Exercise and stress with Aortic Aneurysm

[AZ Don]

New to the site but I had a month to study and learn about aortic aneurysms until I was able to get the necessary follow-ups and tests that confirmed I am already a candidate for surgery due to a bicuspid aortic valve. Perhaps this information has already been posted but I did not see it so am sharing what I found. Of note is that fully 2/3's of aortic dissections and ruptures in a Yale study were coincident with physical or emotional stress:

From the Q&A at the end of this article:
http://www.uthsc.edu/cardiology/articles/thoracic aneurysm.pdf
"We recommend continuing any and all aerobic activities, including running, swimming, and bicycling. Regarding weight lifting, we recommend one half the body weight as a limit. We recommend against contact sports or those that might produce an abrupt physical impact, such as tackle football, snow skiing, water skiing, and horseback riding"

My observations based on a study described in the book Acute Aortic Disease:
http://www.amazon.com/Aortic-Disease-Fundamental-Clinical-Cardiology/dp/084937023X
(You can see some of this from the look inside feature. I bought the book and consider it well worth the money for those with this condition)
The team documented 31 cases of extreme exertion related aortic dissection or rupture. Aortic size ranged from 3 to 7.8cm, mean 4.63cm. What was surprising to me was that the cases involved people not only involved in heavy weight lifting, but: push-ups (2), intense swimming (3), Intense Tennis or Racquetball (2), shoveling snow (1), changing storm windows (1), moving heavy boxes (1), pulling hard against large dog (1). Also worth noting: the mean size (4.63cm) is well below the general surgical standard (5.5cm, or 5.0 with other risk factors).

From a Q&A with Lars Svensson, MD, PhD, Director, Center for Aortic Surgery, Cleveland Clinic:
http://my.clevelandclinic.org/heart/webchat/1145_thoracic-aortic-aneurysm.aspx
"wmurray8: Would you say that playing golf could be detrimental to someone with a 5.0 CM aortic aneurysm (ascending aorta)?

Dr__Svensson: While some people consider golf safe with aortic aneurysms at your size I would not recommend golf since I have seen patients develop aortic dissection"

(Golf?! There is other good info in the webchat as well.)

From this article (and in the book above), towards the end:
http://content.onlinejacc.org/article.aspx?articleid=1140497
From a follow-up study done with patients and surviving family members of people that suffered an aortic dissection or rupture: "Specifically, we found that a majority of patients could recall a specific episode of severe emotional upset" ... " or extreme exertion at the time of their dissection." (in fact the accompanying chart shows 27% of dissections were preceded by physical exertion and 40% WERE PRECEDED BY EMOTIONAL EVENTS! )

Also in this paper, probably the best brief description of this condition:
"The susceptibility to aortic aneurysm and dissection is set from birth by genetics. The aorta is destroyed over time, at least in part by excess proteolysis by the MMPs. The aorta enlarges as its wall is damaged. As the aorta enlarges, the mechanical properties deteriorate, with loss of distensibility and imposition of excess wall tension. An acute hypertensive event supervenes, usually emotional or exertional, and exceeds the tensile limit of the aortic wall, producing an acute aortic dissection."

It seems that intense exercise of any kind, even aerobic may carry some risks for those with aneurysms, though low level aerobic exercise is recommended. Emotional upset may carry similar or even greater risks. Everyone has to decide for themselves based on their specific condition, lifestyle, Dr. guidance, etc, but I think it is fair to say that those living with an aortic aneurysm should carefully consider their lifestyle and possible changes. It is my understanding that changes post-surgery may be required as well, though perhaps not as severe. That doesn't seem to be slowing down Jeff Green. After having aortic aneurysm surgery a year or so ago he is tearing up the court in the NBA:
http://espn.go.com/blog/boston/celtics/post/_/id/4703667/green-shows-heart-in-cleveland. Exercise post aneurysm repair is a subject I'd like to explore further once I'm on the other side (of surgery).

Don

 

[Duffey]

Don, thanks for sharing this information. I've read many posts questioning factors that affect aortic aneurysms and your post answers many of them.

 

[skeptic49]

Sobering information. I was not aware of the emotional component as a significant contributor to aortic dissections. Also, the mean aortic size number is lower than I would have thought. Thanks for posting this excellent recap.

