Society of Cardiothoracic Surgeons and BAV and Aortic Root Diameter

[Robfromwales]

Interested to read on their website that with BAV they recommend surgery where aortic root is greater than 4 cm (where there is significant disease) and 5cm if valve working ok. I hadnt appreciated this and thought the guideline was 5.5 cm i.e. the same for people without BAV? Is this other people's understanding or am I misreading something?

[ClairePap]

I have always been told 5cm by my surgeon. Mine is currently 4.5cm but I’ve just had an AVR and they are hoping that this will stop it deteriorating

[Robfromwales in reply to ClairePap]

Thanks

[Robfromwales in reply to Robfromwales]

Sorry Claire but I should have asked what part of country are you in?

[Robfromwales in reply to Robfromwales]

Sorry - I should also have asked whether given I presume you had sternectomy ( sorry if spelt wrong) - was there discussion of repairing aorta at same time?

[RoyM]

I always understood surgery is considered between 5 cm/ 5.5cm I am at present being monitored at 4.9 cm my root Aorta has been at this for over three years. Long may it continue. Roy

[Robfromwales]

Thanks Roy.

[Cliff_G]

Correct that the standard figure has been 5.5 cm (and still is in various guidelines). However, this was challenged by IRAD as far back as 2007, followed by many papers pointing out that various percentages of people (IRAD 59%, the highest I've seen is above 80%) dissect before 5.5 cm is reached. There are various reasons for this, including the fact that the aorta expands around 10-20% at dissection, so measuring it post-dissection gives a false impression of the diameter just pre-dissection. Another is that the 5.5 was based on a balance of risk, of dissection/rupture/death vs that of surgery back in 1999/2002, but surgery in high-volume specialist centres is now extremly safe, whereas I think that the total downsides of dissection are life-long deterioration in QoL, various neurological issues, etc. and pre-emptive surgery generally stops this.

Not seen the SCTS post yet, but very glad it's been reduced to 5 - I dissected at 4.6 cm, based on a CT less than a year before dissection, so somewhat of a hobby-horse for me.

[Cliff_G]

Rob, have you got a link for that? Couldn't find it.

[Robfromwales]

I will take a look. Based on some further questioning I don’t think it may have officially changed so to speak. I think that the advice is that aortic surgery on an aneurysm at or above 5cm with BAV is a ‘consideration’ in discussion with a surgeon while at 5.5cm it ‘presumably ‘ should be operated on. Based on your experience you will know a lot more than me and these are only what I understand and clearly I am not medically trained. By the way - was your blood pressure controlled when you dissected ?

[Cliff_G in reply to Robfromwales]

Not really. It had been 140/90 for a long while and had crept to 150/100 and I was waiting for a hypertension clinic referral when I dissected(!) Which is another bugbear of mine. NICE guidelines say don't treat until 140/90 but they have refused to accept it needs to be lower (120/80) and urgently rectified in cases of aortopathy.

[Robfromwales]

Cliff - I think the EAS/EACTS 2021 guidelines are interesting in this regard. In essence they say that surgery considered when maximum ascending aorta diameter is at or greater than 5.5cm in all patients. Surgery consisted in Marfans and other syndromes at or greater than 4.5 cm. Interestingly with BAV surgery considered at or equal to 5 cm with additional risk factors or coarctation. Another interesting point is that if aortic valve surgery is considered, replacement root or ascending aorta considered at 4.5cm.

There are some footnotes with more specific issues but I have just sent the main headlines as I read it

[Robfromwales]

Surgery ‘ considered’ sorry not ‘surgery consisted’ !