Hello!!! Happy to be here! Seeking Insight and Clarification

[Johnny_H]

Hello:

I am new to this forum and am glad it's available to gain insight into heart disease and surgical procedures. I recently (spring, 2023) had a very minor stroke and was in hospital for a few days. A follow-up echo was done which revealed I had an aneurysm. A CT Angio was given and the results are below.

CT Angiogram Chest

FINDINGS:

Vascular Structure
There is dilation of the proximal ascending aorta: Measures 5.2 x 5.7 x 5 cm in AP, transverse and coronal diameter.
No sign of dissection.
The aortic arch and descending thoracic aorta within normal caliber.
The aortic arch measures 3.3 cm.
The descending thoracic aorta measures 3.5 cm.
No sign of dissection. No sign of pericardial effusion.
The pulmonary arteries are within normal caliber.

CHEST:
Lungs and central airways. There is minimal alelectasis/scarring seen in the right middle lobe or lingular region. No suspicious pulmonary nodule.

PLEURA: Within normal limits.

Impression: Aortic root aneurysm measure 5 cm in maximum coronal diameter.

I recently (3 weeks ago) had a follow-up CT Angio. The results of that test are as follows:

Findings:

62 mm ascending aorta at level of coronary sinus.
43 mm ascending aorta at level of main pulmonary artery
26 mm aorta at mid arch level
31 mm descending aorta at level of main pulmonary artery
No thorcis lymphadenopathy
Pleural surfaces clear
Minimal centrilobular emphysematous changes
No abdominal aortic aneurysm
Mild fatty infiltration of liver
No abdominal or pelvic lymphadenopathy
No free interperitoneal fluid

Impression: Aneurysmal dilation of the ascending aorta as described. No evidence of dissection. No abdominal aortic pathology.

I have had varying opinions on these reports from two surgeons, one who claims that these findings render me a 'ticking time bomb' and another who says that watchful waiting is required. I'm hoping to get some opinions from group members here which will provide further insight. I'm 61.5 years old. Thank you so much, and it's great to be here.

 

[Chuck C]

Welcome to the forum Johnny and we're glad that you found us.

There is dilation of the proximal ascending aorta: Measures 5.2 x 5.7 x 5 cm in AP, transverse and coronal diameter.

I have had opinions on this report from two surgeons, one who claims that these findings render me a 'ticking time bomb' and another who says that watchful waiting is required.

The American Association of Thoracic Surgery guidelines call for surgery when the diameter of the proximal ascending aorto measures > or = to 5.5cm. It also appears that in Canada this same threshold is used. At 5.7cm, these guidelines would call for surgery now, unless you have some risk factors which would make you a high risk candidate. There is also some debate going on about whether to lower this threshold to 5.0cm. See quotes and links below from the US and Canada.

You have not mentioned any comorbidities which would make you a high risk and at 61 years old you are young. Unless you have not shared something with us, in my view the surgeon who is suggesting you get surgery now has it right. I'd be curious as to the argument of the other surgeon who advocates to watch and wait. Wait for what?

BTW, my mom was just diagnosed with a 5cm aortic aneurysm. Even if hers reaches 5.5cm they will not operate. This is due to her being 81 years old, but also she has advanced dementia, which creates a number of issues. But, at the age of 61, in the OHS world you are young.

US guidelines:

.."the American Association for Thoracic Surgery (AATS) guidelines favor aortic repair when the proximal thoracic aortic aneurysm diameter is ≥ 5.5 cm in patients without significant risk factors"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694044/#:~:text=Hence, the American Association for Thoracic Surgery,of aortic dissection (IRAD) showed that majority

From the Canadian Cardiovascular Society Position Statement:

Canadian Cardiovascular Society Position Statement on the Management of Thoracic Aortic Disease​

"Surgical intervention is recommended at a diameter of 5.5 cm for the ascending aorta."

https://onlinecjc.ca/article/S0828-282X(14)00112-3/fulltext#:~:text=Surgical intervention is recommended at,a diameter of 6.5 cm.

