Tuesday, December 30, 2014

The Risk Of "Smaller" Aortic Aneurysms

CT scan of my aortic aneurysm

Aortic dissection is a medical emergency. Those of us with BAV have to be concerned if we have an accompanying aortic aneurysm, even if the aneurysm is relatively small. Consider the results of this research:

IRAD (International Registry of Acute Aortic Dissection) produced a paper entitled: “Aortic Diameter > 5.5 cm Is Not a Good Predictor of Aortic Dissection” in the journal Circulation in 2008...investigators found that an astounding 60% of acute aortic dissections occurred in aneurysms that measured less than 5.5 cm at the time of diagnosis, 40 % in those that measured less than 5 cm, and approximately 25% at sizes less than 4.5 cm... investigators do not give us guidance on why thoracic aneurysms can and do rupture or dissect at these 'smaller' sizes, but it is important to recognize that they can and that we take them seriously in terms of risk stratification and counseling.

The new 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease acknowledges the risk. Here is the recommendation for patients with BAV undergoing AVR:

Class IIa2.Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR (4.2.3and5.3.3) if the diameter of the ascending aorta is greater than 4.5 cm. (Level of Evidence: C)

Sunday, December 28, 2014

TEE Bicuspid Valve

The images from a TEE (trans-esophageal echocardiogram) are rich in detail. I can see why the TEE is the gold standard for evaluating heart valve disease. This is a video that I made from my TEE and it shows my stenotic bicuspid aortic valve.

Sunday, December 21, 2014

In the Interim: Waiting For Surgery

There is the tendency to spend too much time looking up medical terms, watching medical videos, etc. When I was in the hospital I watched videos of each procedure I was to have prior to getting it. My husband Dan thought I was crazy and that I was making myself into a basket case. But I feel that it helps to be in the know. For example, I think it helped me to warn physicians that I would have a problem tolerating a closed MRI and that my swallowing difficulty meant that I would likewise have problems with the TEE. Bottom line is that they knocked me out for both and I did fine. OTOH, watching a video of the new through-the-wrist cath technique lessened my apprehension about that procedure as soon as I found out that they would do it that way for me.

I don't spend all of my time doing research. I am back to taking my two one-hour walks each day, and I spend time with my trains and doing holiday things too. But I also have to be an informed patient and come prepared when I meet with my surgeon candidates. Therefore I do some amount of research every day. The other day I watched a video of what I believe will be very similar to my surgery: minimally invasive isolated aortic valve replacement. Here is the link to page with the video:


Now, a lot of things have to fall into place in order for me to get this minimally-invasive AVR option, but it's what I am hoping for. This is because minimally invasive surgery is less stressful and recovery times are shorter. On Tuesday I get a CT chest scan to assess the size of my ascending aorta. If the aneurysm is too large and needs surgical attention, then I suspect that a minimally invasive approach will be ruled out for me. However, last time it was measured it was dilated but stable. 4.5 cm is the cutoff...mine was at 4.2 cm. So we'll have to see.

The other issue is the surgeon...does he do mini-sternotomies....if so has he done a lot of them? This brings me to the whole issue of preferred surgeon and hospital. If I had my wish I would have my procedure at the Cleveland Clinic. That is the platinum standard in the US for heart surgery. Sure, I will probably get excellent care and an excellent outcome in Philadelphia, but Cleveland sets the standard for the nation. It is their website that I go to for information, videos and explanations. I have been following their renowned surgeons for years. I even have a favorite surgeon there. Dr. Roselli. I would go with him in a heartbeat (mine! :) But I live in Philadelphia so I'll try to be satisfied with someone here. Hopefully I'll find someone...either the surgeon my cardiologist recommended, or someone else. Luckily, I have time, although the clock is ticking and I definitely don't want another heart attack or stroke.

I just spent a week in the hospital. The curious thing is that nothing was done to correct my problems. Just a lot of testing but at the end of it all, I was discharged with no therapy having been done. They figured I had coronary artery blockages. I was pretty sure I didn't. I was right. You could almost feel the disappointment of the lead doctor responsible for my care when he told me I was being discharged. There was nothing he could do for me. I needed AVR, not CABG or a stent. So that's where we are!

I am really enjoying being home and playing with my "son" Loki. As a dog person, I never thought I would be so close to a cat. He's on my desk all day, we take naps together, we sleep together...we're hardly ever separated when I'm in the house. Dan has been just wonderful and our friends have been very supportive. Life is good. We'll make it all happen.

Sunday, December 14, 2014

Tests Recap Hospitalization December 9-16, 2014

I was admitted to the University of Pennsylvania hospital on Wednesday, Dec. 10 and discharged Tuesday, December 16, 2014. I had the following tests:

Dec. 09: Chest X-rays (2)

Dec. 10: echocardiogram (AM); CT brain scan (PM)

Dec. 11: Brain MRI (PM)

Dec. 12: contrast X-Ray series esophagus (PM)

Dec. 15: TEE and cardiac cath

Scheduled for December 23 (out patient): CT angiogram chest.

