Aortic root diameter at the point of the sinuses?

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Anyone had any experience of having an abnormality at the aortic root around the sinuses?

I recently got results back from an echocardiogram stating that my aortic root was 4.6cm dilated at the point of the sinuses of vasalva. Given that this is the widest part of the aorta, would this still quantify as an aneurysm? or simply just a growth at this point, I've read some places 4.0cm is the cut off whilst other sources state 4.5cm ,all my other measurements on the aorta came back normal but naturally, you turn to google and freak out when you read the worst case scenario.

An otherwise healthy 34 yr old male, with a bicuspid valve as well, booked in to see a cardio in the next couple of weeks. Any advice or similar experiences would be amazing, Thanks.

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  • Posted

    Hi Benjamin - I think your questions are totally sensible and obviously need to be discussed with your doctor, in the context of understanding exactly how your bicuspid valve is structured and how it is functioning. If you haven't already had imaging of the whole of your aorta, with either CT or MRI, you'll need to discuss that. Your cardiologist might also want to get a trans-esophageal echo (rather more unpleasant than a transthoracic one) and to review blood pressure control, etc.

    I was diagnosed nearly a year ago with an ascending aortic aneurysm; I'm still on a massive learning curve about aortic diseases; I'm a patient, not a doctor. I am 60 years old, have a tricuspid valve with an enlarged ascending aorta, where the measurements of my root are 3.9cm at the level of the sinuses of Valsalva and 3.4cm at the sinutubular junction; the aneurysm is a bit higher up, and grew from 4.6 to 4.9cm in 9 months. It's questionable whether I have a dilated aortic root, although I think it's slightly larger than it should be at the ST junction; at present, my valve does not appear to be affected.

    Aortic root dilation is typical in Marfan syndrome, and it can eventually lead to aortic valve regurgitation and heart failure. One approach to stopping this is through PEARS surgery (full details on www.exstent.com) which I'm currently discussing as an option for myself (because of my growing aneurysm) and which has also been used in some cases with bicuspid valve disease too, especially where the valve is basically functioning well.

    My understanding of bicuspid valve disease is that the pattern of enlargement in the aorta depends on which leaflets are fused and that the rate of growth is usually faster than in tricuspid disease, but that's something you can only find out with repeated measurements over time. It is possible that when the valve is surgically modified or replaced, further dilation of the aorta ceases and additional treatment isn't needed. However, at your age, valve replacement would be challenging because mechanical valves mean lifelong anticoagulant treatment and tissue valves, though improving, can wear out and need replacement. Other surgical options would need to be discussed with a surgeon.

    I agree that your aortic root is probably dilated, although as you say, it's the widest part of the aorta and also, because it's a complex structure, there's some debate about how best to measure it. The most convincing images I've seen have been using MRI scans to take a section precisely through the origins of the coronary arteries, with measurements from the middle of each sinus to where the opposite leaflets join; you can't get this level of precision from any echo. I wouldn't get too hung up about whether it counts as an 'aneurysm', and I guess that whether or when any surgery will be considered will be driven by the assessment of the valve, not the root dilation.

    One article I found helpful in understanding the shape and function of the aortic root is this one, by Professor Bob Anderson of UCL; it's very technical, though.

    https://heart.bmj.com/content/84/6/670

    Hope this is helpful - very best of luck in building and sustaining the effective relationships with the medical specialist(s) you will need, going forwards.

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    • Posted

      Thank you so much Julian for your reply and the information you passed on, I've just watched the PEARs video that was on the site, extremely helpful!

      Quoting from my echo results it was described as: "The aortic root at the level of the sinuses is dilated at 4.6cm due to an aneurysmal non-coronary sinus" with ST junction intact and ascending aorta normal size. As far as Marfans goes, I dont believe I have it (based on the symptoms checklist) but have had no test to rule it out as such.

      I think you are right when it comes to measurements re: MRI and CT, I've read alot about the questionnable accuracy of the echocardiogram on these kind of fine margins, so hoping this will be the next steps when I get my cardio appointment. I'd also be curious to see if I'd be ok to fly with it at this size or whether it would be considered a risky thing to do.

      In terms of surgery, are they waiting and monitoring for yours to get to the 5.0cm mark?

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    • Posted

      Hi Benjamin - there shouldn't be any risk attached to flying (certainly, not as an airline passenger; piloting a paraglider might be another matter ...) - it's basically activities that cause unusual surges in blood pressure, such as maximal effort weight training, that are problematic. I flew a few days after I was diagnosed; the sports cardiologists who advised me on dos and don'ts had no issue with that. However, they did advise me to withdraw from the races I was flying to participate in, so I volunteered as a marshal instead ... and ended up working longer and harder than I would have, as a competitor.

      And in answer to your other question, yes, the surgeon I've seen would operate at 5.0 cm (which I may already have passed since my last scan) - hopefully, I'll agree on my next steps with the cardiologist and surgeon in a couple of weeks' time. It is a huge benefit to know about these things before they become urgent, let alone cause emergencies, although initially it's a shock and doesn't totally feel that way. On your report, I'd note that it's very common for most of the root enlargement to be in the non-coronary sinus. I'd also say that the echo doesn't give a clear view of the whole aorta; this is what you will need to discuss, though I have found that when echos are done with good equipment by experienced operators they can be convincingly accurate in relation to that part of the aorta they do show well. I'm lucky that my own enlargement seems to be precisely in that area.

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    • Posted

      I completely agree, knowing is a great thing however those first couple of weeks after diagnosis are a real shock, and with myself being in my 30's, who exercises alot and with a young son it worries you even more, but I'm finding each day is getting easier and you think about it a little less too.