 

[Johnny_H]

Welcome to the forum Johnny and we're glad that you found us.



The American Association of Thoracic Surgery guidelines call for surgery when the diameter of the proximal ascending aorto measures > or = to 5.5cm. It also appears that in Canada this same threshold is used. At 5.7cm, these guidelines would call for surgery now, unless you have some risk factors which would make you a high risk candidate. There is also some debate going on about whether to lower this threshold to 5.0cm. See quotes and links below from the US and Canada.

You have not mentioned any comorbidities which would make you a high risk and at 61 years old you are young. Unless you have not shared something with us, in my view the surgeon who is suggesting you get surgery now has it right. I'd be curious as to the argument of the other surgeon who advocates to watch and wait. Wait for what?

BTW, my mom was just diagnosed with a 5cm aortic aneurysm. Even if hers reaches 5.5cm they will not operate. This is due to her being 81 years old, but also she has advanced dementia, which creates a number of issues. But, at the age of 61, in the OHS world you are young.

US guidelines:

.."the American Association for Thoracic Surgery (AATS) guidelines favor aortic repair when the proximal thoracic aortic aneurysm diameter is ≥ 5.5 cm in patients without significant risk factors"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694044/#:~:text=Hence, the American Association for Thoracic Surgery,of aortic dissection (IRAD) showed that majority

From the Canadian Cardiovascular Society Position Statement:

Canadian Cardiovascular Society Position Statement on the Management of Thoracic Aortic Disease​

"Surgical intervention is recommended at a diameter of 5.5 cm for the ascending aorta."

https://onlinecjc.ca/article/S0828-282X(14)00112-3/fulltext#:~:text=Surgical intervention is recommended at,a diameter of 6.5 cm.

Hello, Charles. I believe the rationale for 'watchful waitng' is to determine whether a patient's condition sems to be worsening over time. If not, then they deem the risk of surgery greater than the risk of moving ahead. And, if so, surgery is recommended. This particular individual recommended I have it done in the next 1-2 years. Pretty flippant, I admit.

Besides having had two strokes (one recently and another in 2009), I don't have any particular comorbidities. I just want to feel fully confident if opting for surgery that I'm doing the right thing. My dad died of a heart attack at 59, so there is family history...

Thanks for your response...

 

[Chuck C]

Hello, Charles. I believe the rationale for 'watchful waitng' is to determine whether a patient's condition sems to be worsening over time. If not, then they deem the risk of surgery greater than the risk of moving ahead. And, if so, surgery is recommended. This particular individual recommended I have it done in the next 1-2 years. Pretty flippant, I admit.

Besides having had two strokes (one recently and another in 2009), I don't have any particular comorbidities. I just want to feel fully confident if opting for surgery that I'm doing the right thing. My dad died of a heart attack at 59, so there is family history...

Thanks for your response...

Whether your aneurysm is growing or not, when it reaches a certain diameter there is a risk of rupture. Usually watch and wait is done when the aortic diameter is below the threshold for surgery. Did they give you a measurement in cm/m2? Perhaps the surgeon who is recommending to watch and wait is using your aortic size relative to body surface area, which is also an indicator as whether to operate or not.

 

[Johnny_H]

I can't be sure of his rationale. I've heard that height alone, rather than body surface area, is justification enough for surgery, once certain thresholds have been met. I only know I'm up in the air. I don't have sypmtoms, and I currently live a very healthy lifestyle. But they say dissection can happen at any time, with or without symptoms. I'm supposed to meet with the pro-surgery surgeon next week. I supposed I'll ask him why surgery is his first option here...

 

[tommyboy14]

Hi Johnny,

have you had your aortic valve checked? If you have biscupid aortic valve, there is a lot of evidence that the right threshold is below 5cm. More like 4.5cm.

