurysms occurring elsewhere.
Julie7759: What physical restrictions are there after a person has recovered from ascending aortic aneurysm repair?
Dr__Roselli: Immediately post op, patients are told not to lift more than 10 pounds or drive for 6 weeks. Once you have fully recovered and completed cardiac rehabilitation, you may be able to resume all normal activities, unless you have active aortic disease elsewhere.
spinja187: Greetings! I have had my aortic valve and ascending aorta replaced, and thankfully, all is well! I an interested in how the tensile strength of the graft and the joints compares to that of healthy tissue, whether the strength increases or decreases over time due to tissue infiltration or deterioration, and whether there is any evidence of increased vulnerability to a blunt trauma to the chest, such as a hard fall or a car accident. Thanks!
Dr._Eric_Roselli: Congratulations on having undergone a successful cardiac and thoracic aortic surgery and recovering well. The tensile strength of the Dacron prostheses is excellent and higher than that of the aorta, especially atherosclerotic or otherwise disease aorta. Another advantage of this material is that it is biologically inert, flexible, relatively elastic and easy to handle in the operating room. The late risk of degeneration is higher for you native aorta (which has already proven to be prone to aneurysm formation) than your new vascular prosthesis. Degeneration of these graft is not unheard, however. They all expand between 10and 20% early after implantation. Occasionally they have been known to become aneurysmal but this occurs in less than 0.5% of implants over their lifetime and seems to be less of an issue with newer configurations of the material. You probably received a woven (not knitted) graft and which has a velour micro surface which stimulates the ingrowth of a fibrotic biologic coating which may add some strength to the prosthesis. Breakdown at the suture lines or a defect in the graft can cause a pseudoaneurysm but these events are very rare unless the device is infected. I would recommend that you are always diligent about taking antibiotics prophylactically with dental procedures to avoid late infection of your new aortic valve and graft.
If you sustain a serious blunt chest trauma or fall you probably have more to worry about than your graft. These are strong, but please don’t have any serious trauma!
Sept14: To what extent are aortic aneurysm patients (specifically the ascending aorta) who have had successful surgery at risk for other aneurysms in the future, i.e. other locations?
Dr_Lars_Svensson: The risk of further aneurysm formation of the ascending aortic surgery is low if any aorta above 4.5cm is repaired. In a study we did of our patients, the risk of further surgery out to 10 yrs was 2%.
http://circ.ahajournals.org/content/111/6/816.full
Cystic medial degeneration has been found to be the underlying cause of the aortic dilatation associated with a bicuspid aortic valve. In one study, 75% of those with a bicuspid aortic valve undergoing aortic valve replacement surgery had biopsy-proven cystic medial necrosis of the ascending aorta, compared with only 14% of those with tricuspid aortic valves undergoing similar surgery.9 Inadequate production of fibrillin-1 during embryogenesis may result in both the bicuspid aortic valve and a weakened aortic wall.10 Fedak et al11 examined ascending aortic specimens from those with bicuspid aortic valves and tricuspid aortic valves undergoing cardiac surgery. They found that patients with bicuspid aortic valves had significantly less fibrillin-1 than did patients with tricuspid aortic valves, and the reduction in fibrillin-1 was independent of patient age or aortic valve function. Interestingly, samples of the pulmonary arteries of the same subjects showed a similar reduction in fibrillin-1 content among those with bicuspid aortic valves. This might account for why some patients with a bicuspid valve having undergone the Ross procedure develop late dilatation of the pulmonary autograft (see later sections). Additionally, in a recent study of patients with ascending thoracic aortic aneurysms, Schmid et al12 found that compared with tricuspid aortic valve controls, the aortic aneurysm tissue of those with a bicuspid aortic valve demonstrated more lymphocyte infiltration and smooth muscle cell apoptosis. This suggests that the walls of aneurysms associated with bicuspid aortic valves may be weaker than more “typical” aneurysms.
I have a bicuspid aortic valve and the quote from the AHAJournal below supports what my Cardiologist told me: “We have to assume that your arteries were formed with material that is weaker than that in a typical person”. So it seems that my risk for a subsequent aneurysm is higher than for those w/o a bicuspid valve or connective tissue disorder. Aside from the info below, I’ve found very little specifics. General recommendations post-op include to stop smoking, control blood pressure, eat a heart healthy diet (limited cholesterol and fat) and exercise regularly.
