Surgery Size for Ascending Aortic Aneurysm

[rtblount]

I am interested in informed opinions regarding the time for surgery on my ascending aortic aneurysm. I had a bicuspid aortic valve replaced with a St Jude mechanical valve in October 1997. It has performed really well. I take 6 mg of coumadin daily and have no problems with it. i don't have high blood pressure or any other major health problems. I am 67 years old. On my annual followup visit to mu cardiologist in April 2005 he had an echo cardiogram run and determined that my ascending aorta appeared somewhat dilated. A couple of weeks later he had a 16 slice cat scan run which indicated that I had an aneurysm of 5.25cm. He called a surgeon locally ( all of this was in Savannah, Ga) and discussed the problem. They both agreed that they did not want to do surgery unless the size increased to near 6.0cm. I am to have a MRA on October 25, 2005 to determine hte current size. Their reason for waiting is that the surgery would be a redo which is riskier as well as the hope that the aneurysm will not increase in size. I see information on this and other websites indicating that surgery should be performed at 5.0cm where a bicuspid valve is or was involved. Please let me hear your opinions about waiting. I don't know whether to insist on surgery or at what point I should. I live 100 miles from a major hospital so my odds of survival aren't good if it dissects.

 

[Ross]

According to the Cleveland Clinic, 5.0 makes it a surgical candidate, as the risk of dissection exceeds the risk of surgery. My own dissected at somewhere between 4.7 and 4.8. I never made it to the 5.0 they were waiting for and nearly lost my life.

 

[Eric]

I was diognosed with a BAV and an aneurism of my ascending aorta in December of 2004. At that time I was at 4.3cm. Six months later, my retests showed that the aneurism grew to 4.7-4.8cm.

At Cedars Sinai, Dr. Raissi recommended surgery. They replaced my ascending aorta with a dacron graft but kept my BAV as it was in very good shape.

As Ross said, 5.0 is usually the point at which they recommend surgery but that is just a rule of thumb and other factors can come into play such as age, physical condition, etc...that could impact the decision in either direction. For example, A friend of mine's father was at 8.3cm in has ascending aorta. They decided not to operate because of other health factors. He died several years later...but from something unrelated to the heart.

 

[Kate]

Prior to my recent surgery, I did quite a lot of research on just this issue. Current studies suggest that people with an aneurysm and a bicuspid valve are likely to dissect at a smaller size than the general population due to an underlying connective tissue disorder (one article I read suggested dissection in this group is 15 times more likely, but that seems awfully high, so I'd take it with a grain of salt.) There doesn't seem to be agreement yet among Dr's regarding when to operate (my surgeon says 4.5 but many say 5.5 or even higher.) One thing I think is very important to keep in mind is that risks related to reoperation have gone down significantly in recent years, especially among surgeons who do a lot of them (for example, the Cleveland Clinic claims a mortality risk of under 2% for reops, assuming no other adverse health issues). As someone who also lives in a rural area, I chose to go ahead and have mine done early but in the end, the choice is up to you. If you want to do it earlier and your surgeon doesn't - find someone who has lots of experience and is committed to earlier intervention. Best of luck! Kate

 

[PJmomrunner]

As others have said, the size at which a surgeon operates is determined by balancing a given patient's chances or surviving with or without surgery. If your odds of dissecting in the upcoming year are 10% and your odds of not surviving surgery are 5%, then it's time for surgery. Major hospitals with aortic centers (and not all major hospitals HAVE aortic centers) have very low mortality rates--1 or 2%.

In your circumstance, it would seem that this is key. If, for example, someone like the Cleveland Clinic, where the mortality rate is really low, told you to wait until 6cm because of your specific situation (it's a re-do and who-knows-what-else), then I'd feel confident waiting. If you are being told by the highly respected local surgeon who maybe operates four times a week and 90% of those procedures are bypass surgeries, I would be concerned that his criteria had more to do with his experience than my specific case and I'd seek a second opinion at an aortic center, for two reasons.