Of course you can choose to watch and weight, but the risk of rupture increases exponentially above 5cm. Risk of rupture is like 12% a year above 5cm and much higher above 5.5 cm. If you get a dissection, they need to operate on you, the predicted mortality is 30%. If you get the surgery done before that, mortality is 1% or less.

I would also consult multiple surgeons. A lot of surgeons do virtual second opinions these days. If you speak to 5 and 2 say operate, then perhaps you can wait. But if 4 says operate you may want to consider the numbers above.

Best of luck to you.

 

[Johnny_H]

Hi Johnny,

have you had your aortic valve checked? If you have biscupid aortic valve, there is a lot of evidence that the right threshold is below 5cm. More like 4.5cm.

Of course you can choose to watch and weight, but the risk of rupture increases exponentially above 5cm. Risk of rupture is like 12% a year above 5cm and much higher above 5.5 cm. If you get a dissection, they need to operate on you, the predicted mortality is 30%. If you get the surgery done before that, mortality is 1% or less.

I would also consult multiple surgeons. A lot of surgeons do virtual second opinions these days. If you speak to 5 and 2 say operate, then perhaps you can wait. But if 4 says operate you may want to consider the numbers above.

Best of luck to you.

I appreciate that. It's not so easy here in Canada to get a referral to a surgeon, especially when, like me, you don't even have a GP. I thought CT scans were the so-called gold standard of cardiac testing, and that the results would be cut and dried. And I just don't understand why the one surgeon would label me as a 'ticking time bomb.' Note that this is a surgeon with over 30 years of experience...

 

[Johnny_H]

Hi Johnny,

have you had your aortic valve checked? If you have biscupid aortic valve, there is a lot of evidence that the right threshold is below 5cm. More like 4.5cm.

Of course you can choose to watch and weight, but the risk of rupture increases exponentially above 5cm. Risk of rupture is like 12% a year above 5cm and much higher above 5.5 cm. If you get a dissection, they need to operate on you, the predicted mortality is 30%. If you get the surgery done before that, mortality is 1% or less.

I would also consult multiple surgeons. A lot of surgeons do virtual second opinions these days. If you speak to 5 and 2 say operate, then perhaps you can wait. But if 4 says operate you may want to consider the numbers above.

Best of luck to you.

Here's an echo that was done in early February.

 

[3mm]

varying opinions on these reports from two surgeons, one who claims that these findings render me a 'ticking time bomb' and another who says that watchful waiting is required. I'm hoping to get some opinions from group members

Johnny - Both Mayo Clinic and Cleveland Clinic will do virtual 2nd opinions. I had Mayo give me a 2nd opinion. The process was easy and took less than 3 weeks. I talked with a Mayo Cardiology nurse for an hour to document my history, then she got all my records from the various hospitals and doctors. About 2 weeks later I had the Mayo surgeon's written review and I talked with him on the phone.

Full disclosure: I then had that Mayo surgeon (Dr Daly) operate on me. Because I'm on Medicare I don't know the Mayo price for a virtual 2nd opinion. Mine was fully covered. I have heard that Cleveland Clinic does similar virtual 2nd opinions and charges US $1850. I don't know how that is handled for Canada's medical system. I realize this is a lot of money. But it is also your life on the line.

Good luck!

 

[Chuck C]

This publication has some graphs and charts that may be of interest to you. In particular the charts that may be of interest would be 1) the one with your BSA on the Y axis and aortic aneurysm diameter on the X axis, and 2) the graph with height on the Y axix and aortic aneurysm on the X axix. They categorize your risk of dissection, rupture or death as mild, moderate, high or severe, which is expressed in % chance of such an event per year.

