What Diameter Aorta Requires Replacement?

[Ultrarunner]

I'm sorry if this has been discussed before. I scanned the last few months of posts but didn't see this as a topic.
My cardiologist said the current standard (assuming no complicating factors) is to replace an aorta in BAV patients when the ascending aorta is 55 mm or more. He has referred me to a surgeon because I asked so many questions. While I wait, I've been doing way too much reading Today I came across this paper from July 2015:

http://www.ncbi.nlm.nih.gov/pubmed/26209494

The conclusion: Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm2/m.

My ascending aorta just happens to be exactly 10 cm2/m.

So the question is (if I'm given a choice), should I wait a few years until my aorta expands enough, or be proactive and eliminate the possibility of dissection? Any thoughts? Maybe this study will result in changes to the current guidelines?

 

[pellicle]

I don't know more than you've just written, but I had mine signaled as dangerous at 5.6 or something like that. Mine was not tracked and "found" dilated at a checkup.

I expect that there is some variation in size among people, so how far it has streched would depend on how big it was to start with. As to proactive, I think that's best judged by the surgeon , I know its good to ask here, but in reality those guys are the experts. Perhaps they may monitor it, but I'm surprised no one has talked to you yet ... or are you getting in quick here?

To them its all risk management. If its risky leaving it they'll take it.

I would ask them that question and ask them "why" when they answer. If they seem brusk it may just be that they are really busy and don't have good bedside manner.

best wishes

 

[W. Carter]

They (all cardiologists that I saw) flat out told me that if I didn't have surgery it could be catastrophic. I said does that mean I might just drop dead, They said yes thats what it means, if it bursts you will bleed out before they can get you to a hospital. Mine was 5.7 and it scared me into getting it fixed.

 

[Ultrarunner]

I expect that there is some variation in size among people, so how far it has streched would depend on how big it was to start with. As to proactive, I think that's best judged by the surgeon , I know its good to ask here, but in reality those guys are the experts. Perhaps they may monitor it, but I'm surprised no one has talked to you yet ... or are you getting in quick here?

This is Canada. Waiting is a big part of the health care system! I'm trying to get in on a cancellation, but no luck yet. The formula used to calculate the 10 cm2/m already takes height and weight into account so there really isn't more for the surgeon to factor in. Just wether to use the AHA/ACC guidelines of 55 mm or the recommendation of the above quoted study. Cleveland Clinic also suggests aortic replacement at 10 cm2/m.

 

[Ultrarunner]

Here is the calculator I referred to:

http://valleyheartandvascular.com/Thoracic-Aneurysm-Program/Calculate-Your-Relative-Aortic-Size.aspx

 

[DachsieMom]

Body size matters. Read Dr. Elefteriades' articles on body surface area and aorta size. My sister was 4.8 cm but her aorta was so deteriorated the surgeon said she could have died any day. They thought I was 3.8 before surgery - still operated - turns out I was 4.5. I am only 4'9", so that was very large for my size. Other factors, such as genetic mutations or Marfans, can also change that 5.0 or 5.5 baseline. Also, if you experience any symptoms they consider earlier intervention.

 

[AZ Don]

In the AHA/ACC guidelines, the team concluded that the evidence was not strong enough to consider anything more than just measuring the aorta at the widest point. I think it is safe to say that not all Dr's agree with the guidelines given the number of references I have seen to measurements accounting for height/weight. The way I looked at it, there was a small but real risk of dissection each year that I waited until surgery. These risks compound over time. I've read that once an aneurysm reaches 4.7cm, it is likely to continue to progress. So in this case surgery is virtually inevitable and it also carries a small but real risk. While OHS is not something to rush into, if it is virtually inevitable, it seems logical to me to wait as little as possible to minimize the only risk that can be controlled - the time spent waiting. That's how I looked at it. The guidelines are just that, guidelines. Some Dr's may be willing to consider the criteria that accounts for body size.

 

[Ultrarunner]

It seems to me that using the calculator I linked to, which takes weight and height into consideration would be a better guide than just using the number 55. I was thinking the same way as you Don. I will have to get the surgery sometime between now and a few years from now. The cumulative risk of waiting a few years is higher than the surgery risk. Plus I'm very fit now so perhaps the risk of surgery would be lower in my case. Were you at 5.1 when you decided to undergo surgery?

 

[Ultrarunner]

DachsieMom, how could they have gotten your aortic diameter so wrong? Was it measured by CT/ MRI as well as echo?

 

[AZ Don]

My initial diagnosis was 4.7 and I was thinking I wanted surgery when it hit 5.0, but CT confirmed 5.0 - 5.1 and I learned that I had a BAV at the same time. At the time the guidelines were 5.0 for those with BAV so I had the surgery the next month.