      Next steps is waiting for my appointment (wait times in Alberta, Canada are not great) and look at maybe a CT/MRI to confirm sizing and just chat things through with a doctor.

      Just wanted to thank you again for all of your advice on this, as I'm fairly new to it all and hope you get the answers you are looking for from your cardiologist in a couple of weeks time!

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  • Posted

    Hey Benjamin, yes this can definitely be scary and sorry to hear about your echo. Let me give you some brief history.

    I am a 42 year old guy in decent shape, 6'2.. They found my aortic root dialated via an echo, measuring 4.3cm. I had subsequent MRA (not MRI) of the heart for the past three years and hits measured 4.1CM. So i have gone to a few cardiologist and one known cardio surgeon. The surgeon said that its just a wait and monitor game if you are below 5.0. he suggested that either (1) i caught it earlier, or (2) i just have a larger aortic root which is still in "normal" range. Those who are taller will inherently have a larger aortic root.

    I have followed the doctors advice which is below

    (1) Do not lift more than 50 lbs. There is a ton of evidence showing that when you lift weights, your blood pressure could raise to above 200/100 which pushes a high volume of blood to your aortic walls. You want to minimze that as it could stretch the walls.

    (2) I am on lozartan 25mg. I never had high blood pressure but the goal is to keep my blood pressure well below 120/80...its currently around 110/65. Again, goal is to reduce the high pressure of blood pumping through the aortic walls

    (3) on a low salt and low carb diet. Not only did i lose about 15 pounds and feel great, it does help reduce strain on your heart, reduce cholesterol levels and decrease blood pressure.

    (4) Dont focus on it. This was hard for me especially in the first 6 months.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462295/

    will calculate your BSA

    https://healthonecares.com/service/relative-aortic-size-calculator

    pg 5 will give you an idea of height to aortic size risk...

    https://pdfs.semanticscholar.org/be81/b08d83dff2dfee4fbc0b6ebd2f9ee3f461be.pdf

    Happy to help answer any questions you may have. I would definitely recommend an MRA/I to confirm size.

    Good luck to you ..

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    • Posted

      Hey Mikey,

      Thanks for all of the valuable advice here, its really helpful and does re-assure me that I may still be in the low risk category as I'm 6'0" even and 175 pounds so my BMI is in fairly good shape.

      With my diagnosis being "aneurysmal non-coronary sinus" I'm wondering if this still counts as an aortic root/aorta aneurysm or not, My cardiologist (once i get an appointment) will be able to clarify but the symptoms and consequences do seem quite different to a traditional aortic aneurysm.

      In terms of exercise, did your doctor give you any tips on cardio exercize and max BPM or anything like that? or is it really just heavy lifting that is the one thing you should strike from your exercise regime? Lifting my 3 year old son is unavoidable in my day to day and he's creeping up to 40lb now! I'm looking to get the MRA/CT pencilled in once I get my appointment sorted but the healthcare wait time in Canada are a joke at the moment...

      With your root in the 4.1cm region, are they monitoring yearly or every 6 months?

      Thanks again for all your advice its really helped, hope you are doing well.

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    • Posted

      Hey Benjamin...so i also have young kids, 5 years old. So was also very concerned about this. So the weight threshold they told me was 50 lbs and i do try to stay within that, including my boys. This was super hard for me as i used to workout with heavy weights (250lbs+) but its not worth the risk if they are right.

      As far as aneurysmal non-coronary sinus, not really sure if that would consider aortic root or not. Actually sounds more like cusp of the aorta v. root.

      The lifting was very consistent from three cardhiologist and a cardiosurgeon, not to mention everything i have read. Without trying to scare you, lifting is one of the fastest ways for a potential rupture. As far as cardio, i am avid cyclist and that was ok...just not as aggressive as i used to ride. they suggested Max HR around 150-155. I try to stay around 140.

      For the first year i got monitored every 6 months and then yearly.

      Hope that helps...happy to clarify anything.

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  • Posted

    Julian, you are brilliant! I am so stressed over my fast growing root aneurysm of 4.4 cm, but your info gave me some hope. I am wondering how many patients per year got PEARS surgery at London clinic? Any research about outcomes compare to regular OHS? I have a normal valve, but dilated root. Seems I can qualify. I am 50 y.o. with low blood pressure all my life. Seems this is genetic defect. Told my kids to get checked as well.

    Will be happy for any additional info.

    Thank you very much everyone.

    Elena

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  • Posted

    Thanks, Elena - I've sent you an email. Apologies to Ben for going on about PEARS when it isn't currently available in Canada, though there's clearly interest and if Canadian patients, surgeons and cardiologists want to make it happen, then the successful and expanding programmes now established at several centres in Australia and New Zealand show precisely how it can be done. The New Zealand programme started because one patient, a company CEO with Marfan, discovered the cost of a private referral to the Royal Brompton Hospital in the UK would be eye watering. He got talking, set up a local crowdfunding programme to bring over a surgeon from the UK, landed with getting two local surgeons trained, more than 20 varied patients (including himself, of course) lined up for the first operations, and it's now becoming a standard option offered to patients for whom it is likely to be of benefit. The Australian patient featured in the news report sparked by the recent launch of the Brisbane PEARS programme is a personal trainer with a bicuspid valve (there's a link on the ExStent website).

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    • Posted

      Hey Julian, no apologies necessary! I'm a dual Canadian/British citizen (born and raised in northern England and moved to Canada in 2012) so still have my NHS number and all of those documents (European Health card, not useful for much longer!) so it might be a possibility if deemed appropriate or available, it looks like a great option - thanks again for the insight into this 😃

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