Discussion about Aortic Aneurysm Dr. Birdi

[Alisbabas]

Interesting discussion on aneurysms in the aorta

youtu.be/68TN5Tm69a0(Not working as expected?)

[JulianM]

I've watched this video and I'm unimpressed. It seems to be a promotional thing for some private clinic which, based on what is said, I could not recommend.

The doctor mentions guidelines but doesn't say what guidelines he is actually referring to.

This is important because a major revision of international guidelines was published last year (2022) by the American Heart Association and American College of Cardiology - acc.org/Guidelines/Hubs/Aor...

When you read those guidelines, you will find that the doctor's talk DOESN'T MENTION the key criterion in those guidelines for deciding between a threshold of 5.0 and 5.5 cm for intervention in ascending aortas.

This criterion is whether the centre that is offering surgery has a multidisciplinary aortic team and is regularly performing the operations in question: if so, then it is reasonable to offer surgery at 5.0 cm; otherwise, 5.5 cm.

The doctor does mention genetic and family history as a reason for earlier surgery, but doesn't discuss how to access genetic testing or that imaging may be offered to close relatives of people with ascending aortic dilation or dissections. This is another key part of the latest guidelines.

So, what outfit is this doctor promoting and what volume of aortic operations do they do, with what results? The video isn't helpful and his suggestion that the ascending aorta might be replaced with transplanted donor tissue doesn't inspire confidence.

The fact that the word 'keyhole' flashes up on the screen also doesn't inspire trust: ascending aortic surgery does come in several varieties but keyhole surgery is pretty much limited to valve replacement.

[Alisbabas in reply to JulianM]

Hi JulianM,

Yes I think you're right, I was just wondering and researching as I'm short and looking to see whether my intervention would be earlier? I'm still not fully educated about all of this as I've not had much information from my Cardiologist.

Thanks

Ali

[JulianM in reply to Alisbabas]

The question is worth discussing with a consultant cardiothoracic surgeon working in a multidisciplinary aortic team. Basically, you are right. The guidelines say this:

4. At centers with Multidisciplinary Aortic Teams and experienced surgeons, the threshold for surgical intervention for sporadic aortic root and ascending aortic aneurysms has been lowered from 5.5 cm to 5.0 cm in selected patients, and even lower in specific scenarios among patients with heritable thoracic aortic aneurysms.

5. In patients who are significantly smaller or taller than average, surgical thresholds may incorporate indexing of the aortic root or ascending aortic diameter to either patient body surface area or height, or aortic cross-sectional area to patient height.

(There's a great deal more in the guidelines, which are fully referenced to the research on which they are based. So, you'll find there is a body of research, especially out of the Aortic Institute at Yale, much of which is publicly available, which backs up this recommendation in the guidelines. Search on the name of John Elefteriades, the surgeon who founded the Institute, and you'll see them. But the key ones are those referenced in the latest guidelines,)

[Adhtz21]

Morning Alisbabas. Thank you so much for this video…do you please have a link to the one how to use the chart as mentioned in the video? I had surgery in 2020 but between 21/22 my aorta dilated by 2cm on the rising part and 1cm on the arch. I was not too worried until I saw this video. 0.5cm growth over the year suggests surgery. I was on annual monitoring (only at my doing) and suddenly got called for a 6 month CT Scan rather than a year. Might be because I have a complaint running with the GMC over a local Cardiologist who did nothing with this information. Thankfully, due to my persistence I have moved hospitals. Kind regards, Andy

[Alisbabas in reply to Adhtz21]

Hi Adhtz21,

No sorry I found the link on another valve forum but like JulianM said above it may just be a promotional video. I'm still learning as I've not had surgery yet as I'm not at that stage.

Take care

Ali

[Adhtz21 in reply to Alisbabas]

Ali, promotional or not as the case may be, from previous experience of when my surgery took place (NHS), I believe it’s factual. Andy

[JulianM in reply to Adhtz21]

The guidelines I linked to in answer to Ali do clearly set out the growth criteria for aortic root and ascending aorta. 5 mm or more in a year is a strong case for surgery, unless there's good reason to believe it's a measurement error.

