The aorta, the largest artery in the body, is your lifeline.
Problems with the aorta can range from an aneurysm, which is a bulge in the aorta, to tears and ruptures that can be fatal without immediate treatment. Today, doctors are researching how to treat aortic problems in less invasive ways to achieve better outcomes.
Dissection and rupture
When actor Alan Thicke died of a ruptured aorta in December 2016, it started with a tear in the aorta’s inner wall, or a dissection. Aortic dissection occurs in about two of every 10,000 patients and is most common in men ages 40 to 70, according to the National Institutes of Health.
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“A dissection is considered a surgical emergency,” said Edward Savage, director of the Heart & Vascular Center at Cleveland Clinic Florida. “When people come to the hospital, about 50 percent could potentially die within 24 hours, because it could lead to a rupture and compression of the heart.”
Symptoms of dissection and rupture are the same: acute, sharp chest pain. “Usually with a dissection you notice it first in the front of the chest, and then typically up toward the head then down the back, but it doesn’t have to be that way,” Savage said.
Dissection can occur in people with normal size aortas or those with aneurysms, an enlarged aorta. Doctors can measure the size of aortic aneurysms above the heart and operate prophylactically if needed, Savage said.
“It’s really hard for us to say who with a normal aorta might have a problem, but we do know the bigger the aorta, and the more aneurysmal it is, the higher the likelihood that you will have an event,” he said.
Chest aneurysms can’t be felt during a physical exam because of your rib cage, Savage said. They are often detected through chest X-rays, CT scans, an ultrasound of the heart or other imaging while looking for other things, he said.
Certain people are predisposed to having aneurysms, such as those with a family history or a connective tissue disorder like Marfans syndrome, which often affects the heart, blood vessels, bones, joints and eyes.
If you are in a risk population, keep blood pressure in check, stop smoking and do things in moderation, like avoiding heavy lifting and straining. If you lift weights, light weight-lifting for toning is okay, Savage said.
Aortic root aneurysms
The aorta has multiple parts, and the aortic root is where it really starts, at the intersection of the heart and the aorta, said Dr. Steve Xydas, chief of cardiac surgery at Mount Sinai Medical Center in Miami Beach. If you have an aortic root aneurysm, the valve that is part of that system must be replaced or repaired.
Traditional surgery involves replacing the aortic valve. But a newer surgery, valve-sparing aortic root repair, treats the aneurysm while repairing the valve. The technique has been done for about 20 years but has been perfected in the last decade, Xydas said.
“Valve-sparing root repair been done consistently over the past 10 years with excellent results, and now the data is showing its durability and superiority versus other options,” he said. “We’re seeing benefits like lower mortality in patients who have had a repair versus a replacement.”
Mechanical valves are durable but require a patient to take blood thinners like Coumadin or Warfarin for the rest of his or her life. “That affects quality of life, because you don’t just take Coumadin once a day and forget about it,” Xydas said. “The dosing varies, so you always have to be in a strict range.”
Forgetting medication can lead to a clogged valve or a stroke, and blood that is too thin can cause internal bleeding.
The best candidates for valve-sparing root repair are patients with large aortic root aneurysms who are middle-aged and younger.
“It is more complex and you have to see an experienced surgeon,” Xydas said. “There can be failures. The valve can start out competent, but over time the repair can break down. With the newer technique, in an experienced center, there is about a 3 percent chance of repair failure lifetime versus a replacement tissue valve.”
Xydas has recently started an aortic aneurysm clinic at Mount Sinai. After being diagnosed, a patient still sees his or her primary-care doctor or cardiologist but can be evaluated by a surgeon, learn about dos and don’ts, and compare imaging year to year.
Aortic stenosis is a narrowing of the aortic valve opening that restricts blood flow. It causes the valve not to open properly so blood backs up into the heart and, ultimately, the lungs, said Eduardo de Marchena, an interventional cardiologist with the University of Miami Health System. “With this type of diseased valve, you can’t avoid replacing the valve,” he said.
The most common form of aortic stenosis affects patients ages 50 and older. Some aortic stenosis can happen earlier due to a condition called a bicuspid valve. Symptoms are shortness of breath, chest pain and potentially loss of consciousness.
In the early 2000s, doctors started to research how to change the aortic valve without opening the chest and doing open-heart surgery, de Marchena said. They began studying a minimally invasive procedure called transcatheter aortic valve replacement, or TAVR.
The technique threads a catheter through the major plumbing of the body, the arteries, he said. The catheter is used to inflate the blocked valve, then a new valve is placed at the site of the old diseased valve. The procedure requires fewer days in the hospital and fewer transfusions, de Marchena said.
“It’s a major step forward in that it’s so much less invasive,” he said.
The University of Miami began studying TAVR in 2008. “When the FDA approved it in 2012 for high-risk patients and those who were not a good candidate for surgery, we were already doing several types of valves.”
In 2016, one of the valves was approved for intermediate risk patients and is now standard practice, he said.
“Now we’re going one step further. We’re studying, under a large FDA trial, whether patients who are at low risk for surgery could benefit from TAVR, making it a therapy we could use in a large number of patients,” de Marchena said.
One disadvantage is that valves replaced using the TAVR method tend to have a bit more leak than surgical valves, but it doesn’t seem to have a clinical consequence, he said.
For Bruce Kirsch, 62, of Deerfield Beach, the TAVR procedure was life-changing. Kirsch had his aortic valve replaced through traditional surgery in 2006. Years later, when it became blocked again, he joined a clinical study at the University of Miami and had the TAVR procedure in 2014.
“It was amazing. For the first valve replacement, I was in the hospital for a month,” Kirsch said. “With the TAVR method, I was in the hospital for two days and got out on the third day. Dr. de Marchena saved my life. There is no way they could have cut me open again.”