Firstly, the timing of your operation is going to be determined by the size of your aneurysm whoever operates and only an aortic specialist is truly qualified to definitively interpret the imaging study. Secondly, especially as a re-do with increased risk, do you really want someone who is not an aortic specialist doing the surgery anyway?

 

[rtblount]

Aortic Aneurysm Size

Aortic Aneurysm Size

I appreciate your opinion as well as the others I've received. The more I find out the more I believe I need to seek a surgeon at one of the Aortic Centers. Do you know of any Centers located in the Southeast. I am aware of the Cleveland Clinic and Cedars Sinia?

As others have said, the size at which a surgeon operates is determined by balancing a given patient's chances or surviving with or without surgery. If your odds of dissecting in the upcoming year are 10% and your odds of not surviving surgery are 5%, then it's time for surgery. Major hospitals with aortic centers (and not all major hospitals HAVE aortic centers) have very low mortality rates--1 or 2%.

In your circumstance, it would seem that this is key. If, for example, someone like the Cleveland Clinic, where the mortality rate is really low, told you to wait until 6cm because of your specific situation (it's a re-do and who-knows-what-else), then I'd feel confident waiting. If you are being told by the highly respected local surgeon who maybe operates four times a week and 90% of those procedures are bypass surgeries, I would be concerned that his criteria had more to do with his experience than my specific case and I'd seek a second opinion at an aortic center, for two reasons.

Firstly, the timing of your operation is going to be determined by the size of your aneurysm whoever operates and only an aortic specialist is truly qualified to definitively interpret the imaging study. Secondly, especially as a re-do with increased risk, do you really want someone who is not an aortic specialist doing the surgery anyway?

 

[PJmomrunner]

I'm sorry, I don't. The U. S. News and World Reports list of the top 50 heart hospitals includes Duke, Emory and St. Vincents Medical Center in Jacksonville, FL. I think these would be the closest to you.

I started with this list when I went looking. I selected the hospitals on the list that I was willing to drive to (I want people to visit me), wrote down the names of all of their cardiothoracic surgeons, looked up their interests on the university/hospital website and ran their names through PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Pager&DB=pubmed) to see what kind of publications they had done. In some cases there was an aortic center/clinic (Cleveland Clinic, U of Michigan) in others there was not (U of Chicago).

You might also try contacting the bicuspid aortic foundation. (http://www.bicuspidfoundation.com/Patients_and_Families.html) Perhaps they maintain a list of centers?

 

[Ross]

One thing I think is very important to keep in mind is that risks related to reoperation have gone down significantly in recent years, especially among surgeons who do a lot of them (for example, the Cleveland Clinic claims a mortality risk of under 2% for reops, assuming no other adverse health issues). Kate

One thing very important to keep in mind is that this is a roll of the dice. You may go in do great and be out in 3 to 7 days. On the other hand, you may go in and have the fight of your life on your hands and things won't go so well. Kate I'm not trying to deflate your statement on stats, but actually this is 50/50. Statistics get me when it comes to your life on the line, sorry.

Regardless of scientific statistics, reops or even this surgery, should not be taken lightly.

 

[Lynlw]

OT but

OT but

Has anyone heard anything about Mee leaving the Cleveland clinic? Lyn www.caringbridge.org/nj/justinw

 

[BAV Pt's daughter]

Aortic Aneurysms

Aortic Aneurysms

We've had little experience so far, but it seems to me that the cardiologists and even general CT surgeons tend to recommend holding off until 5.5 cm if there are no other complications. However, many aortic specialists tend to recommend surgery much sooner, as early as 4.7-4.8 cm. Try looking at these websites for more info:

http://www.bicuspidfoundation.com/

http://www.csmc.edu/3885.html Follow all the appropriate links for you on this one...lots of valuable information here!!!

Hope this is of some help to you!!!

 

[Ross]

Has anyone heard anything about Mee leaving the Cleveland clinic? Lyn www.caringbridge.org/nj/justinw

No, but then I never knew McCarthy left until after it was a done deal either.

