aortic root 4.2 (no BAV) growth rate???

[chrisc]

i don't have a bav, but don't know where else to really post this...

will try and make this as brief as possible but i am covering many years here. i am a 35 year old male with an aorticroot of 4.2, first found in 2004. In 2004, i felt like i was having a rapidheart beat and palpitations, for which among other things an echo was performed. an aorticroot of 4.2 was found and to be honest in my 20's I didn't really understand the impact. I continued to workout, lift VERY heavy weights (boarder line body building), etc. all against doctors orders. as more time went by i actually forgot about this diagnosis, and just happily did whatever i wanted. i was ~168 pounds and benched nearly 300#'s. in 2011 i had an echo for some chest pain, which was 100% normal (aorticroot was 3.7). I was shocked because I recalled the 4.2 reading from years earlier, only after the doc mentioned it was a normal echo.... meh, i kept lifting (heavy) though the heaviest i did was ~ 100# dumbells on bench press...

In 2012 i went for another echo to follow-up and the 4.2 reading was again there (likely an error in 2011). This 4.2 was confirmed via CT. cardiologist was not very concerned but limited me to reps of 12-15 on weights. told me to go see a surgeon if i was that uneasy. i did exactly that and now have a much more serious set of limitations (from surgeon) and as a 35 year old I understand the severity. i was also told these things usually grow .1cm a year and surgery would be a likely outcome in ~7 years. to be honest i can't mentally get it out of my head, i was much better off with the ignorance is bliss approach i had from 2004 to 2012... i did just send the records from 2004 to the surgeon this past friday and i am awaiting response.

just curious if anyone else has one which is very stable. is it possible a 4.2cm root can stay 4.2? is there a way to assess wall thickness of the aorta? what is the best resource for my questions?

with the costs of medical appt's its not like i can go see 5 different cardiologists...

i want to run, i want to jog, i want to lift... arg...

 

[RBCola]

Hey Chris,

I have a larger ascending aortic aneurysm than you and im still able to jog eithout restrictions. My cardio said to cut the weight lifting and contact sports. He also said I need keep my bp low (<120 systolic). Im currently on a beta-blocker (metoprolol). Keeping your bp as low as possible and cutting down on the "heavy" lifting will give you the best chance at keeping the growth rate as slow as possible. Go to high rep lifting. I know its going to be hard. I can sympathize I use to be an avid weightlifter, but its not worth my aorta dissecting.

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[chrisc]

RBCola,

believe it or not i was diagnosed with boaderline hypertension last year (maybe stress induced). i was told to take BP meds (tropol) by my GP. i decided to increase the cardio and eat better. bear in mind this was all before the 2nd 4.2 root diagnosis. i got my cholesterol down from 212 to 143 and BP now runs about mid 120's over mid 70's with a resting pulse of about 60ish (somtimes lower). i asked about BP meds after i found out about the 4.2 root for the second time and the cardiologist said no....

just very confused to be honest and speaking to others in similar situations seems a bit comforting to me...

my insurance will likely only cover so many '2nd opinions'

 

[RBCola]

Congrats about getting the bp and cholesterol down. The situation may be a little different
for you since you don't have a bicuspid valve, which is also a connective tissue disease that makes us prone to aortic disease. Also, my aneurysm is borderline needing surgery so my management is different. Stick to what you cardio says and just try to live healthy.

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[MGene]

After 35 years of competitive bodybuilding and heavy lifting I was shown to have an ascending aortic size of 4.7- 5.3 cm. Many successful competitive years drug free and tested. Competed against non- tested guys and at times I was nationally qualified but really wasn't good enough to be serious about it. My new workout formula has been sets of 30 reps, if it's too heavy for 20 -30 reps don't do it. Stabile for 4 years now, bp at 115/75 pulse resting 50. intolerant of any statins or lisinapril (sp). Slowed down with anxiety meds and antidepresents starting to adjust well to life, think puppy dogs, butterflies and unicorns. Control it, don't let it control you but be smart not ignorant. Life is still good!

 

[Roxx]

I am glad you asked this question as it weighs on my mind constantly as well. I am almost 34, no BAV, a trileaflet with 2 leafs bigger than the 3rd.....but a aortic root (twice confirmed) of 3.7..... I dont have any restrictions, but i have often wondered the following:

Why is mine this size? I am a fitness guy p90x 11 time repeater, 5'11, 180-ish....32 inch waist.
Are there other men my age and size that have aortic roots in this area of size?
What is the chance that i can avoid surgery for this?
Would aortic valve area have anything to do with having a bigger root? Mine is a estimated 2.3cm to 2.5cm

Like you my friend.... i wish i could shake this topic from my brain..... its very hard.