My own Dr’s have weighed in on the conservative side, with my surgeon suggesting that I keep my heart rate below 120. This was guidance for after full recovery! Before surgery that was just a flight or two of stairs, or a mild hill on my bike! My cardiologist also advised only light to moderate exercise and to avoid weight lifting. While I found their guidance overly restrictive I have no ambitions to engage in competitive athletics and I plan to accept some level of limitations on exercise once I have fully recovered.
Following are some relevant quotes and links that I found. In response to my query to the Cleveland Clinic, I was provided this text taken from a 2007 webchat:
http://my.clevelandclinic.org/heart/webchat/aorta071107.aspx
cyclejoe: I am a 40 year old athletic man who had surgery on a dilated aortic root and 5 cm ascending aneurysm. Had a graft placed. I am cycling again after a great recovery. Do I have any restrictions? Can I do light weight lifting? Do I need to worry about the aneurysm returning? How long does this surgery last?
Speaker_-_Dr__Svensson: If you had a successful repair, cycling is fine as long as your aortic valve is working well. I would not recommend weight lifting unless it is light aerobic exercise.
The risk of the aneurysm returning is about 1 in 20 but it is very dependent on why you originally needed the repair. If you had a bicuspid aortic valve or Marfan's syndrome, the risk is increased. The new tube graft that you had inserted will stretch by at 10% but will otherwise not wear out. However, the aorta adjacent to the new tube graft may enlarge over a long period. Therefore, you need yearly or two yearly follow up.
(So in 2007, Dr Svensson recommended avoiding weight lifting, but in the webchats that I could access, all 2010 or more recent, he essentially said that no restrictions were necessary
From Cleveland Clinic webchats:
http://my.clevelandclinic.org/heart/...-aneurysm.aspx
edg202: What is the probability of a second ascending aortic aneurysm developing several years after a first occurrence was successfully resected?
Dr__Svensson: That is very dependent on what the original indication for surgery was. As mentioned above, if you had a successful resection in association with a bicuspid valve, the risk is only 2 % in the next 10 years.
If the reason was aortic dissection, then the risk goes up to about 10%.
Dr__Svensson: To answer your questions:
• What is the probability of another one from showing up in another location - It is very unlikely. (re. an individual with a current aneurysm)
milessusan: My son had a thoracic aortic aneurysm (8.5cm) that was repaired last year at the Clinic. His surgeon said that it is likely that sometime over the course of his lifetime that he will have another aneurysm. He has been tested for Marfan Syndrome and other genetic disorders, but everything came back "negative". He does have other "symptoms" that would indicate he has some sort of connective tissue disorder. Do you think aneurysm recurrence is likely? Also, he still takes atenolol....will he have to remain on this med indefinitely?
Dr__Svensson: The risk of recurrence is dependent on blood pressures and whether dissection was present.
GARY: I had an expanding aorta replaced above the heart. What are the chances of an aneurism (sp) happening elsewhere along the aorta? GARY
Dr__Svensson: Gary, the chances are very small that you will have an aneurysm in another place on the aorta.
Shawnee: In 2004, I had surgery to replace my aortic root and ascending aorta replaced with a graft and remodel and reimplantation of my aortic valve (modified David procedure). What is the expected need for reoperation?
Dr__Svensson: At Cleveland Clinic, the freedom from reoperation at 10 years is 95 percent.
Shawnee: Following my 2004 surgery to replace my aortic root and ascending aorta, I have remained very active. This includes bicycle racing (32 races this season). I often see max heart rates of 183-187, with averages of 168-174. My BP is well controlled w/o medications. Is there any data regarding high performance athletics following surgery? Also, I have been a bit frustrated with the lack of "exacting” post surgical care. Other than imaging, are there other suggestions, (meds etc.)?
Dr__Svensson: I have a couple NBA players doing well after David root repairs; so exercise is not an issue. Yearly echoes and MRI would be fine. You should speak to your cardiologist about your concerns or we would be happy to provide you with a second opinion at Cleveland Clinic.
rkunglaub2: I was diagnosed with an ascending aorta aneurysm of 4.7 cm last fall. I an a very active athlete age 64. What are your recommendations for exercise, running biking swimming--heart rate limits and time limits? If I have surgery, are there any exercise limitations?
Dr__Hammer: Keep your HR at 80% of you max heart rate.
