Dx New Thoracic Aortic Aneurysm

[milo_1]

I am a 45 y/o female, lifetime nonsmoker. I had surg in 97 for congenital bicuspid valve disease, AV regurg. The Ross was done on me. On yearly exam 2 years ago, Echo showed 'enlarged aortic root, 4.0 cm".  This years Echo shows "6.3 enlarged aortic root" and severe aortic regurgitation.   I looked up the root thing on the internet and found info on this forum that says after 4cm it is called an aneurysm.  My cardiologists office called me and told me the same thing. They had me get a CT to confirm, and it did. Upon confirmation, they made appt with surgeon for me...this coming Friday. What can I expect at the appt?  What are my surgical options?  Is surgery indicated again? Can they replace valve and do repair or stent of aneurysm all in one surgery? What is my recovery time? What are odds I will develop another aneurysm later?  Is stenting an option for me? Any answers will help.
Thank you,
Colleen

[Cleveland Clinic]

Yes it sounds like you need surgery for the enlarged aortic root and aortic valve replacement. In my opinion this surgery is far more involved that your first surgery and I would only get it performed by a leading world class thoracic surgeon. I don't know where you are, but I would ask the surgeon how many of these procedures he has performed to get an idea of his experience, and what his rate of complications is ( strokes, heart attacks and other embolic events are). If you were a relative of mine, I would advise you to seek surgical care here at the Cleveland Clinic with one of our most experienced surgeons, such as Dr. Svenson, Dr. Petersson or Dr. Lytle.

[mark29357]

My Aortic root at the Sinuses of Valsalva is dilated at 4cm, with a bicuspid
aortic valve and with mild regurgitation. Also, "annuloaortic Ectasia" is present. I am 33yr old male.
My actual measurements are:
> AO Sinus: 40mm
> AO St jct: 34.2mm
> AO acs prox: 33.5mm
> AO asc mid: 36.6mm
> Ao transverse: 28mm
> Ao desc prox: 21.8
> Ao desc. mid 17mm
and Ao Diameter 36mm (M-mode) (whcih apparently on my last echo in
2004 was 33mm)

From what I understand, dilations among those with bicuspid aortic valves (BAV) is sensitive since BAV signals an inherent weakened Aorta, which means that a dissection can occur even if the aorta is not dilated over 5cm (whereas normally, they would only consider surgery if over 5.5cm).

The latest academic publications state that:

1) some BAV patients, especially males without stenosis, appear to be
at significant risk of root involvement and should probably be
followed-up more carefully and treated more radically (European
Journal of Cardiothoracic Surgery (2007;31:397-405))

2) It is recommended that patients with bicuspid valves should undergo
elective repair of the aortic root or replacement of the ascending
aorta if the diameter of these structures exceeds 4.5-5.0 cm.(Mayo,
etc.)

3) More importantly, "even with more aggressive guidelines (<5 cm),
preemptive aneurysm surgery would fail to prevent 40% of acute aortic
dissections seen in our registry" (Circulation. (2007;116:1120-1127.)
It further stated "The results show that nearly 60% of the 591 type A
dissection patients enrolled in the International Registry of Acute
Aortic Dissection had diameters <5.5 cm, and 40% had diameters <5.0
cm. It was assumed that, if they had been measured immediately before
dissection occurred, aortic diameters would have been even smaller
than at presentation because dissection causes an expansion of the
aortic media and/or adventitia (information not available).

First, my cardiologist, did not mention any of this and simply said it
was "very mildly dilated" and to come back in 12mths. My questions are:

1) What is "annuloaortic ectasia"? There seems to be a number of
definitions:

A) Aneurysms of the ascending thoracic aorta most often result from
the process of cystic medial degeneration (or cystic medial necrosis).
Histologically, cystic medial degeneration has the appearance of
smooth muscle cell necrosis and elastic fiber degeneration, with the
presence in the media of cystic spaces filled with mucoid material.
Although these changes occur most frequently in the ascending aorta,
in some cases the entire aorta may be similarly affected. The
histologic changes lead to weakening of the aortic wall, which in turn
results in the formation of a fusiform aneurysm. Such aneurysms often
involve the aortic root and may consequently result in aortic
regurgitation. The term annuloaortic ectasia is often used to describe this condition.

or

B) Annuloaortic ectasia (AAE) is a clinicopathologic condition with
primary or secondary dilatation of the aortic annulus and aneurysm of
the proximal thoracic aorta, leading to aortic regurgitation.

2) how is annuloaortic ectasia related to the aortic root aneurysm and
the bicuspid valve?

3) what should be my next steps? I scheduled a 6mth echo. what about
MRI? If a significant number of disscetions occur under 5cm,
especially those with Ectasia and connective tissue disorders
(bicuspid), how do we diagnose a particular case (What the difference
between 4.4cm and 4.5cm in terms of risk? Evidently someone at 4.5cm
may be at more risk than someone at 5cm - how is this determined?


4) According to an article in the Annual Thoracic Surgery entitled
"Surgical treatment of the dilated ascending aorta: when and
how?"(1999;67:1834-1839), the authors discuss the importance of
calcualtion ratio size of aorta, taking into consideration certain
genetic factors. Could you explain how someone can make their own
claculation? Is the idea of ratio size valid and accepted in 2008?

5) THe 2006 AHA Guidelines specifically discuss "aortic root dilatation and bicuspid valves" and state the between 40-45mm, you should do light to moderate cardio. Did their definition of "aortic root" include the sinuses of valsalva?

[milo_1]

Thank you so much for the guidance. I truly had minimized the severity of the surgery. You helped me realize I need a world class surgeon for this, and now I know the questions to ask. I am on the E. Shore of Maryland.
Thanks again,
Colleen