Chances of Aortic Aneurysm Repeat?

[Graveheart]

So after I get my aortic anyeurysm fixed with the dacron hose and probably get an AVR, how likely is it that further disease of my aorta would occur? (I'm 40, and I REALLY only want to be cracked open once.)

Also, the doc says he might be able to repair the valve, but they have only had about five years of data on that, although the results have been "great" so far. Anybody have knowledge on that dealio?

Thanks again for all your support!

 

[Mike C]

Typically they do not develop further than the ascending aorta. It is possible into the arch but not typical. However, it depends on why you have the aneurysm in the first place. Since you have an issue with the aoritc valve I will make an assupmtion that you may have bicuspid aortic valve disease. If you have Marfans the answer is different but i would expect you know if you ahve marfans..

Also, I suggest doing lots of research on aortic valve repair, I do not beleive they hold up all that well and if you have the theory of one surgery, it may not be best decision but others can chime in on it.

I recomedn getting a cat scan or mir on aorta every few years just in case.

 

[Ross]

Mike pretty well covered it. I had mine repaired when my aneurysm blew, but the Doc was never able to make it any better then a 2+ regurg right out of surgery. I lasted like that for 7 years and had to have it replaced.

 

[MrP]

I had my BAV replaced and ascending aneurysm resected...and will answer your questions with the assumption you have BAV as well....sure sounds familiar. With respect to repair vs. replacement of your aortic valve, replacement was recommended by EVERY doctor/surgeon I consulted with. Others will answer this way also I am sure. In my case, I chose a mechanical valve because the odds are better that I will not have to repeat this surgery vs. a for-sure repeat operation if I had chosen a tissue valve. The mechanical valve and Dacron graft (prosthetic aorta) came together as "one piece" and not "separate pieces". My surgeon was Dr. Coselli in Houston....studied under DeBakey...long resume and more experienced at thoracic surgery than any surgeon in the world I believe...highly recommended for excellent track record and low morbidity rate. Can't emphasize enough the value of experience, experience, experience for this surgery. In my case, my ascending aneurysm extended into the transverse part of the aortic arch, although the aortic root was not dilated. In order to avoid another surgery 10 years down the road. Dr. Coselli made the decision during surgery to attach another graft to extend the prosthetic into the transverse part of the aortic arch. This required first cooling my blood for a couple of hours via the heart bypass machine to suspend the flow of blood to the brain and then turning off the heart bypass while the aneurysm was resected...this is called circulatory arrest. Dr. Coselli was able to resect the aneurysm within a 14 minute window! This is fast! The faster the better....one reason to go with a very experienced surgeon. The entire surgery took about 8 hours, but the amount of time blood was not being pumped through my body was only 14 minutes after cooling. As for your second question about repeat aneurysms, this is difficult for anyone or any study to really accurately answer. I think this is because surgeons' experience and techniques vary considerably. In addition, each of us is different and many variables unique to our genetics and physiology come into play. There is always the risk of another aneurysm, and this is why annual CT scans after surgery are recommended....to look for more aneurysmal dilaton in the entire aorta. This is also one reason why beta blockers for blood pressure relief are used after surgery....to reduce blodd pressure and risks of another aneurysm. As for whether or not repeat aneurysms are only found in the ascending aorta, my family has a history of both ascending and descending aortic aneursyms. I don't think one can conclude aneursyms are only found in the ascending aorta. I believe research also shows the rate of dissection is greatest among BAV patients....this in itself suggests to me the entire aorta is prone to weakness.
Rsearch your surgeon's track record in terms of reputation, thoracic expertise, number of operations, morbidity rate, etc.
Hope this helps. Best of luck!

 

[CCRN]

Ditto

Ditto

I agree with Preston on all. My situation was pretty much the same as his but I don't have the descending probelm....yet. There is a connetive tissue disorder with BAVD but not everyone has it. Some have the problem located only in the ascending aorta. However, descending aneurysms AND cerebral (head) aneurysms are also not ucommon with the defect as well as a few other annoying things. My cardiologist told me the rule of thumb is once the BV is diagnosed, aortic evaluation is in order.This is best done by CT with contrast. Once it is established the aneurysm is present, the follow-up for the patient should be the same as someone with Marfans and other tissue disorders until the disorder in other areas is ruled out. I recently had an MRI with contrast of my head. I do not have a cerebral aneurysm. This June after a year out I will have a CT with contrast of my entire aorta. If that exam is normal as well he said he might wait a couple of years before he repeats the scans and compare for changes. I work in cardiac surgery. Once you have the vessel replaced correctly with the dacron graft you won't have a problem in the repaired area again. Note that I said correctly. Preston is also right about the importance of the surgeon's experience. Not all cardiac surgeons perform the Bentall procedure with ascending aortic replacement on a regular basis. (Which is what we had.) Only fourteen minutes off pump is phenomenal! I think mine was about 22 min but I have seen difficult cases go as long as nearly an hour and the patient is up in the chair eating breakfast the next morning. It still amazes me and I participate in the procedures all the time. It was a scary time for me but I got through it just fine. Hope this helps.