 

[ElectLive]

I am almost 34, no BAV, a trileaflet with 2 leafs bigger than the 3rd.....but a aortic root (twice confirmed) of 3.7...Are there other men my age and size that have aortic roots in this area of size?
What is the chance that i can avoid surgery for this?

One thing to keep in mind is that the "normal" range of root measurements for men is 3.63 to 3.91 cm. While anything above 4.0 is pretty much an aneurysm (50% larger than normal dilation) at the ascending aorta, a location where so many of us here have or had our enlargement, a measurement around 4.0 cm at the root may only be mildly dilated. Now, normal is relative to the rest of your aorta, though, not everyone has the same baseline measurements (impacted by body size for instance), so a 3.7 or a 4.2 could mean one thing for one person, and quite something else for another.

Unfortunately, no one is able to accurately forecast the odds of avoiding surgery because growth rates are different for everybody. An area of dilation does not get smaller, but staying stable for an extended amount of time is certainly possible, and I'm pretty sure that has happened for a few members here. Rapid growth is possible as well, though, which is why monitoring is so important. But, if you and Chris are lucky enough to have escaped the connective tissue disorder associated with BAV, future aorta growth and weakening might be less likely than what happens to so many of us BAV folks here.

I wonder if an aorta/vascular specialist might possibly be a good resource, since not all cardiologists or surgeons have that knowledge. There are a number of other diseases and genetic conditions (besides BAV) that can cause aorta disease and dilation. That's not meant to suggest that either you or Chris have one or would even be definitively diagnosed if you do, but in any case, if interested in trying to learn more, that might be an option.

 

[Roxx]

Nice post electlive. What about aortic valve area? I am estimated at 2.3 to 2.5cm....where do I stand with that? The cardio tells me he hears a very faint murmur on me, but he will not elaborate, and he is very foreign and hard to understand. My guess would be that although my aortic valve is not BAV, IT is a irregular shaped TAV...... perhaps this irregularity in shape is where he is hearing a murmur? (Note: family doc and 2 other cardiologists say that cant hear a murmur)....... its tough, I know how Chris likely feels, some days are pretty normal, other days I can't shake these thoughts from my mind.

 

[ElectLive]

What about aortic valve area? I am estimated at 2.3 to 2.5cm....where do I stand with that?

Sounds like pretty good news to me, 2.3 cm to 2.5 cm is only very mildly stenotic (as compared to people with normal valves). Moderate stenosis typically ranges from 1.0 cm to 1.5 cm and severe stenosis is anything under 1.0 cm. I read through the murmur classification system once, it was amazing, almost like part science and art. For what it's worth, I had a murmur (plus an amazing set of ears on my pediatrician) at birth, so I did just fine with a murmur not presenting symptoms or need for surgery for 35+ years.

 

[Roxx]

Sounds like pretty good news to me, 2.3 cm to 2.5 cm is only very mildly stenotic (as compared to people with normal valves). Moderate stenosis typically ranges from 1.0 cm to 1.5 cm and severe stenosis is anything under 1.0 cm. I read through the murmur classification system once, it was amazing, almost like part science and art. For what it's worth, I had a murmur (plus an amazing set of ears on my pediatrician) at birth, so I did just fine with a murmur not presenting symptoms or need for surgery for 35+ years.

You are right about part science part art. My last echo said "trace stenosis" but then the cardio went on to say "this number is good"...... so it obviously doesnt take much to hit "trace" amounts of stuff on todays echo equipment.

 

[chrisc]

how is aortic valve area calculated? i do not see it on my echo reports (though there is a note of no stenosis or regurgitation on the aortic valve). all the other valves leak, just the aortic valve make a good seal despite the enlarged root. puzzling...

 

[RBCola]

Do you mean aortic area? (not valve) use formula to calc area of circle

Area of your aorta = pi x radius squared (use half the aortic diameter given on echo/CT/MRI to get radius)

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[chrisc]

what is Roxx speaking about above? at 2.3-2.5 it cannot be aortic area?