With the arch, things get more complicated because surgery on the arch is higher risk than on the root and ascending aorta. But if there is clear evidence of 1 cm growth in a year, that should definitely be followed up: shifting to 6-monthly scans makes complete sense to me.

A lot depends on what your previous surgery was and on the wider picture of your health and what may be going on. It's something that only makes sense to discuss with medical specialists who have full access to your records.

[Adhtz21 in reply to JulianM]

Thank you Julian. I really appreciate it.

Firstly, I must correct my error…2mm dilation of my ascending aorta and 1mm on the aortic arch over one year. Sorry!

My situation was surgery just before the onset of the pandemic. No face to face consultations as follow up. No cardio rehab.

I did have a CT Scan with contrast dye and an echocardiogram. All ok. So discharged to local cardiologist. Now that is where everything went wrong. Whilst I have no issue with the surgical team at their hospital, locally at ours, it was a sham. The consultant wanted telephone reviews. The first year, she was nigh on useless and I got into a bit of a disagreement with her over follow up. The next year came and again she wanted a telephone review. These were arranged and cancelled by her 5 consecutive Mondays. I contacted the Surgeon who had performed my operation (first rate chap now retired) and he personally arranged for me to get a new local Cardiologist. This was to be face to face. I attended, the guy showed no interest whatsoever, was very poorly prepared, sat fiddling with papers, asked a question but then cut me off. I’m a respectful person but his manner made me rather annoyed so I spoke my concerns. He then sent me for an echocardiogram.

The echocardiogram result was sent to him. He wrote a brief covering letter sending the report to my GP. The report gave a new diagnosis of dilated aortic arch and a measurement. The GP practise filed the letter as the consultant had not specifically requested any action and the named GP never saw it (allegedly).

Fortunately for me I checked the NHS app. I saw a summary of the result but could not see the report itself. I therefore obtained a copy from my GP surgery.

The report was concerning and as I had lost confidence locally, I contacted the surgical registrar who kindly sent me for a CT scan with contrast dye - gated. This showed the dilation of 2mm on the ascending aorta and 1mm on the arch. They immediately agreed to monitor me on a 12 month CT scan. Fortunately after persisting two GP’s at my practise, the second one referred me to my surgical hospital to be allocated a new cardiologist.

As the local consultant had not done any follow up, I have a complaint running with the BMA.

My plan was annual CT with contrast dye - gated by surgical registrar and two yearly echocardiogram and follow up with Cardiology.

Suddenly now the BMA are involved, I had an earlier than expected 6 month CT scan for which I am currently awaiting the result

I do have other issues which have developed post surgery over the last 1-2 years :-

1. Blood pressure was often high despite lots of meds. Surgical team said keep it as low as possible and that my Cardiologist and GP should manage it The (local) cardiologist sent me for an ambulatory blood pressure 24 hour monitoring. The report showed higher blood pressure than commensurate to my bioprosthetic aortic valve and graft. He did nothing apart from sending a copy to my GP. No plan was included. The GP wanted a plan but clearly could not be bothered to write requesting one. So the dire circle of incompetence continued. I should point out the salary taken by my local GP as published is circa £126,000.00 per annum!!!

2. Grade 1 Heart Block. Suddenly, my apple watch was alerting of low heart rates often my resting heart rate was 49 sometimes as low as 42 GP (1) was useless. I self reduced my Bisoprolol by half 2-5mg to 1.25mg GP (2) actually did his job well and referred my to a different hospital

This is why I say its paramount to do your own research and to not sit back thinking others will look after you

[JulianM in reply to Adhtz21]

Hi Andy - yes, that is a very different picture! It sounds to me that getting your blood pressure under good control is the priority, with a focus on finding the right combination and dosages, ideally with a beta blocker and an ARB, and doing what you can about lifestyle and diet, which is where the guidelines direct us. There's a question mark over calcium channel blockers, which may not be suitable with some genetic conditions.

