Cleveland_Clinic_Host: Thank you for joining us! Today's chat with Dr. Svensson will begin shortly. Please submit your questions by typing them below and then clicking 'Ask'. We'll get to as many questions as we can.

Cleveland_Clinic_Host: As we start the chat, I would like to remind everyone that this chat is for questions regarding Aorta Surgery. We have received several questions unrelated to the chat topic. We suggest asking those questions through the contact us button and check our transcripts area.

Cleveland_Clinic_Host: Welcome Dr. Svensson and thank you for being with us today. Let's begin!

Speaker_-_Dr__Svensson: I am happy to speak to you all who are logging in. Please understand that my answers are based on incomplete information and studies and I am giving general advice. Ultimately, your primary physician or cardiologist need to give you advice based on the studies you have had.

Aorta Aneurysm and Aorta Dissection

kathyg: What is the difference between aortic aneurysm and dissection? Are they treated the same?

Speaker_-_Dr__Svensson: Kathy, the definition of an aneurysm is not a hard definition but most surgeons would agree that if the aorta is twice the normal size of that segment, it is aneurysmal and may require surgery. Aortic dissection is present when the aorta is been split into its constituent layers so that they are two tubes - like double barrels. The weakened wall from the dissection tends to dilate with time and may rupture. If the dilatation is significant, then it is called aneurysmal.

anglechild: i have a abdominal aneurysm stable at 3.2, what is the best thing to do?

Speaker_-_Dr__Svensson: Make sure your blood pressure is controlled and if you smoke, stop smoking. And, if you have any chronic infections, such as bronchitis, they should be treated.

steve: I found out I have an aortic aneurysm of 3.5 mm. Do I need to see a specialist or can my primary care doctor follow me? Do I need to follow any precautions?

Speaker_-_Dr__Svensson: Your primary care doctor can follow this and if you are a smoker you need to stop smoking and make sure your blood pressure is well controlled.

bobls: What is the normal size of the aortic root? What is the normal size for the ascending aorta and descending aorta? Is it ok if their size is different? What is the best way to diagnose an aorta aneurysm? MRI or CT?

Speaker_-_Dr__Svensson: The normal size of the aortic root is dependent on your height and age. It should not be more than about 3.5 cm. Similarly for the ascending aorta. The average size of the first part of the descending aorta is approximately 2.3 cm. The best way to diagnose an aneurysm is CT scan. However, in younger patients who may require multiple studies, we prefer to use MRI.

niagrafalls: I am not sick but my doctor did some tests and found my "aortic root" measure 5.3 cm. The doctor said also said I have some aortic valve leak. Does this mean I need surgery. This was found during a yearly physical? are there other tests I need to see if I need surgery

Speaker_-_Dr__Svensson: If you are otherwise fit, we would recommend surgery for your root being 5.3 cm. The fact that you also have a leaking valve would suggest that it is leaking because of the root aneurysm. The operation we do on a regular basis for this is called the David Reimplantation Operation. This is quite a complicated operation and thus there are only three of us who regularly do the operation in the United States. For surgery, if you already had a CT scan or MRI, the only other additional tests we require are cardiac catheterization. I presume you have already had an echocardiogram that showed your valve was leaking.

Pockey80: I was initially diagnosed with a ascending aneurysm, 4.5 cm, last July by a Calcium Scan. A follow-up echo showed no ascending, but an aortic root aneurysm of 3.8cm. 6 months later my echo showed a 4.01 cm aneurysm. Should i have an X-ray or MRIO or CT to validate the previous findings?

Speaker_-_Dr__Svensson: There is often a discrepancy in the size of measurement between CT scan, MRI and echo. The reasons include whether the internal or external diameters are measured, the axis of the aorta that is measured, and the site of measurement. Generally, a 3D reconstruction of the aortic root is the most accurate. However, echocardiography is a safer method for regular follow up because of the radiation dosages with CT.

Aorta Surgery

johnr: What size does an aorta aneurysm need to be to be operated on?

Speaker_-_Dr__Svensson: The size of the aorta that we operate on is dependent on your age, where the aneurysm is, what caused it, and if you have any underlying genetic type of problem, like a bicuspid valve or Marfan's syndrome.

hostutler: What are the specific home going instructions for patients who had an aortic aneurysm repair? Do they need monitor their blood pressure at home? Can they resume heavy lifting activities eventually or is this always restricted?

