2nd opinion now or later for Aortic aneurism?

[afraidofsurgery]

Hi! When my aortic valve was replaced (mech valve - all is well) the surgeon described it as 'bicuspid with a poorly formed 3rd leaflet'. I have a new cardiologist recently since my original retired, the new doctor started asking questions about whether it was a BAV (it's not clear) and if I was screened for an aortic aneurism (no but you'd think the surgeon would have flagged that during my valve replacement). So in I went for imaging and indeed I have a thoracic aortic aneurism, "stable aneurysmal dilatation of the ascending thoracic aorta measuring 5.2 x 5.2 cm. Mid aortic arch measures 2.6 cm. Proximal descending thoracic aorta measures 2.6 x 2.6 cm."

Genetic tests don't show any of the known mutations for connective tissue disorders. I'm being imaged (CT) every 6 mos or so but aneurism looks stable (3 scans so far).
My question is: Should I see a surgeon at another teaching hospital system who specializes in aortic aneurisms or wait till my current team flags me for surgery due to a change in the aneurism dimensions?

I am not in any hurry to sign up for surgery - at the same time, this would be a 2nd surgery and I understand it's a bit tricker than de novo. And I may want to hear if the expert option differs from my team's although I don't expect it to. My cardiologist has of course made sure my bp is lowered etc. with the expected warnings about dissections.

Thanks for your input!

Patty

 

[ATHENS1964]

I think but I am not sure that in the BAV if during the surgery the aorta is 4.5cm they replace it. If not then after the replacement of the valve the limit is 5 cm. In the general population without a problem in the valve it is 5.5 cm. My opinion is to see a surgeon and another cardiologist.

 

[pellicle]

Hi

When my aortic valve was replaced (mech valve - all is well) the surgeon described it as 'bicuspid with a poorly formed 3rd leaflet'.
...I have a new cardiologist recently since my original retired, the new doctor started asking questions about whether it was a BAV (it's not clear)

Seems your new cardio is on the task and your old one did many a favor by retiring. My view is that the genetics are one thing, but the reality makes the cause unimportant.

from:
https://www.anzsvs.org.au/patient-information/aortic-aneurysm/

When an aneurysm reaches 5.5 cms most surgeons would consider​

offering surgical intervention. This is because, at this size, the​

aneurysm has a greater risk of rupture. It then becomes as safe to​

have an operation to repair the aneurysm, as it is to leave the​

aneurysm alone... ​

Surgery may also be considered if your aneurysm is​

rapidly expanding on regular scans or it starts to cause other​

complications (see above). Rapid expansion means more than 7mm in 6​

months or 10mm in one year. ​

"stable aneurysmal dilatation of the ascending thoracic aorta measuring 5.2 x 5.2 cm. ...
My question is: Should I see a surgeon at another teaching hospital system who specializes in aortic aneurisms

since its not going to go away I would be seeking surgery sooner than later but would be curious to see if its growing and if at any rate

Best Wishes

 

[Warrick]

I would second Athens reply.
Of interest here-
https://badaorta.com/double-trouble-bicuspid-aortic-valve-bav/

 

[ATHENS1964]

Surgical management of BAV disease with concomitant ascending aortic aneurysm has often been treated with a straightforward approach that addresses each problem individually. However, because of the heterogeneous presentation of BAV disease and the gaps in knowledge of the associated aneurysmal behavior and molecular characteristics, a thoughtful approach carefully assessing individual risk factors of the aortic valve and aorta is required to determine the most appropriate surgical intervention for optimal outcomes. Current guidelines of the European Society of Cardiology (ESC) [130] and the joint guidelines of the American College of Cardiology (ACC)/American Heart association (AHA) [113] recommend elective aortic repair in patients with a proximal aortic diameter >45 mm and concomitant indication for elective aortic valve repair/replacement. In asymptomatic patients with well-functioning BAV, elective repair is recommended for diameters ≥50 mm, if aneurysmal dilatation is >5 mm/year, if the patient has a strong family history of dissection/rupture/sudden death, or if pregnancy is planned.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3503270/

 

[pellicle]

Surgical management of BAV disease with concomitant ascending aortic aneurysm has often been treated with a straightforward approach that addresses each problem individually. However, because of the heterogeneous presentation of BAV disease and ...

wow ... for a minute there I thought you'd developed an entire new vocab, then I sussed that you were quoting it.



I would share that view too btw. (not that it matters what my opinion is on the matter)

 

[afraidofsurgery]

Thanks for the opinions! Forgot to mention a surgeon is following me, and the guidelines and usual thresholds for repair have been explained. They’re watching to see if it expands and are leaving it be in the meantime. There was some mention of likely scar tissue from avr surgery as the reason for the conservative approach.
Patty

 

[pellicle]

There was some mention of likely scar tissue from avr surgery as the reason for the conservative approach.

I don't really understand this but:

• redo operations are tricky but not impossibly so in the modern world (I've had 3 OHS in my life
• they may have meant something else such as the scar tissue supporting it rather than it being an impediment...