A carotid ultrasound was deemed not necessary.

Friday, December 12, 2014

Hospitalization Chronology December 9 - 16, 2014

Tuesday evening, December 9... I was in the basement in our home on Aspen Street in Philadelphia working on my model trains. I was not exerting myself. At around 5 pm an episode of chest and throat tightness and palpitations came on me. I began to feel poorly. I stopped what I was doing and decided to try a short walk outdoors with our dog to see if the air and walking might help me feel better until the episode passed. However, I still felt bad after returning from the walk. In addition to the chest and throat pressure and malaise, I noticed some problem with the peripheral vision in my right eye. I sat on our sofa and alerted Dan that I was in distress and that I felt it advisable to go to an ER that specializes in stroke. We discussed the options in terms of hospitals. We opted to take a taxi cab to HUP, the hospital of the University of Penn Pennsylvania, since we are familiar with it. Upon arriving at the ER I explained my condition and I received immediate attention. I was in significant discomfort but a nurse provided me with two Nitroglycerin pills. These made me feel much better. A blood sample was drawn and I was placed in an observation room for the night.

Wednesday morning, December 10... at 4 AM I was admitted to the hospital and given a room 1169 in the CICU (Cardiac Intermediate Care Unit) on the 11th floor of HUP. I was put on a variety of anti-coagulants including an IV Heparin drip, and Plavix and Aspirin orally. Blood tests had revealed a low level of Troponin, an indicator of heart muscle damage or stress. Weary from the episode and lack of sleep, I tried to get naps whenever I could. I was scheduled for tests including an echocardiogram, which I got Wednesday morning, and a heart catheterization. Being out of my room for most of the day, I missed the visit of the care team and so I was lacking information about my condition. Later my nurse told me that my troponin levels were trending up. In the afternoon I was taken to the cath lab and prepped for the procedure. However, when my attending Cardiologist, Dr. Witlack, learned from me about my vision abnormality that I reported as happening at the same time as my cardiac episode, he decided to have the vision issue evaluated prior to the heart cath for safety in case there could be loose embolisms floating somewhere. So the next test I had was a CT scan of my brain. That ended the tests for the day so I was finally able to eat a small meal, my first solid food since Tuesday mid day.

Thursday, December 11... I found out that, while the CT brain scan was negative, neurologists wanted further detailed evaluation of my brain so three MRI studies were ordered. I finally spent 45 minutes in an MRI machine in the afternoon under significant sedation due to my claustrophobia. No further tests that day so I was able to have a nice salad for dinner courtesy of Louise and chocolates that Dan bought for me. The same morning Dan and I were able to speak with the attending physician's substitute and his team. We asked various questions about troponin levels, why was Lipitor prescribed (ad a precaution,) the cath will evaluate the coronary arteries and the aortic valve. A post release plan will be provided. If the aortic stenosis is believed to be the cause of my episode, options include scaled back activity or AVR. Options were not discussed in the event of coronary artery disease.

Friday, December 12... A cardio physician named Mike visited to explain that the brain MRIs show several small strokes which could be older or could account for the vision loss I experienced Tuesday during my episode. He mentioned the possibility of additional heart studies to determine whether something is being thrown off that could cause the strokes. My cardiac cath was scheduled for that afternoon, but it was decided that I should have a TEE before the cath to insure the safety of the procedure. A further glitch was my history of difficulty in swallowing. This made it necessary to schedule a series of contrast X-Rays of my esophagus to insure that there were no abnormalities. I had the X-Rays done Friday afternoon. The TEE and cardiac cath were pushed off until after the weekend.

Saturday and Sunday December 13 and 14th... Various meetings with doctors took place. In addition to the TEE and cath scheduled for Monday, there may be a full chest CT scan ordered for later in the week. Two days must pass in between the cath and the CT scan to allow contrast media to dissipate from my system. Also pending is a carotid artery ultrasound.

Monday December 15...I had a TEE and cardiac cath back to back. The cath was negative for coronary artery disease. The heparin drip was ended.

Tuesday December 16...discharge day. AVR is recommended. A CT Angiogram is scheduled. Left the hospital mid afternoon with copies of all of the imaging. RX for nitro glycerin, 40 mg Lipitor and daily baby aspirin.

Thursday, December 11, 2014

Time For AVR?

Well, the crap seems to have hit the fan finally. Ten years after being diagnosed with BAV and AS, on Tuesday I had a fairly severe episode of chest pressure and malaise. Went to the ER and I was admitted after bloodwork showed troponin levels. Today I'm waiting for my cath. My echo still shows a mean gradient in the 30s but troponin would signal damage. So if I have s problem caused by cad, that's one thing, but I don't personally think it's that. If OTOH it's valve-related, then it's time for surgery. I'll know more soon. Anyway, season's greetings to everyone from this long time waiting roomer. Jim Kelly-Evans