The one using height has you in the high risk category, based on your hight of 71 inches and the diameter of your aneurysm. But, the chart using BSA puts you in the moderate risk category, based on your BSA of 2.09m2. Perhaps the surgeon who is advising to watch and wait is doing so based on the BSA risk stratification, which has you in the moderate category. BTW, moderate would mean having an approximate risk of 7%/year of dissection, rupture or death. Important to note that the BSA chart has you just one colum away from being in the high risk category, which estimates the risk at 12%/year. You don't want to have a dissection, rupture and certainly not death.

So, three ways to look at your risk; aortic diameter alone; diameter vs BSA and diameter vs height. Two out of three of these put you in the high risk zone, estimate of 12% risk of an event/year, and the BSA method puts you in the moderate risk zone, with an estimate of 7% risk of an event per year.

The surgery is a one time risk, while the risk of dissection, rupture or death from your aneurysm is ongoing, expressed in % risk of event per year. Even the moderate risk of 7%/year of one of these events, as estimated by the moderate category, is not something which I would personally want. There is a highly successful surgical solution, which is a one time event. I believe that the mortality risk is about 1% if done at a competent high volume center with a young low risk patient, but you should ask your surgeon what his estimate would be. If it were me, it would be a no brainer and I would follow the guidance of the one surgeon who is advising to get the surgery now. You will almost certainly need the surgery at some point even if you opt for watch and wait currently and so the risk of needing surgery will be something you either deal with now or at some point in the future. But, as the one surgeon has pointed out, and as the related charts confirm, you have a very real ongoing risk every day that surgery is delayed.

I would read up the data in this study linked below and be prepared to discuss during your upcoming surgical consult.

https://www.jtcvs.org/article/S0022-5223(17)32769-1/pdf

 

[tommyboy14]

I would look at it from the good news perspective. You only have an aneurysm. They will most likely be able to spare your valve because it is completely normal. However, your aneurysm puts you in the 7% chance dissection a year. So if you take my stat of 30% death at emergency surgery at face value, you have a 2% mortality risk from your Aneurysm per year in the best case scenario. These risks cumulate over time. The surgery is a one time 1% or less risk at a high volume center in the hands of an experienced surgeon.

These are the numbers. Of course it is up to you to decide what to do with them, but in your shoes, I totally get you may not want to listen to a stranger on the internet, so best option is to get more surgical second opinions.

The good news is that if they can spare your valve, there is a good chance this will be the only OHS you have, given your valve is completely normal.

One final thing. These measurements arent everything. There is also your aorta itself. It can become very thin and that is not something we can measure. Very thin meaning about to rupture. There are people on this board whose aorta was falling apart in the surgeons hands when they were operated on...

 

[Protimenow]

I had my aortic valve replaced when I was 41 -- I knew that I would eventually need to have it done.

I asked my cardiologist 'how sick do I have to be before I can get it done?'

I had it done about a month or two later. By that time my heart was already weakened - and, 33 years later - I'm paying for the delay.

I'm glad that I had this done when I was young and strong - recovery was easier than it would have been, say, 20 years later.

I know that an aortic aneurysm is a different thing - but it IS a ticking time bomb. If it was me, I'd have it repaired sooner rather than later. Plus, when the surgeon is in there, snooping around, she can see if there are issues with the aortic valve (and do a replacement if needed).

Second opinions won't hurt but, again, if it was me, I wouldn't want to wait - especially with risk of dissection at any time.

 

[Croooser]

Sorry to go a little OT here.

Chuck, sorry to hear about your mother's condition. My father in law suffered from Alzheimer's and eventually succumbed to complications from a fall.

It's a very cruel disease. I wish you the best in dealing with the challenges.

 

[Chuck C]

It's a very cruel disease. I wish you the best in dealing with the challenges.

Yes it is. Thank you very much.

I'm grateful that Mom is generally happy despite her cognative issues. My daugher and I visited her yesterday at the memory care facility. She still knows my name, but struggled to remember my daughter's name. Despite her poor memory, she still seems to appreciate many things in life; good weather, good food, nice artwork, cards from friends, conversations and especially having visits from family.