Anyway, don't be afraid of surgery ... unless of course you prefer the other alternative.

Best Wishes

 

[Rapidman]

A thoracic aortic aneurysm is different than an ascending aortic aneurysm. So it would be good to get that clarification.

 

[Rapidman]

My bad sorry read your description wrong, from reading looks like ascending with minimal involvement of arch.

 

[Keithl]

Yeah if this is ascending aortic, 5.2 is time to get done generally. Some docs will say 5.5, it will depend on how much it is changing. Not sure what the guidelines for thoracic is, but when I read ascending I usually hear it as refectences as the aortic that leaves the heart and arches back down to the thoracic.

 

[Sheenas7]

At the risk of sounding stupid, are aneurysms happening in all mechanical valves? Mitral too?

 

[ATHENS1964]

At the risk of sounding stupid, are aneurysms happening in all mechanical valves? Mitral too?

No, the aneurysm is a different condition but those with a bicuspid aortic are more likely because of the genetic problem .

 

[pellicle]

At the risk of sounding stupid, are aneurysms happening in all mechanical valves? Mitral too?

its unrelated to the valve type, and is a "connective tissue" disorder. Its quite strongly correlated to bicuspid aortic valve. I've never heard fo aneurysm around the mitral but googled it and found it exists and is rare.

 

[Warrick]

BAVD is a sub group of Marfans syndrone like neighbours on the same street, and I believe Loey Dietz as well which I think is the most high risk when it comes to aneurysm’s.

https://www.marfan.org/about/marfanhttps://www.marfan.org/loeys-dietzhttps://www.marfan.org/bicuspid-aortic-valve

 

[pellicle]

BAVD is a sub group of Marfans syndrone like neighbours on the same street, and I believe Loey Dietz as well which I think is the most high risk when it comes to aneurysm’s.

nice summary of notes!

 

[AZ Don]

Good that you have seen a surgeon. The guidelines used to recommend surgery at 5.0cm for those with BAV, but this was revised to 5.5cm several years ago, which is the same guideline for those without BAV. Although not adopted by the American College of Cardiology Guidelines, many of the better centers consider body size when considering when to recommend surgery. Yale has taken it a step further and says that simply height, rather than body size is useful in predicting risk - which in turn is used to determine when to recommend surgery.
https://www.jtcvs.org/article/S0022-5223(17)32769-1/pdf

I think this all assumes no prior OHS. While the risks of a 2nd OHS at a good center are low, I don't think they are as low as the risks of a 1st OHS. The decision on when to operate is all about determining when the risks of the aneurysm are greater than the risks of the surgery.

 

[Keithl]

I have seen that more and more DRs are leaning toward physical size and also lowering the aneurysm size threshold. When I was at 5.2, local surgeon said do it as did Cleveland clinic as stats are starting to show doing it sooner and smaller reduces risk and provides for better outcome. I can say when I did mine; valve and aorta it was a fairly easy recovery and let them do a full chest crack to further assure they had all the visibility they needed. I would encourage folks to talk to multiple surgeons and weigh all factors, your overall health, age, BAV and aortic size and make the decision best for you.

 

[Maineiacs]

Hi! When my aortic valve was replaced (mech valve - all is well) the surgeon described it as 'bicuspid with a poorly formed 3rd leaflet'. I have a new cardiologist recently since my original retired, the new doctor started asking questions about whether it was a BAV (it's not clear) and if I was screened for an aortic aneurism (no but you'd think the surgeon would have flagged that during my valve replacement). So in I went for imaging and indeed I have a thoracic aortic aneurism, "stable aneurysmal dilatation of the ascending thoracic aorta measuring 5.2 x 5.2 cm. Mid aortic arch measures 2.6 cm. Proximal descending thoracic aorta measures 2.6 x 2.6 cm."

Genetic tests don't show any of the known mutations for connective tissue disorders. I'm being imaged (CT) every 6 mos or so but aneurism looks stable (3 scans so far).
My question is: Should I see a surgeon at another teaching hospital system who specializes in aortic aneurisms or wait till my current team flags me for surgery due to a change in the aneurism dimensions?

I am not in any hurry to sign up for surgery - at the same time, this would be a 2nd surgery and I understand it's a bit tricker than de novo. And I may want to hear if the expert option differs from my team's although I don't expect it to. My cardiologist has of course made sure my bp is lowered etc. with the expected warnings about dissections.

Thanks for your input!

Patty

Patty
Bicuspid Aortic Valves go hand and hand as we get older, with developing Aortic aneurysm! Patty the magic number now is 5.5 dilation, it was 5.0. This is all on the premise that the walls of the aneurysm are STABLE.

I just had my BAV and Aneurysm replaced 9/2018. I had a bio prosthetic valve placed which developed thromboembolism on two leaflets.
Where are you located. Have your cardiologist review or ask for before surgery aortic measurements, and compare now.
Stacy

 

[Maineiacs]

nice summary of notes!

you bring to light Marfans, but this isn’tnecessarily accurate in regards to an Aneurysm, with BAV. Congenital vs Connective disorder vs Marfans.