 

[cldlhd]

Mine was supposedly 4.8cm but I decided to have it done. Reading the post surgical report it actually measured 4.99cm and was described as "very thin" . I had it done at a high volume center also. My surgeon acknowledged they recently raised the limit with BAV to 5.5 but said I was on the cusp so he's do the surgery if I wanted . He said I had no other current health issues and being relatively young and in good shape the risk of surgery was pretty low .

 

[Ultrarunner]

Mine was supposedly 4.8cm but I decided to have it done. Reading the post surgical report it actually measured 4.99cm and was described as "very thin" . I had it done at a high volume center also. My surgeon acknowledged they recently raised the limit with BAV to 5.5 but said I was on the cusp so he's do the surgery if I wanted . He said I had no other current health issues and being relatively young and in good shape the risk of surgery was pretty low .

There seem to be a number of people who's aorta ended up being larger than the echo or CT indicated it was. Thanks for posting. I think, based on these posts, and thinking about it more, I'll elect to have the surgery sometime within the next year, when it fits with my schedule. Of course, if I ever get to see a surgeon, he or she may have something to say about all this too. ;-)

 

[MethodAir]

I'm just over 6 ft (weighed around 200lbs the time of the echo). My ascending aorta was 4.4, aortic root 3.9 (bicuspid valve was in bad shape). Replaced with ascending aortic prosthesis.

 

[cldlhd]

There seem to be a number of people who's aorta ended up being larger than the echo or CT indicated it was. Thanks for posting. I think, based on these posts, and thinking about it more, I'll elect to have the surgery sometime within the next year, when it fits with my schedule. Of course, if I ever get to see a surgeon, he or she may have something to say about all this too. ;-)

That's how I decided to do it, picked the time of year , surgeon, got some things in order, not that I ever felt totally ready but ....

 

[Ultrarunner]

I'm just over 6 ft (weighed around 200lbs the time of the echo). My ascending aorta was 4.4, aortic root 3.9 (bicuspid valve was in bad shape). Replaced with ascending aortic prosthesis.

That works out to a cross-sectional to height ratio of 8.3 cm2/m, which is below Cleveland's recommendation of 10 cm2/m. Why did they recommend replacement "early"?

 

[Ultrarunner]

That's how I decided to do it, picked the time of year , surgeon, got some things in order, not that I ever felt totally ready but ....

I like the idea of scheduling well in advance so I can choose a quiet time of the year for my business. Plus I need to teach my wife a few things like how to operate our audio-video system, in case I don't make it!

 

[cldlhd]

I like the idea of scheduling well in advance so I can choose a quiet time of the year for my business. Plus I need to teach my wife a few things like how to operate our audio-video system, in case I don't make it!

Oh hell good luck with that-ha! Funny I tried showing mine also but to no avail. Our son, 8 at the time, was a lot more proficient at running it. I even have a Harmony One setup and programmed to make it easier.

 

[MethodAir]

That works out to a cross-sectional to height ratio of 8.3 cm2/m, which is below Cleveland's recommendation of 10 cm2/m. Why did they recommend replacement "early"?

They were seeing a pattern of patients requiring an additional surgery as the aneurysm increased in size after the initial valve replacement. So they like to take care of the problem areas while they are in there. Plus, the surgeon described how the valve is seated better in an ascending prosthesis (as opposed to stitched into the aorta directly). It made sense to me.

 

[Heart Of The Sunrise]

When discovered in October of 2012 mine was 4.5 cm. February of 2013 it was 4.7. This is when I first saw my surgeon. He wanted to operated in 2 weeks.
I needed more time. My surgery was a month later. At this point it had grown to 5.0. So my understanding has always been 5.0 is time for surgery!!!!

 

[Roberta]

This is Canada. Waiting is a big part of the health care system! I'm trying to get in on a cancellation, but no luck yet. The formula used to calculate the 10 cm2/m already takes height and weight into account so there really isn't more for the surgeon to factor in. Just wether to use the AHA/ACC guidelines of 55 mm or the recommendation of the above quoted study. Cleveland Clinic also suggests aortic replacement at 10 cm2/m.

Ultrarunner...just wondering if you are dealing with a high volume center? I don't know what part of Canada you live in, but my experience has always been that I have been seen quickly and in a timely manner depending on what the issue is. My father has also had the same experience. Once my cardiologist decided I needed a surgical referral, I was seen by the surgeon for a consult within a week. The centers both of us have dealt with have been in Ontario and in Newfoundland.
My understanding is that surgeons refer to these as guidelines only; however, they also use their own experience and expert opinion. Good luck. Hope you get in soon.