Should I push to replace my mid ascending aorta?

[tommyboy14]

I am just going to add that the definition of aneurysm varies by age. A 50mm Aorta in an 80-year old would be considered normal, but indication for replacement in a 40-year old.

This article has a useful table:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461294/

The article says:

According to the classic understanding, a diameter increase of 50% marks the borderline between ectasia and aneurysm—the threshold at which a dilated ascending aorta/root should be considered an aneurysm, therefore, is

• 
  ~40 mm in a 20-year-old
• 
  ~ 45 mm in a 40-year-old
• 
  ~ 50 mm in a 60-year-old
• 
  ~ 55 mm in an 80-year old

 

[tommyboy14]

@Nesphito I think it is very sensible of your surgeon to make the call once he has opened you up. From my personal experience, the measurements can be different once they open you up. My measurements were around 4.5cm. When I had surgery three months later, it was above 5cm in the widest section. I was 34 at the time. Either measurements via Cather are not very accurate or I just got very lucky that I was operated on right before it raptured.

So of course it is the surgeon;s call, but perhaps you can indicate to him that if there is any doubt in this mind, your preference is to have a one and done and hence to replace the Aorta as well. I will also say, if you look at this influential study by Dr. David, the inventor of valve sparing,

https://www.jtcvs.org/article/S0022-5223(04)00984-5/fulltext

You can see below that biscupid patients without root replacement with greater than 4.5cm aorta, only began to have aneurysm re-intervention after 5 years. So any study you should look at should have a long follow up. I would not be guided by studies with short follow up.

Best of luck in your surgery.

 

[Survived03]

I understand now. Thanks and good luck. Let me know if I can help.

 

[Gail in Ca]

My aneurysm measurement was 6 before surgery. When I read the notes after surgery, it was apparently 7. It fell apart in my surgeon’s hands when he was going to cut it and place a graft inside then close it. He had to cut it out and just do the graft along with valve replacement.
That was at Stanford Hospital when I was 34yo. At 54yo, I had to have it removed and replaced with a valve in hemashield graft after endocarditis did a number on me. My surgeon the first time might not have done too many AA on someone my age. I didn’t specifically ask about just the aneurysm part of it. He was very confident about doing my surgery, but the aorta falling apart was not what he expected.
My subsequent surgeries were done by the best, most experienced surgeon at Stanford. I had a great cardiologist advocating for that surgeon to do my repeats.

 

[Jeff Lebowski]

Greetings

Two and a half months ago, my bicuspic aortic valve was replaced with a mechanical valve. My aortic root width is 40 mm and no surgical intervention was performed. When I asked the cardiovascular surgeon why he did not perform both operations at once, he told me that my aorta was not yet at a level that would require surgery.

I realise that it is a bit unfair to ask questions that a specialist surgeon can answer on this distinguished forum site, but I still think that some of the forum members may have the same aortic width as me.

Therefore, I think that the most important factor causing the increase in my aortic width is my impaired bicuspid aortic valve, which I finally got rid of completely.

Apart from that, another usual suspect may be high blood pressure, but my blood pressure values are normal.

Anyway, let me get to the point, does the aortic root width tend to expand or can it remain at its current width until the end of my life?

 

[tjay]

Greetings

Two and a half months ago, my bicuspic aortic valve was replaced with a mechanical valve. My aortic root width is 40 mm and no surgical intervention was performed. When I asked the cardiovascular surgeon why he did not perform both operations at once, he told me that my aorta was not yet at a level that would require surgery.

I realise that it is a bit unfair to ask questions that a specialist surgeon can answer on this distinguished forum site, but I still think that some of the forum members may have the same aortic width as me.

Therefore, I think that the most important factor causing the increase in my aortic width is my impaired bicuspid aortic valve, which I finally got rid of completely.

Apart from that, another usual suspect may be high blood pressure, but my blood pressure values are normal.

Anyway, let me get to the point, does the aortic root width tend to expand or can it remain at its current width until the end of my life?

How old are you? Aorta is relatively more stable in older patients than younger. Rate of changes is also important, so please monitor is periodically (e.g. annually).

You mentioned blood pressure, that sure is a factor. Not only control it, consider taking ARBs like Losartan which are known to potentially stabilize the aorta (while controlling the blood pressure which's its primary intended use). Please discuss with your cardiologist on measures such as ARB and others to help keep aorta where it is currently (4.0 am). It can take a lifetime for it to get to 5.0/5.5cm which's its surgical criteria. Hopefully you won't need that in this lifetime. Do everything you can proactively to ensure the same.

 

[Warrick]

This article is a good non complicated read on this-
https://badaorta.com/double-trouble-bicuspid-aortic-valve-bav/

 

[tjay]

Not sure what the core discussion is about on this long thread here but at one time (before 2014 let's say), surgeons were very concerned about aorta sizes for BAV patients and were little too aggressive in recommending surgical intervention even at 4.5 cm (with valve replacement as applicable) let alone 5.0 cm. BUT they came back very strongly in 2014 that it can be 5.5 cm since they weren't seeing noticeable dissections in BAV in that lower range.

https://www.jacc.org/doi/full/10.1016/j.jacc.2014.02.536

They don't touch aorta at 4am, no matter what. 5.0 cm if someone is getting valve replacement and/or have a family history etc. Else 5.5cm if aorta needs replacement by itself. Please take a look and discuss with your cardiologist. Depends on different cardiologists and surgeons, and patient's own comfort level of course, you hear somewhat different opinions.

Once again, I don't know what the core discussion here is about.

 

[tjay]

This article is a good non complicated read on this-
https://badaorta.com/double-trouble-bicuspid-aortic-valve-bav/

This article says 10% of population is born with BAV. I thought it was more like 2%.
And author is raising alarms for aorta at 4.5 cm for BAV which is not true.
https://www.jacc.org/doi/full/10.1016/j.jacc.2014.02.536

 

[pellicle]

article says 10% of population is born with BAV. I thought it was more like 2%

Agreed (first link google returned)

"Approximately two percent of the population has BAV, making it the most common congenital heart condition. While there is no known cause, it’s possible to inherit a bicuspid aortic valve."
https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/bicuspid-aortic-valve#:~:text=Approximately two percent of the,inherit a bicuspid aortic valve

 

[SatoriFound]

Yes I have a bicuspid valve. I heard that insurance won’t cover an aorta replacement unless it’s above 5cm. Which means I won’t be able to afford it if that’s true.

I saw this study https://www.sciencedirect.com/science/article/pii/S000291492030535X#sec0004

It says there’s no difference in people with BAV

View attachment 889952

What I read on this today was that the cut off is lower for those with BAV and aortic aneurysm. Mine is 4.5cm according to yesterday's CT. Still waiting on confirmation of BAV as none of the scans have been able to definitively say.