Speaker_-_Dr__Svensson: After aortic surgery, you should have regular follow up of your aorta every year or two. Your blood pressure will be an important determinant of long term outcome. It would be wise to check your blood pressure every now and again.

As far as heavy lifting, this will depend on what the original repair was for and where it was done. If you had aortic dissection, then it would be wise to abstain from heavy lifting. If this was abdominal aneurysm repair, then moderate lifting would be fine.

rocky: I have a descending aortic aneurysm. I was on the internet and someone said there is something called EVAR to treat aneurysms and that is better than surgery. What is EVAR?

Speaker_-_Dr__Svensson: For descending aortic aneurysms, if your anatomy is suitable, and you are over 60 years of age, an EVAR type of stent graft is a reasonable option. It is unclear at this stage what the long term durability beyond 10 years will be . Furthermore, you will require regular CT scans to follow the stent graft for potential further aneurysm expansion or leaks around the stent. Generally, in patients who are younger and have involvement of the aortic arch or visceral segments of the aorta, we recommend open surgery, especially if chronic aortic dissection is present.

cyclejoe: I am a 40 year old athletic man who had surgery on a dilated aortic root and 5 cm ascending aneurysm. Had a graft placed. I am cycling again after a great recovery. Do I have any restrictions? Can I do light weight lifting? Do I need to worry about the aneurysm returning? How long does this surgery last?

Speaker_-_Dr__Svensson: If you had a successful repair, cycling is fine as long as your aortic valve is working well. I would not recommend weight lifting unless it is light aerobic exercise.

The risk of the aneurysm returning is about 1 in 20 but it is very dependent on why you originally needed the repair. If you had a bicuspid aortic valve or Marfan's syndrome, the risk is increased. The new tube graft that you had inserted will stretch by at 10% but will otherwise not wear out. However, the aorta adjacent to the new tube graft may enlarge over a long period. Therefore, you need yearly or two yearly follow up.

jlanese: I am scheduled for a repair of an ascending aortic aneurysm. Will I continue blood pressure medication after surgery? I am 58 years old and typically have BP 125/85.

Speaker_-_Dr__Svensson: Your risk of ascending aortic aneurysm repair should be less than 1% risk of death. After surgery, you should be on blood pressure medicine, particularly beta blockers, baby aspirin, and cholesterol lowering medications, as indicated.

Combined Aorta and Aortic Valve Surgery

spinja187: Hi! I had my aortic valve repaired by Dr. Frazier at the clinic back in '96. In 2001, my ascending aorta had dilated to 4.1 cm. As of last week, dr. sterba said it was up to 5.1 cm, but then said to return in a year as after careful measurement, it was only 4.8 cm. what is the real difference in risk there?

Speaker_-_Dr__Svensson: The decision when to operate on patients again who have had previous surgery is dependent on a patient's age, comorbidity, size of the aorta, and condition of the aortic valve. Generally, if the aorta diameter is less than 5.2cm, and the aortic valve is functioning well, we do not recommend reoperation. The risk of aortic dissection or rupture is approximately 1 - 3% per year in the 4.8 - 5.1 cm range and there is some protection because of the previous surgery.

The risk of reoperation is approximately 2 - 3% and thus the risk of surgery is weighed against the risk of waiting. I would recommend careful blood pressure control and beta blocker administration and follow-up with Doctor Sterba.

miller2917: My father was diagnosed with a porcelain aorta and told that valve replacement could not be done. Are there any options

Speaker_-_Dr__Svensson: The risk of aortic valve surgery combined with a porcelain aorta when it can be done, is about a 5 - 10 % risk of death. This depends on whether the porcelain aorta also involves the aortic arch and any other co-morbid disease like coronary artery disease and emphysema. In some patients we can enroll them into a study of so-called percutaneous aortic valves. These valves are threaded over guidewire and through a catheter in the groin up to the aortic valve and then placed in the aortic valve position. This is an experimental study that is FDA approved. However, there are very strict criteria for entry into the study.

perrys3: When performing an aneurysm repair in the aortic arch, does it typically involved work on the aortic valve as well?