 

[aussigal]

Yep...

I am still pre-surgery but one thing i am having done and will have forever is scans of my Aorta and other usual areas for other aneurysms...
I apparently have the dodgy connective-tissue-version of BAV. My Cardio says this because I have several aneurysms and bulges along my entire aorta (ascending, descending & abdominal ....) & I get results of my brain-scan this Thursday. I have an impressive collection of DVD's from my procedures .

This has supposedly made for difficulties in my case in issues of timing the surgery. My BA.valve is not as bad as my annie and my Cardio and Surgeon really-really only want to crack-me-open once. Me too...I am a big chicken!

I for one, just want it all fixed now and shall worry about the rest if and when it happens.

I would go for the "fix it for-good now" option if i get a choice! none of that repair and see how long it lasts stuff for me ...

 

[Graveheart]

Thanks

Thanks

Thanks for the repsonses. I do not have a BAV, but they haven't figured out why my aortic diameter is 4.4cm. My surgeon says to have the op (of course), my cardio says to wait and see. I too am dicey about the "good news" of maybe being able to repair the valve.

 

[Ross]

It goes like this, Surgeons would rather fix you before damage sets in, Cardologists prefer to wait until damage sets in.

 

[aussigal]

It goes like this, Surgeons would rather fix you before damage sets in, Cardologists prefer to wait until damage sets in.

Oh great Ross !!!! ...

But how do we get past the Cardioligist to see the surgeon when they hold the special key to the surgeons' door!?

 

[Turkey Hunter]

I couldn't dissagree more with tis statement. If you have a cardiologist that is as Ross has described....GET A NEW ONE !!

Monitoring a condition and waiting for damage to set in are two very different things.

This is a statement that leads folks to dissbelieve their cardio, I am sure Ross may have experienced it, but it is no where near the norm. Not from my experiences and many others.

Ben

It goes like this, Surgeons would rather fix you before damage sets in, Cardologists prefer to wait until damage sets in.

 

[Ross]

Perhaps the words- Some Cardiologists like to wait too long would be more appropriate?

 

[geebee]

I think there are probably quite a few people who have had problems with cardios. I have fired at least 3 in the past 30 years. One ignored an emergency call when I was taken to the hospital after being unconscious for over an hour. Another told me to wear ear plugs so I wouldn't hear my heart valve sticking - would be dead today if I had listened to him. A third one was so arogant that he told me to stop talking about my condition as he would read my chart and then make a decision on how to treat me because all the information he needed was in the chart.
I have had 2 surgeons tell me that cardios tend to wait too long to fix things.
Granted there are good cardios out there and I am very happy for the people who have found them. However, it is very important that people understand that cardios are not God and they do not have all the answers. If they did, we would not need surgeons, PCPs, etc.
There is nothing wrong with questioning.

 

[Karlynn]

I think there are many of us that would agree that cardiologists do like to wait until they see that the heart is in jeopardy to some degree. This idea has been an oft repeated at VR because many of us have experienced it. I don't think stating it means that you have a bad cardiologist. Cardiologists like to exhaust all non-surgical options before recommending surgery and it appears that for valve disease, we reach a point where surgery is just the best thing to do, regardless of other options.

I had a wonderful cardiologist - considered the best of the best at Northwestern Memorial in Chicago (The 'god of cardiology' as one C-T surgeon put it) and he was very conservative in his waiting. In my, and my husband's opinion, he waited about a year too long to okay surgery. Had I been a member of this group 15 years ago, I would have pushed him more actively. I still feel I owe my life to him because he believed me when other doctors were telling me it was all in my head.

I think the only thing that this type of statement about cardiologists says is that we all need to be educated in our valve disease and be able to apply that to how we feel so we know when to put our foot down with conservative cardiologists.