 

[Lynlw]

No, but then I never knew McCarthy left until after it was a done deal either.

one of my friends who's daughter had 2 of the 3 fontan surgeries (like Katie) said he is leaving in dec and it isn't pretty, it's a shame he is one of the few surgeons in the US that does the surgery for one of the chds (LTGA) Lyn

 

[Kate]

One thing very important to keep in mind is that this is a roll of the dice. You may go in do great and be out in 3 to 7 days. On the other hand, you may go in and have the fight of your life on your hands and things won't go so well. Kate I'm not trying to deflate your statement on stats, but actually this is 50/50. Statistics get me when it comes to your life on the line, sorry.

Regardless of scientific statistics, reops or even this surgery, should not be taken lightly.

Ross,
I certainly understand your point and agree with you to some extent - this is very serious surgery and should not be taken lightly as in any individual case something could go wrong and the person could die or end up with very serious life-long complications. However, I think it is also important to make decisions based upon a realistic understanding of the risks involved. Assuming that the Cleveland Clinic is accurately reporting its outcome statistics, the risk is not 50/50 - it's 98/2. Kate

 

[Ross]

Well then you have to ask yourself, am I 98% or 2% and hope the coin lands as you called it.

 

[geebee]

Well, I am not one to put much stock in statistics but, if people seem to be basing choices on them, I would really have to know a lot of factors about a 98/2 on resurgeries. I was not even given those odds on my first surgery, to say nothing of the second and third ones.

There may be a small percentage of situations that have a 98/2 success rate but I have to believe that this is not the case with your average repeat OHS.

I will have to check CC's website to understand just what they are promising these odds on.

 

[Mary]

Well then you have to ask yourself, am I 98% or 2% and hope the coin lands as you called it.

Come on Ross.
Are you advocating that rtblount delay surgery because he might be in that 2%? Any surgery can be a gamble, but he's got a 5.25 aneurysm.

 

[PJmomrunner]

All right, true, Ross. Like a coin flip, one could say that surgery has either a good outcome or a bad outcome. Unlike a coin flip, we have the opportunity to influence the outcome and increase the odds of which side of the coin lands up: with our choice of surgeon and facility, by controlling blood pressure, by employing accurate diagnostics, by choosing to operate rather than being forced (i.e., emergency surgery), by living within restrictions, etc...

 

[JohnnyV_46]

I find out things here everytime I come here that make me more and more greatful that #1 I had a slight heart attack and #2 that I found this board. My anneuryzm was 5.6 and I had no idea what so ever I even had it. No doctor ever said anything about a murmur or diagnosed me with a BAV.They found it all during the tests because of the chest pains. The Cardiologist I'm seeing now asked me about my murmur. I said "What Murmur". He said that I had no damage to heart tissue from the Heart attack...I never felt any Elephants on my chest I'm not sure it really was a heart attack. I did get one of those 2300.00 shots when I got in the ER tho.

 

[Ross]

Come on Ross.
Are you advocating that rtblount delay surgery because he might be in that 2%? Any surgery can be a gamble, but he's got a 5.25 aneurysm.

Not at all, I'm only saying that all too often this surgery is played to be no big deal by statistical standards. Until one goes through this surgery and finds out just what is involved, those stats sound almost too good to be true. For some people, they are. Bottom line-When you go in there are no guarantees on the results or the outcomes. You may do great, which is most often the case and what we all hope for, or you could also have the fight of your life on your hands. I'm not sugar coating this for anyone.

 

[Ross]

All right, true, Ross. Like a coin flip, one could say that surgery has either a good outcome or a bad outcome. Unlike a coin flip, we have the opportunity to influence the outcome and increase the odds of which side of the coin lands up: with our choice of surgeon and facility, by controlling blood pressure, by employing accurate diagnostics, by choosing to operate rather than being forced (i.e., emergency surgery), by living within restrictions, etc...

Yeah I know, bad analogy on my part. Some day, I'll develop Tobagotwo explanations so that I can come across perfectly understood. Until then, I may mess up from time to time. You did know I was human even though I was hatched right?