Do you mean aortic area? (not valve) use formula to calc area of circle

Area of your aorta = pi x radius squared (use half the aortic diameter given on echo/CT/MRI to get radius)

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[Roxx]

Ava = aortic valve area. From what I can tell from mayo clinic website, 2.0 to 3.0 is fairly normal, 1.5 to 2.0 is mild stenosis, 1.0 to 1.5 is severe, and less than 1.0 is critical. With most websites saying that many patients are non-symptomatic until its 1.0 or less.

 

[ElectLive]

how is aortic valve area calculated? i do not see it on my echo reports (though there is a note of no stenosis or regurgitation on the aortic valve). all the other valves leak, just the aortic valve make a good seal despite the enlarged root. puzzling...

There are actually several diferent ways, and somewhat surprisingly, it's usually calculated primarily through flow and something called the Continuity Equation. The obvious guess of course would be that they just trace and measure the actual opening via echo image. But that's not common for several reasons - imprecise perimeters from calcification, "fuzzy" echo images, and the inherent imperfections of echo technicians. The Continuity Equation calculates the valve area indirectly by a mathematical equating of flow and the related measurements from echo. I will gladly stop there, and not attempt to explain further, but here is an example of a calculator: http://echocardiographer.org/Calculators/Calculator.AVA.html

Not all echo reports have all this information, particularly if the valve is normal. Sometimes it's not reported even for those with stenosis becausethe pressure gradient is given more weight for diagnosis. In any case, you most likely have a perfectly normal valve, so no reason to report the area. I've seen "normal" indicated anywhere from 2.0 cm to 4.0 cm, but I think more commonly as 2.5 cm to 4.0 cm.

 

[Roxx]

Electlive, i have a few questions for you as you seem to be very knowledgeable with a lot more research and education on this subject than most, let me ask your opinion:

1) on my echos, it does say that the normal parameters for aortic valve area is 2.0 to 4.0 (just as you stated) but I wonder whom would have the 4.0? The tech that did my last echo told me she does 10-12 echos a day, 5 days a week..... and 3.0cm is about the max she ever sees, and she has 9 yrs experience. So I would think a 3.5 or 4.0 ava would be almost an exception rather than a rule.

2) you mentioned for an adult male 3.6 to 3.9 is the average root size, yet why do so many echo charts call 2.0 to 3.7 the normal range? I mean....who is 2.0? A newborn? It would really be great ease on my mind if I knew for a fact that its true, that most adult men are in the 3.5 to 4.0 area on root size.

 

[ElectLive]

1) on my echos, it does say that the normal parameters for aortic valve area is 2.0 to 4.0 (just as you stated) but I wonder whom would have the 4.0? The tech that did my last echo told me she does 10-12 echos a day, 5 days a week..... and 3.0cm is about the max she ever sees, and she has 9 yrs experience. So I would think a 3.5 or 4.0 ava would be almost an exception rather than a rule.

2) you mentioned for an adult male 3.6 to 3.9 is the average root size, yet why do so many echo charts call 2.0 to 3.7 the normal range? I mean....who is 2.0? A newborn? It would really be great ease on my mind if I knew for a fact that its true, that most adult men are in the 3.5 to 4.0 area on root size.

Two excellent questions, Roxx. I wish I had definitive answers, but as much I hate to admit it, there is a surprising lack of universal truth to these very critical numbers we all worry about then plan surgery around.

Relative to AVA, there are several "normal" ranges published, and it appears your echo report is encompassing the lows and highs of the various ranges as a whole. So let's just take one source...according to the American Society of Echocardiography - Recommendations for Clinical Practice (Stenosis), in other words the guidelines for those who perform echo ultrasound, the normal range is ~ 3.0 to 4.0 cm. It then cross-references the ACC/AHA Valve Disease Severity Table and explains that severe stenosis is present when valve area is reduced to ~ 25% of normal size - which aligns with the 1.0 cm value in the Severity Table. But immediately after identifying these "standard" range of values, indexing for body size is brought up as an important consideration for evaluating valve area, particularly in children, adolescents, and smaller adults, since a relatively small AVA measurement could overestimate the actual severity of stenosis in smaller patients who might really be much closer to "normal". Anyway, long story short, the Guidelines reinforce the totality of echo diagnosis and emphasize the importance of clinical decisions being made based on the totality of the available information (such as pressure gradient and velocity), and not AVA alone.