 

[MrP]

And getting back to the original post, timing of surgery is a judgment call given the size of your aneurysm. The cardiologist must weigh the risk of rupture or dissection vs. the risks associated with surgery (morbidity rate depends upon your overall health and experience of your surgeon...I prefer one who's done on the order of thousands of this type of surgery as opposed to one who's done on the order of a hundred). The risk of rupture increases with larger aortic sizes, and based upon good science ad medical research, an ascending aortic aneurysm at 6cm represents the "hinge point" for bad things to happen....rupture, dissection in about 1/2 of patients. So, if a cardiologist waits until the median size of an ascending aortic aneurysm is reached (6cm), then half the patients would suffer a devastating complication by the time of intervention. Preemptive elective surgery is therefore recommended to be carried out a size smaller than the median size. So, good science says one should have elective surgery for ascending aneurysm (includes aortic root) at 5.5cm and at 5.0cm for bicuspid and marfan patients.
And as mentioned above by someone, an echo will not always indicate a bicuspid valve...a catherization will tell you this. So, in your case you may consider talking to your cardiologist about using 5.0cm as the criteria for elective surgery (measured using CT scan). And if you want to reduce risks of a repeat operation, strongly consider replacing your aortic valve instead of repair.
Sorry for rambling so long. Good luck!

 

[xbxb]

Repair

Repair

First a little history.
I am 43 and on August 2, 2005 (I was 42) had a Bicuspid Tissue Saving Repair of the Aortic Valve and Aortic Root Replacement.
My surgery was performed at the Mass Gen Hospital in Boston.
I had known about my bicuspid valve since I was twenty. A month prior to my surgery I went to the emergency room due to shortness of breath.
Many surgeons are not very experienced in Bicuspid repair. Because it is a relatively new procedure and often the patient is older so a replacement is easier. Some surgeons I spoke with did not do repairs so they leaned towards a mechanical valve due to my age.
I did a lot of research along with my cardiologist before deciding on Mass Gen. - and there is just not a lot of data in the medical literature on repairing a bicuspid valve. I got opinions from Dr Cosseli at the Texas Heart Institute, Cleveland Clinic, Brigham and Womans. Before surgery they were not sure if a repair (given 50% chance by all of the above if it was possible) and I had to decide which type of valve I preffered. After I had a TEE my surgeon thought 80% chance of a repair was possible. It was my decision. I would have gone with an animal valve - I think I preffered a bovine. However my surgeon uses porcine valves. I did not want a lifestyle change with a mechanical valve being so young. That and the Aorta specialist made me comfortable in his words "he does not fear a second surgery". This because I was having it done in a major institution and that the technology keeps improving. The risk factor goes up - due to scar tissue and I was always pretty confident that they would repair my own valve.
50% of the people that have a Bicuspid Aortic valve have a dilated Aorta that they will need replaced. The genetic defect of a bicuspid Aortic valve is also a defect of the Aorta.
All my doctors and second opions agreed though they cannot really tell you why, is that it is always better to use your own tissue. I even asked my surgeon that in the event of a resurgery would he repair my bicuspid again - he said that he never thought about it, but yes he would try given that situation.
The hope is that my repair will last the rest of my life - or at least till I am very old where there should be many new options available. My Aorta dilation is no longer a high risk - was much more of a concern than the valve itself.
My surgeon who is an older person has done only 15 surgeries (in his whole career) of my type - has never had to rerepair a tissue saving bicuspid repair.
There is a little bit of data from the medical literature 98-02 where success was soso on bicuspid repairs but the data pool is very small - remember most people that have a bicuspid valve repair are older and have it replaced.
My coronary arteries were clean and that I was told make the surgery 10 times easier - no bypass needed.
6 months after surgery I am doing great. I recently went back to work and I had joined a cardio rehab which I highly recommend. I am working out 5-6 times a week including playing basketball 2-3 times a week and having more energy than before.

One of the biggest hurdles to get over after surgery is being convinced that you are "fixed". My Aorta specialist lets me play hoops for 2 hrs. He says that there is no fear of a problem with my Aorta. He said very, very, unlikely I would ever have a problem with it. In hindsight the root seemed a much bigger concern to my Dr's than the valve. The good news is they can fix it.
Good luck.

 

[Mary]

And as mentioned above by someone, an echo will not always indicate a bicuspid valve...a catherization will tell you this.]


Very heavy calcification on the valve can make it difficult to conclusively diagnosis a bicuspid prior to surgery. I had two heart cath's, but it wasn't certain that I had an BAV, until I had surgery.