1mm over a year is not an immediate concern. Measuring the aorta is always challenging because it's a flexible elastic tube that changes size with every heartbeat, so the accuracy of individual measurements is +/- 2mm, and it's important to compare like with like. Because of the measurement issue, anything less than 5mm in one year, or 3mm in two successive years, isn't automatically taken as growth.

CT scans and/or MRIs with ECG gating are the most accurate, provided they are read by a specialist who knows what they are doing, though if you're lucky (as I am) echos can give a fair guide when things are stable. My current monitoring, 5 years in and at 4.8cm, is an MRI every 2 years with an echo in between.

I've had both telephone clinics and in-person ones: it all depends on the person at the other end of the line! When they know what they are talking about, have read the notes, and have good scans to refer to, they can be great, in my experience. All the best!

[Adhtz21 in reply to JulianM]

Hi Julian, I’m now on additional Doxazosin 2mg and now additional 2mg afternoon following review by GP.

[JulianM in reply to Adhtz21]

There's some evidence that in aneurysmal disease, both beta blockers (such as bisoprolol) and angiotensin-II receptor blockers (I'm on low dose irbesartan, even though my blood pressure is normal and steady) can slow the rate of enlargement and reduce the risk of aortic dissection. On the other hand, there are some genetic mouse studies, backed up with a bit of clinical evidence, that calcium channel blockers may do the opposite. The ARB and CCB effects are both thought to be due to influence on signalling pathways that control arterial wall repair, rather than their effect on blood pressure - but if you have a dilated aorta, you do need to aim for a lower blood pressure target than would be set for most people. Doxazosin is an alpha blocker, so it shouldn't be a problem, and if it gives you good results without serious adverse effects that sounds good to me, but I'm definitely not a doctor and there's a great deal I don't know about BP meds! Does sound like the GP is doing their job now.

[Adhtz21 in reply to JulianM]

Hi Julian, I’ve been on ACE inhibitors for years. Perindopril 8mg now. I assume this works similarly to the ARB you mention? KR, Andy

[JulianM in reply to Adhtz21]

No, ARBs are a separate category of drug from ACE inhibitors. The original and most widely used ARB is losartan; irbesartan as I understand it may have better pharmacokinetics and was picked for the AIMS trial which BHF funded and showed some effect in people with Marfan; these two are the ones most studied in clinical trials, but there are a few others around - and they all end in 'sartan'.

[JulianM in reply to JulianM]

The interest in ARBs in aneurysmal disease is because blocking the angiotensin II receptor has an effect on the transforming growth factor beta (TGF-beta) signalling pathway which is disrupted - and becomes over-active - in several of the genetic aortic diseases. The thinking in my own case - where we think the problem is genetic, but I've had genetic testing that has excluded all the known high risk conditions - is that, even if my TGF-beta signalling isn't disrupted, damping it down could still help reduce my risks. But this has nothing to do with any ARB effect on my blood pressure: I monitor my BP very closely and it has not really changed at all since I've been on it. However, at higher doses than I'm taking, ARBs can and do reduce blood pressure.

[Adhtz21]

Alisbabas…located it thanks.

[Alisbabas in reply to Adhtz21]

Can you send it me via a message please Ali

[Adhtz21]

Ali, here is the link to the Dubois calculation he uses. I will try to locate the video again. One minute. Personally, I think this is excellent stuff to know. I was extremely well researched pre my surgery which helped me when meeting the Surgeon.

e-echocardiography.com/page...

[Adhtz21]

Ali, here is the video link

youtu.be/NTJNbkefmTc(Not working as expected?)

[Petercat1]

Hi. Thanks that was very helpful and informative.

Best wishes

Denise

[Tedthedog]

thank you for sharing that, I thought it was informative