Dr__Roselli: Avoid heavy lifting as a general rule not more than 1/2 your body weight. I have had many patients return to competitive athletics after surgery.
Blumen: Does a 2.2 cm rt iliac aneurysm and a 4.8 cm ascending aortic aneurysm indicate possible additional aneurysms? And is the rt. common iliac aneurysm a concern? Thank you.
Dr__Roselli: Yes aneurysms in multiple locations are suggestive of a connective tissue disorder or at least a propensity for aneurysms occurring elsewhere.
Julie7759: What physical restrictions are there after a person has recovered from ascending aortic aneurysm repair?
Dr__Roselli: Immediately post op, patients are told not to lift more than 10 pounds or drive for 6 weeks. Once you have fully recovered and completed cardiac rehabilitation, you may be able to resume all normal activities, unless you have active aortic disease elsewhere.
spinja187: Greetings! I have had my aortic valve and ascending aorta replaced, and thankfully, all is well! I an interested in how the tensile strength of the graft and the joints compares to that of healthy tissue, whether the strength increases or decreases over time due to tissue infiltration or deterioration, and whether there is any evidence of increased vulnerability to a blunt trauma to the chest, such as a hard fall or a car accident. Thanks!
Dr._Eric_Roselli: Congratulations on having undergone a successful cardiac and thoracic aortic surgery and recovering well. The tensile strength of the Dacron prostheses is excellent and higher than that of the aorta, especially atherosclerotic or otherwise disease aorta. Another advantage of this material is that it is biologically inert, flexible, relatively elastic and easy to handle in the operating room. The late risk of degeneration is higher for you native aorta (which has already proven to be prone to aneurysm formation) than your new vascular prosthesis. Degeneration of these graft is not unheard, however. They all expand between 10and 20% early after implantation. Occasionally they have been known to become aneurysmal but this occurs in less than 0.5% of implants over their lifetime and seems to be less of an issue with newer configurations of the material. You probably received a woven (not knitted) graft and which has a velour micro surface which stimulates the ingrowth of a fibrotic biologic coating which may add some strength to the prosthesis. Breakdown at the suture lines or a defect in the graft can cause a pseudoaneurysm but these events are very rare unless the device is infected. I would recommend that you are always diligent about taking antibiotics prophylactically with dental procedures to avoid late infection of your new aortic valve and graft.
If you sustain a serious blunt chest trauma or fall you probably have more to worry about than your graft. These are strong, but please don’t have any serious trauma!
Sept14: To what extent are aortic aneurysm patients (specifically the ascending aorta) who have had successful surgery at risk for other aneurysms in the future, i.e. other locations?
Dr_Lars_Svensson: The risk of further aneurysm formation of the ascending aortic surgery is low if any aorta above 4.5cm is repaired. In a study we did of our patients, the risk of further surgery out to 10 yrs was 2%.
http://circ.ahajournals.org/content/111/6/816.full
Cystic medial degeneration has been found to be the underlying cause of the aortic dilatation associated with a bicuspid aortic valve. In one study, 75% of those with a bicuspid aortic valve undergoing aortic valve replacement surgery had biopsy-proven cystic medial necrosis of the ascending aorta, compared with only 14% of those with tricuspid aortic valves undergoing similar surgery.9 Inadequate production of fibrillin-1 during embryogenesis may result in both the bicuspid aortic valve and a weakened aortic wall.10 Fedak et al11 examined ascending aortic specimens from those with bicuspid aortic valves and tricuspid aortic valves undergoing cardiac surgery. They found that patients with bicuspid aortic valves had significantly less fibrillin-1 than did patients with tricuspid aortic valves, and the reduction in fibrillin-1 was independent of patient age or aortic valve function. Interestingly, samples of the pulmonary arteries of the same subjects showed a similar reduction in fibrillin-1 content among those with bicuspid aortic valves. This might account for why some patients with a bicuspid valve having undergone the Ross procedure develop late dilatation of the pulmonary autograft (see later sections). Additionally, in a recent study of patients with ascending thoracic aortic aneurysms, Schmid et al12 found that compared with tricuspid aortic valve controls, the aortic aneurysm tissue of those with a bicuspid aortic valve demonstrated more lymphocyte infiltration and smooth muscle cell apoptosis. This suggests that the walls of aneurysms associated with bicuspid aortic valves may be weaker than more “typical” aneurysms.
