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Aortic dilation, had degenerative disc disease operations. Do I need additional opinion?

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Cardiologist, Interventional
Practicing since : 1996
Answered : 192 Questions
I would like to request your opinion input analysis regarding the following description of an ascending aortic dilation that was recently accidently diagnosed about me. It has me worried. I am a 60 year old male, 5’10” in height, and weigh 180 lbs. My BSA is 2.04 and my BMI is 24.88. I have felt to be in overall good physical condition all my life with the exception of degenerative disc disease operations for my neck and lower back.
This past XXXXXXX 2011, I had a CT scan with contrast as part of testing to address a dry cough that I had. During this procedure that found a small 5mm lung nodule, it was also noted from the CT that I have a fuseform type of enlargement of my ascending thoracic aorta that they indicated in two locations as 42.5mm and two frames higher as 43.5mm in diameter. My family physician at that time recommended another CT in 6 months to monitor these findings. Because of my concern, he also referred me to a cardiologist for discussion of this. The cardiologist performed an EKG which was fine and stated that he would also perform an echocardiogram at the time of the 6 month CT.
I had the second CT with contrast in late December 2011 and the echocardiogram the very next day. The second 6 month CT scan indicated that both the lung nodule and aortic dilation as “stable” for their purposes. (The periodic cough is still with me mostly in the evening before bed. It is suspected to be caused by acid reflux and I’m going in for further ENT tests) The aortic area that was formerly noted as 42.5mm in diameter this time had a notation of 42.6mm with no additional notations. When the echocardiogram results came back and I had my meeting with the cardiologist, he showed me how he could measure the mid-ascending area as 44.2mm. Aortic walls appeared good with no indications for dissection. Other measurements on the echo for the aorta area indicate a mildly thickened normal functioning tricuspid aortic valve with no aortic valve regurgitation. There is moderate-severe Sinus of Valsalva dilation at 50mm. Sino-Tubular Junction measures 39mm, Aortic Arch measures 34mm, and Upper Abdominal location as 18mm. This Sinus of Valsalva finding at 50mm has really given me additional concern but my cardiologist doesn’t seem as concerned about this and has recommended another CT one year out for monitoring the mid-aorta, etc. I mentioned that I had read in Wikipedia that a 50mm Sinus of Valsalva aneurysm is “an indication for surgery”. cardiologist opinion is that this would be a very aggressive response at this time. The cardiologist believes my aortic condition most likely developed over many years as congenital or from atherosclerotic causes. Overall, he indicated to me that from my test results, my measurements appear as “stable” but that he wants to look at that third point of reference in a year because a mm difference on test results can also be interpreted for test difference error. I was put on a prescription for 25mg of Metoprolol Tartrate to control any periodic blood pressure issues that sometimes ranged 120-160mmHg. I have also been on 20mg Atorvastation or Lipitor for the past 10 years.
I am wondering what another cardiologist’s opinion might be for me. As I stated, I am worried about my prognosis and am hoping my measurements do not grow to a dissection or rupture emergency. I am also concerned about potential future surgery for this as I understand the procedure is quite invasive and risky. I also do not wish to be sitting on a “ticking time-bomb” when some other intervention should be considered. I would like to request your input regarding my condition, especially regarding the ascending aortic dilation and sinus of valsalva. Do you feel that I need to seek out additional opinion as to actions that need to be followed now?
For your information, the following are the full result findings indicated on the echocardiogram report that I had in December:
1.      Normal left ventricular chamber size. Calculated EF; 66%.
2.     No regional wall motion abnormalities.
3.     Grade ¼ left ventricular diastolic dysfunction, consistent with low to normal left ventricular filling pressure.
4.     Valve changes consistent with patient age at 60. Tricuspid aortic valve.
5.     Moderate-severe sinus of Valsalva dilation (diameter 50mm)
6.     Moderate ascending aorta dilation (diameter 44 mm at mid level).
LEFT VENTRICLE: Normal left ventricular chamber size. Normal left ventricular wall thickness. Normal left ventricular systolic function. Calculated left ventricular ejection fraction; 66%. No regional wall motion abnormalities. Grade ¼ left ventricular diastolic dysfunction, consistent with low to normal left ventricular filling pressure. RIGHT VENTRICLE: Normal right ventricular size. Normal right ventricular systolic function. Unable to detect peak tricuspid regurgitation velocity for pulmonary artery systolic pressure calculation. ATRIA: Borderline left atrial enlargement. Left atrial volume index 29 cc/mm2. Normal right atrial size. CARDIAC VALVES: Mildly thickened aortic valve. No aortic valve regurgitation. Mildly thickened mitral valve. Trivial mitral valve regurgitation. Normal pulmonary valve. Trivial pulmonary valve regurgitation. Normal tricuspid valve. Trivial tricuspid valve regurgitation. OTHER ECHO FINDINGS: Moderate ascending aorta dilation (diameter 44 mm at mid level). Moderate-severe sinus of Valsalva dilation (diameter 50 mm). No intracardiac mass or thrombus, but the left atrial appendage cannot be visualized adequately with transthoracic echo to exclude thrombus in this location. No pericardial effusion. Normal inferior vena cava size with normal inspiratory collapse (>50%).
Again, I thank you for any input, information, or help you can give me regardingmy health situation.
Sincerely, XXXXXXX Hofmeister
1405 Lor XXXXXXX Drive
North Mankato, MN 0000
Posted Mon, 30 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Raja Sekhar Varma 12 hours later
Hello Mr. XXXXXXX Hofmeister,

Thank you for your query.

You have given an excellent and detailed description of the problem. As I understand, you are a 60 year old gentleman on treatment for hypertension with periodic cough, a lung nodule and asymptomatic fusiform dilatation of the ascending aorta and sinus of Valsalva without any aortic valvular disease. You also have an enlarged prostate, lumbar and cervical spondylosis and you have undergone cholecystectomy and appendicectomy in the past. I assume that your blood sugars are normal and that your cholesterol levels are under control with the statin.

I hope that you are not a smoker.

The cause of the lung nodule needs to be determined. This is best done by a procedure called FNAC (CT guided Fine needle aspiration cytology) or by a thoracoscopic biopsy. The treatment would depend on the cause.

The fusiform dilatation of the aorta measures approximately 4.3 cm (CT) and the sinus measures approx 5cm (echo). Some variations may be there when different modalities are used and when measurements are taken at different times due to varying distensibility of the aorta in relation to heart rate, blood pressure, etc.

Since you are asymptomatic and there is no valve regurgitation, I too feel that there is no indication for surgery now. Surgery would be indicated if there are any symptoms of chest pain/breathing difficulty/palpitation, etc or if serial echo/CT shows a rate of progression of increasing size > 1 cm/year, or if absolute size of ascending aorta is > 5.5 - 6 cm or if sinus of Valsalva diameter is > 6cm.

Your current treatment with a beta blocker is good and you may consult your cardiologist to further optimize the dosage of the beta blocker depending on the heart rate and blood pressure. Adequate exercise, nutritious low fat diet and control of sugar, BP and cholesterol levels will also help.

I hope this answers your query. Feel free to contact me for any further clarifications.

With regards,
Dr RS Varma
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