 

[anutherbuddy]

My dh had AR with Bentall procedure and MVR 8 months ago. He was dx with aortic aneurysm about 10 years ago when he was in his early 50s, so he was "in the waiting room" for a long time. The first cardiologist he saw said "you are the first person I've seen alive with this condition" (great bedside manner) and then went on to tell us he should try not to get upset if the phone rings in the middle of the night (like one has any control over that?!) and asked if he was a Type A personality (which he isn't) since that would probably cause it to dissect and told him not to have road rage (which he never does) for the same reason. He also told him to stop running and don't lift anything heavy. He left that appointment ready to quit work and get a handicapped parking pass. Needless to say, he went for a second opinion. The next cardiologist was much less alarming, while still dx the same condition. He (and all the cardiologists and CT surgeons he has seen since - and there have been about 10 since he was in the military) said to keep active to ensure that the rest of the heart remains healthy - meaning keep up cardiovascular work outs (at least fast walking) but limiting upper body work outs; no strenuous heavy lifting like lifting boulders. Regarding Type A personality- you are what you are. And no one should ever get upset enough to have road rage since that can have dire results that have nothing to do with dissection. And phones ringing in the middle of the night? I guess you could turn the phone off... Just breathe.

 

[spartangator]

Thanks for sharing, Don. This morning's Boston Globe has another follow-up on Jeff Green, featuring Dr. Svensson (pasted below, otherwise it's behind a paywall). All the best with your upcoming procedure. Nice to have you here.

Celtics’ Jeff Green reflects on heart surgery that cost him a season, the doctor who saved his career
by Baxter Holmes / Globe Staff / April 29, 2013

The first question Jeff Green said he asked the doctor who would open his chest and repair his heart was if he’d be able to play his game again — driving to the basket, drawing contact, etc.

Dr. Lars Svensson told the Celtics forward yes, and that if he were stronger and more powerful, it was going to be easier to block out any fear.

“And I trusted him,” Green said recently.

Green worked hard to regain the muscle mass he lost while his body healed, downing protein shakes like water before his appetite finally returned, lifting weights, biking, running.

And he also set a goal to not only play his game, but to play his game in every game a season after playing none while he recovered.

That meant every regular-season game, and each one in the playoffs, including Game 5 on Wednesday, when the Celtics face the New York Knicks in Madison Square Garden, trailing, 3-1, in the best-of-seven first-round series.

He stood at his locker April 17 in Toronto after the final regular-season contest, the 81st, and beamed with relief: he’d played in them all.

“Man, I’m truly blessed,” he said. “Coming from heart surgery one year ago to come back and play the way I did and get better as the year went along, it was all I wanted.”

From afar, Svensson, a renowned cardiac surgeon at the Cleveland Clinic, kept tabs on his former patient and grew more impressed as the season went along, as Green’s scoring average rose from 9.4 points in the team’s first 42 games to 16.5 in its last 39.

Green is also the Celtics’ second-leading scorer in these playoffs, averaging 20.8 points to Paul Pierce’s 21.3.

It wasn’t just that Green, 26, was nearly 16 months removed from surgery to repair an aortic aneurysm; it was that he returned and was playing the best basketball of his career.

“That’s really quite remarkable,” Svensson said in his thick, native South African accent. “That shows an incredible amount of discipline and self control and mental stamina that he has.”

At the start of this season, Green grew fatigued and was concerned about being hit in the chest, where a 9-inch vertical scar is centered.

But after that first blow, he’d realize he could withstand it.

“All right, let’s move on,” he said he’d tell himself. “Because I’ve got to move on. That’s the only way.”

Green has worn a customized padded tank top beneath his jersey to help protect his chest. But, in truth, Green’s chest is stronger after the surgery, Svensson said.

“It’s very porous in the breastbone, and that’s because a fair amount of blood is produced in the breastbone,” he said. “But after this, the bone scars up and it becomes very strong and dense.”

Green is on pace to be completely recovered, though it’s unclear when, Svensson said.

“From some of the studies we’ve done, it takes about six months and patients tend to be back to normal activity level, but that’s not a super player playing in the NBA,” he said.

“It’s obviously going to take longer, first, to get their muscle bulk back again and to get practices in to get hand-eye coordination going again. As you know, that’s a lot of practice and habit forming to get those right again.”

Green acknowledges he still gets fatigued, though not nearly as often as in the beginning of the season.

“I hope I’m past it,” he said. “You never know. If my body talks to me and tells me to chill out a little bit, that’s what I’ll do.”

And Svensson has told Green how impressed he is that he bulked back up so quickly.

“He’s taken great pride in showing how he’s been able to come back,” Svensson said. “It seems to have stimulated him even more to work hard. I think it’s paid off.”