Aortic Valve Surgery

djm1950: I have moderate leakage of the aortic valve, possibly as a result of calcification. What does calcification of the aortic valve mean? Does the calcification generally get worse over time? Can a calcified aortic valve be repaired , or must it more often be replaced? If replaced, how long does a replacement valve usually last?

Speaker_-_Dr__Svensson: Calcification of the aortic valve occurs normally with aging. If you have a bicuspid aortic valve, this will occur earlier. Generally the calcification does get worse with time but may possibly be slowed down by cholesterol lowering medications.

Calcified valves, we tried to repair many years ago, but most failed within a year. Depending on your age, the durability of valve replacements is excellent, however, in younger patients, a mechanical valve may be required.

harris7lr: can the aorta valve be repaired

Speaker_-_Dr__Svensson: Yes the aortic valve can be repaired but is influenced by if there is calcification or not and your age.

kmr0038: I'm not sure if there is another Kathy or if the questions have gotten mixed up. My name is Kathy I was diagnosed with aortic regurgitation at the age of 32 I am now 44yrs old. I do go for echo cardiograms every other year and all they tell me is that there is very little change. It is considered mild/moderate. what are my chances of having to have a aortic replacement in the future?

Speaker_-_Dr__Svensson: The risk of aortic valve surgery is dependent on whether you have a bicuspid aortic valve or aortic root enlargement. Generally with time, there is a progression of the degree of aortic regurgitation. Current guidelines recommend surgery in patients when they develop symptoms or is evidence of Left Ventricular dysfunction. However, if regurgitation is severe in young patients, we will often recommend surgery. Particularly if we think we can repair the valve and aortic root.

bimalshrestha: i am 30 year young male and i want play soccer and active live , it this possible after surgery? what kind of procedure you apply ?

Speaker_-_Dr__Svensson: When to operate for a leaking aortic valve is dependent on symptoms and degree of regurgitation. In young patients if feasible, we try to repair the valve. If not able to, then the options are replacement with a mechanical valve or a biological valve. The problem with playing soccer, with the mechanical valve is that patients need to be on the blood thinner coumadin. Thus the other option is a biological valve, however, the risk of needing another operation would a biological valve is approximately 30% in the next 12 years for a patient of your age. Never the less, the risk of death with a reoperation would be between 1 - 2%.

Either way, you can expect an active life after valve surgery.

bjsirota: How much greater are the risks for complications and morbidity when an aortic valve replacement surgery is combined with by -pass surgery to remove blockages?

Speaker_-_Dr__Svensson: For our minimally invasive aortic valve replacements without coronary artery bypass surgery the risk of death in our most recent study was 0.6%. For combined aortic valve replacement and bypass surgery, the risk of death is 1 - 3 percent, depending on comorbid disease.

richardb: I have a aortic valve leak moderate to severe how do you do the procedure? i live in nyc is the follow up going to be a problem?

Speaker_-_Dr__Svensson: The procedure that you will require will be dependent if your aortic root is enlarged or not. In many patients with leaking valves, we can repair the valves, particularly if you are young. In older patients, we would replace the valve. Typically, your local cardiologist would follow you up after surgery.

donata: my mother is 58, she is diabetic and has high blood pressure. During a regular check-up, they found out she has partial blockage of root the aorta and of its valve. The mitral valve also is partially blocked. She shows no symptoms at all. Doctors said she doesn't need surgery yet. How much blockage must there be before replacement?

Speaker_-_Dr__Svensson: Most recommendations for valve surgery are dependent on the finding of symptoms, such as chest pain, shortness of breath, and dizziness. Typically, we don't recommend surgery without symptoms either. However, if there is evidence of heart failure and dilation of the left pumping chamber, we may intervene earlier.

bettyb4358: How do you know that the valve replacement surgery is working without leakage? What are the symptoms of a leaking replacement valve?

Speaker_-_Dr__Svensson: The way to check your valve is to have an echocardiogram. The most common symptom of a leaking valve is shortness of breath. However, by then it is usually quite far advanced.