Anyway, back to your question, my AVA actually measured 3.25 after my replacement (which is always smaller than the original valve), so it certainly happens. But honestly, that measurement still seems abnormally high since it is beyond the expected sizes given in the Edwards literature. But in any case, I would guess that a 3.5 to 4.0 AVA would primarily happen in larger patients (more so height, obesity doesn't affect) who have normal valves. I would assume your tech for the most part is evaluating patients who do not have normal valves so "normal" for her would naturally be lower. In any case, whether that is the reason or not, the numbers really are all over the place even in healthy individuals, and it certainly would still make sense that a 4.0 AVA in anyone would be the exception.

Ok, moving on to the root size, I have an echo chart with the identical 2.0 to 3.7 normal range, and from several common citations, it appears to possibly be sourced from an Echocardiography textbook published in the 70s. I haven't reviewed the actual text (purchase only) so don't quote me on that. Now, there are numerous publications reconsidering this range of values as well. I mentioned body size for valve area, and guess what, that comes into play too. But so do other factors such as age and sex and sometimes blood pressure. I've seen a fascinating publication of the AHA documenting all the determinants of aortic root size and the impact over time, and it really highlighted for me again the stark contrast to the natural tendency to universally trust a given set of measurements and a supposedly "standard" range of clinical diagnosis.

Anyway, the average root size values I gave you are part of the current Thoracic Aorta Disease Guidelines, see page e36 here: http://content.onlinejacc.org/cgi/reprint/55/14/e27.pdf. So, in other words, in the presence of multiple ranges in different publications and studies, I quote the one most agreed upon clinically. Those values actually come originally from the Society for Vascular Surgeons back in 1991. But, back to your question, I would guess that a 2.0 would most likely be seen in young small females, and given that the lowest values I've actually read about in adults were around 2.4, then yes, a 2.0 most likely would be seen in a child. Now, let's talk about you, though, you are at 3.7. Before I was opened up for surgery, my root as measured was dilated to 4.1. My surgeon told me in advance that he would evaluate it when he got in there since my aneurysm was separate, at the ascending aorta. He had me open, he evaluated the root, and he left it alone. Now, he said at the time that the root dilation would recede, which was very surprising to me, but he's the expert, so I didn't question him. A month later my root measured 3.6. A year later my root measured 3.0.

So, either my measurements are off (certainly a possibility) or he was exactly right (more likely). But the point is that my root was more dilated than yours (ignoring for a second that your normal is different than my normal - humor me), I have BAV and confirmed connective tissue disorder resulting in an aneurysm, and yet he still left my root alone. So I would take that as good news relative to the urgency (or lack thereof) of your own situation. Oh, and one more thing, if your root starts getting bigger, don't automatically jump to conclusions...it often does as you get older. Anyway, no guarantees here certainly, but hope that might help ease your mind a little.

 

[Roxx]

Excellent post Electlive.....just excellent. Thank you for tbe time, thought, and consideration put into it, and best wishes to your health (which you wont need as you seem to be just fine)

To the original poster, I am sorry about hijacking your thread, I just thought these were issues that may be useful for many that are here.

 

[ElectLive]

I appreciate the kind words Roxx...and wishing you the same. We have diverted a bit, but still pretty useful I think. Let's get back to Chris, though...

Chris - Relative to your "all the other valves leak" comment...I just touched on that in the other thread, but let me restate here, trace and mild leakage shows up all the time on echo analysis and very often means absolutely nothing...perfectly normal.

 

[chrisc]

ElectLive, As stated in the other thread, many thanks for your contributions to this forum. While unfortunate, some doctors cannot devote the time that some patients (like I) would really benefit from. For some the physical situation won’t change but the discussion, knowledge and clarity assist in managing it and your contributions help tremendously…

In your experience, is there a difference in echo VS CT without contrast for aortic root? My echo (read) by the same cardio have been very consistent. 4.2, 4.1, 4.2 and 4.2 at the root. The 2nd to last 4.2 was read by someone else as a 3.7 but as stated the 2nd cardio whom did the 1st 2 said he sees a stable 4.2 across all the echo’s. The CT showed a 4.38 at the root without contrast. I was told if I did contrast that may have gotten 4.2 (would have measured just the contrast area) as well as the CT can give larger dimensions due to imaging a moving target as well as the CT # is most accurate…