For context, the surgery itself was, Svensson said, “a bit of a tricky operation.”

It involves, the doctor said, the section of the heart where the four valves come together. It’s also near, he said,“the electrical system of the heart.”

He added, “We are very careful about not interfering with the electrical system because, especially in the athletes, the last thing we would want to do is have them end up with a pacemaker.”

Naturally, Green had concerns.

He even wondered if he was the youngest patient Svensson had operated on. The doctor said no, that he had performed a similar surgery on a girl closer to 21 just a day or two before.

Green can’t remember her name, but the two got in touch and stay connected through social media. “She’s doing all right,” Green said.

As for Green and Svensson, they haven’t talked much since the surgery.

“He’s busy saving people’s lives,” Green said.

And Green is busy playing professional basketball, playing his game.

Green said he sent Svensson and his assistant autographed jerseys, and the doctor and patient saw each other in Cleveland in late March, when the Celtics played the Cavaliers.

Svensson was sitting near the tunnel the Celtics used, and as Green left the court after making the winning layup at the buzzer, Svensson called out to him.

Green heard him, came back toward the court, and hugged Svensson, to whom he dedicated the game.

“That was extremely kind and gracious and generous of him,” Svensson said. “I didn’t expect that at all.”

Nor was Green expected to play at this level and in every game following open-heart surgery.

“It shows that he has a strong heart,” guard Avery Bradley said.

In more ways than one.

 

[Rachel]

Wow Don - thanks for posting this information I also found it very sobering!

My ascending aortic aneurysm was 5.2cm before surgery almost two years ago and no one told me about the emotional part.... and I was quite emotional after I was diagnosed!!!

Thanks so much for putting up some solid data on this topic, it should be helpful to those with this condition still in the waiting room!!!

As for post-surgery, I too am very interested in knowing the reasonable restrictions/lifestyle changes to follow. I'm sure it varies from person to person, but I'm finding that even my own medical doctors disagree on this one (surgeon says no restrictions go run a half marathon - cardiologist says - don't run at all you've got a graft.....)

Frustrating

 

[Rachel]

How appropriate Spartangator!!!!!

Thanks, inspiring story!

 

[TheGymGuy]

I bookmarked this post for a comment later.

.....“From some of the studies we’ve done, it takes about six months and patients tend to be back to normal activity level, but that’s not a super player playing in the NBA,” he said.

I can tell you first hand that recovery would be in large up to how hard you try. I have gained and rebuilt most of my muscle and strength by end of month 4. At 6 months post surgery I was competing again.

There are not nearly enough studies on athletes with AVR, but if there were I think the recommendations would be changed for highly active population segment.

 

[Classtime Sailer]

Nice collection of articles. Pre-surgery, it is hard not to worry. My Dr. warned me against the valsalva maneuver and heavy weights. But in fast group rides, or racing, it was impossible for me to determine when hard efforts might be too hard. There is no monitor that we can wear that will beep when we approach the point of no return. Consequently, I had my repair done sooner rather than later. My surgeon says that it is better than new and I can do what ever I want without worry. My cardiologist says that I had heart surgery and that I should not overdo it. We are part of an ongoing study.

 

[spartangator]

Yeah, it is fascinating how we really are part of this ongoing study. Well said, Classtime Sailor. It is a real balance, and as GymGuy pointed out above, the lack of research on athletes really is a limiting factor for physicians guiding our care.

 

[pellicle]

AZ, great info thanks. Perhaps a little late to help me but none the less

Skeptic

Sobering information. I was not aware of the emotional component as a significant contributor to aortic dissections. Also, the mean aortic size number is lower than I would have thought. Thanks for posting this excellent recap.

Have you ever heard of this?

http://en.m.wikipedia.org/wiki/Takotsubo_cardiomyopathy

Emotional state seems to have a profound effect on health in many ways.

 

[pellicle]

Hi

There are not nearly enough studies on athletes with AVR, but if there were I think the recommendations would be changed for highly active population segment.

Given how conservative doctors (by necessity) are, while I agree it should happen, I don't anticipate it will.

Still, we as a community can get the word out that following the letter of doctors instructions is not the only way.

As always monitor and proceed with some understanding of what your body is telling you.

 

[AZ Don]

In looking for info re. exercising post-aneurysm repair, I found some guidelines more relevant to this thread. They are much broader, covering not just aneurysms but various other conditions, such as valve issues:
36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities
http://www.cardiosource.org/~/media.../Clinical_Documents/BethesdaConference36.ashx

In glancing thru this document the guidance is conservative but acknowledges gaps in knowledge and in some cases recommends stress testing.