Aorta Stent

JudithT: How does an abdominal stent affect the heart? and if so how?What is best for my health with the stent? Thank You, Respectfully, Judith T

Speaker_-_Dr__Svensson: Your stent should not affect your heart function unless some problem would develop with it like kinking. This is very rare. As far as your health, stop smoking if you smoke. Make sure your blood pressure is well controlled. And - if you do have a heart problem, you should probably be on a cholesterol lowering medication.

carol: My doctor said I need aortic aneurysm surgery? What is an aortic aneurysm stent? Is that surgery? Can they fix the aorta without open heart surgery?

Speaker_-_Dr__Svensson: Aortic stents are commonly used in the abdominal aorta and the descending thoracic aorta. They consist of a wire stent covered by a type of cloth. In suitable cases, this is a good alternative to open surgery. However, if the aneurysm involves the ascending aorta or aortic arch, then open heart surgery is a better alternative.

Atherosclerosis of the Aorta

bonnie: I am 45 years old and had testing that showed I have atherosclerosis in my aorta. Will that lead to an aortic aneurysm?

Speaker_-_Dr__Svensson: At 45 years of age, an aneurysm is unusual even in heavy smokers. We would recommend further testing for this particularly if it involves your ascending aorta. You don't mention where the aneurysm is.

Transapical aortic valve replacement

miller2917: What can you tell me about the transapical thoracotomy study?

Speaker_-_Dr__Svensson: I presume what you are referring to is the transapical aortic valve replacements we have been doing as part of an FDA approved study. These valves are placed over a guidewire through a sheath in the chest wall, through the left ventricular apex and into the aortic valve position. This is an experimental procedure and the criteria for entry are very strict. Mostly, patients have to be very high risk or inoperable by current open heart surgery methods. The other approach we use is through the groin artery with the same valve system.

Sinus of Valsalva Aneurysm

caralynncohen: i have an Unruptured Sinus of Valsalva aneurysm that was an incidental finding last year. There is no indication of MArfans at this point, just an Indeterminate Bowel Disease as well as possible Heterotropia in the brain. I am 37 yr old female. is this aneurysm something that can be repaired?

Speaker_-_Dr__Svensson: Sinus of valsalva aneurysms can involve one to three of the sinuses. The operative technique is dependent on the number involved and the size. In most patients we can repair the aortic root and preserve the aortic valve which would be particularly important for you as a young female.

Marfan Syndrome

DLClarmont: Please. My nephew died at 20yrs of age from Aortic aneurysm. He had Marfan Syndrome. It is a connective tissue disorder. My daughter has many chronic issues in multiple systems. She is NOT tall and lanky like her 1st cousin was. Does she still need an echo? Are all Marfan patients tall?

Speaker_-_Dr__Svensson: With a nephew who died of Marfan's syndrome, Marfan's syndrome would not be present in your daughter unless it was transmitted through you. It seems unlikely that this is the case since you would probably have been diagnosed as having Marfan's syndrome by now. As far as height and Marfan's syndrome, virtually all men with Marfan's syndrome are taller than 6 foot 2 unless they have kyphosis scoliosis. In women, height is not as strong a finding. A high arched palate and the ability to squeeze down on ones thumb so that it protrudes beyond the palm of ones hand are common findings in Marfan's syndrome. Nevertheless, if your concerned that your daughter has some features of Marfan's syndrome, I would recommend an echocardiogram.

vegasmom: My son was diagnosed with Marfan syndrome. He has a mild aortic valve leak and dilated aorta of I think the doctor said 3. He is active and wants to participate in sports. His doctor said it is ok but I don't know. Is it ok for him to exercise?

Speaker_-_Dr__Svensson: The guidelines for patients with Marfan's syndrome are very dependent on a patient's size of the aorta in relation to height and age. Generally, cycling, swimming, jogging is fine. But, Marfan patients should not participate in any sport that involves straining and rapid chest and arm movement, such as basketball, baseball, golfing, lifting heavy objects, etc.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Lars Svensson. Dr. Svensson thank you again for taking the time to answer our questions today. If your question was not answered, please use the contact us button to submit your questions.

Speaker_-_Dr__Svensson: Thank you for having me. I am sorry if I did not have time to answer all questions during this chat.

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