 

[pellicle]

Don

if you are at all in touch with the feelings and messages your body sends you (some are surprisingly unaware) then I recommend just going in for stuff well below your limit. I was told that a high heart rate was not as significant as things which caused higher blood pressure (such as the stress of powerful contractions of major muscle groups).

Thus hill walking was fine but sqats with 100Kg were not.

I used a sports heart rate monitor (the same one I use when training) and aimed for keeping my target HR below 150 for the first 6 months. Humans are inherently endruance creatures and while we can develop strength even gym guy could not compete in strength with an ape of equivalent mass to himself, especially one which had trained as he has done. Essentially we are not as strong, but have better endurance.

I avoided cycling for the first 8 weeks (fear of effects of falling off, and have no safe place in this area to cycle away from cars) but now cycle as often as I can (weather permitting). Walking and beach jogging are what I do now ... although going back to work has restricted my exersize regime more than surgery did.

 

[AZ Don]

Well I am less than 3 weeks post op so I'm taking it easy for now. I'm finding that the Cleveland Clinic has virtually no restrictions on exercise post aneurysm repair (and recovery). I'll post on that in a separate thread but I'm still looking for other sources.

Regarding listening to my body. I see this mentioned a lot and for someone with valve issues I think this is good advise, and probably also good for those post aneurysm repair (assuming no connective tissue disorder), but I want to clarify that someone with an aneurysm should not rely on listening to their body. The first symptom of an aneurysm is generally a rupture/dissection and more often than not that is fatal. I was exercising regularly and at a high intensity and I had absolutely no clue that I had aneurysms or a heart condition. If not for having cancer which led to the scan that found my aneurysms, it is likely I would have died from them (my cardiologist said that scan saved my life).

 

[pellicle]

I found that a hot sour taste was gradually increasing in my mouth similar to being (but slightly different) out of breath. I noticed this vanished and has not recurred since my operation.

The medical people should have done some investigations (such as an angiogram) and will give you quite good imaging of your aneurysm and good estimates of its likelihood for 'tearing'. I was told (pre surgery) that aerobic was fine, but to tone it down. Weight training to be reduced ( so I went for reps) and my wife bought a horse whip to threaten me with should she catch me doing anything she thought 'dangerous'.

 

[ElectLive]

The team documented 31 cases of extreme exertion related aortic dissection or rupture. Aortic size ranged from 3 to 7.8cm, mean 4.63cm. What was surprising to me was that the cases involved people not only involved in heavy weight lifting, but: push-ups (2), intense swimming (3), Intense Tennis or Racquetball (2), shoveling snow (1), changing storm windows (1), moving heavy boxes (1), pulling hard against large dog (1). Also worth noting: the mean size (4.63cm) is well below the general surgical standard (5.5cm, or 5.0 with other risk factors).

Thanks for putting all this info in one place Don, and great discussion all around.

You know, those numbers I quoted above aren't an anomaly. I've seen very similar data from a retrospective study my hospital did of 5-10 years worth of emergency cases of dissection/rupture. One person meets their fate at 3.0 and another at 7.8. Unfortunately, medicine only goes so far in explaining life...

 

[pellicle]

Hi

You know, those numbers I quoted above aren't an anomaly.

I missed those numbers, did you post them on a different thread? I did a quick search of your posts but couldn't find them. (don't tell me I'm blind and they are here ... wouldn't surprise me)

 

[sood]

Don,

I have been going to cardiac rehab and it has been great for me just to know what I can and can't currently do. There is a lot I feel I can do but they are being ultra conservative. And since I'm not training for the Olympics I haven't pushed it too much. They are adamant about not raising heart rate about 30 bpm over resting for now. And I've only curled 8-10lb dumbells. I plan on going to cardiac rehab once per week for the rest of the year, just so they can guide me on my recovery pace. I'll take their homework and do about 4 other days at the gym.

Being almost 6 weeks post op, I feel like they are just starting to give me some flexibility to push it. I don't mind sharing my homework notes with you on what I was able to do at what particular week based on their recommendations. PM me if you are interested.

 

[ElectLive]

I missed those numbers, did you post them on a different thread? I did a quick search of your posts but couldn't find them. (don't tell me I'm blind and they are here ... wouldn't surprise me)

Not blind at all...my wording may have not been the best. Those numbers of Don's (aortic size and mean) that I quoted as part of my post aren't an anomaly.