DR. MARK J. RUSSO, MD, MS

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Aortic Root Aneurysm

What is an aneurysm?

An aneurysm is an abnormal dilatation of the wall of a blood vessel that is  50% greater than the artery’s normal diameter (width). An aneurysm may be located in many areas of the body, such as the blood vessels of the brain, the aorta (the largest artery in the body), the intestines, the kidneys, the spleen, and the vessels in the legs.
 

 

What is the aortic root?

The aortic root, the first part of the aorta, begins just above the top of the main pumping chamber of the heart (the left ventricle).  The root of the aorta includes the aortic valve and the origin of the coronary arteries.  This valve prevents blood pumped out of the heart from leaking (or regurgitating) back into the heart when the heart relaxes.  The coronary arteries allow blood and oxygen to flow to heart muscle.

The valvular apparatus of the aorta begins at the aortic annulus and extends to the sinotubular junction. Most commonly Between each commissure of the aortic valve and opposite the cusps of the aortic valve, there are three small dilatations called the aortic sinuses.  The sinotubular junction is the point in the ascending aorta where the aortic sinuses end and the aorta becomes a tubular structure.


What is an aortic root aneurysm?

The aorta is the most common place for aneurysm.  In an aortic root aneurysm, the most proximal potrion of the aorta becomes dilated
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Ascending Aortic Aneurysm
 

 

What are the causes of aortic root aneurysms?

Causes of aortic root aneuryms may include, but are not limited to, the following:

  • cystic medial degeneration (necrosis): breaking down of the tissue of the aortic wall. This is the most common cause of this type of thoracic aortic aneurysm.
  • genetic disorders which affect the connective tissue, such as Marfan’s syndrome and Ehlers-Danlos syndrome
  • family history of thoracic aortic aneurysm with no incidence of Marfan’s syndrome
  • atherosclerosis: hardening of the arteries caused by a build-up of plaque in the inner lining of an artery. This is a rare cause of ascending thoracic aortic aneurysm.
  • infection, syphilis (rare causes of thoracic aortic aneurysm)
 
FAQ

What is an enlarged aorta?  
An enlarged aorta is also known as an aortic aneurysm…

What is transcatheter aortic valve implantation (TAVI)?  
TAVI also known as transcatheter aortic valve reimplantation (TAVR)…

Can I exercise if I have an enlarged aorta, aortic aneurysm, or chronic dissection?  
Though some types of exercise should be avoided, exercise is generally encouraged…

Who should be screened for an aortic aneurysm?
Most people with aortic aneurysms experience no symptoms…
 

 

Why does an aortic root aneurysm need to be treated?

An aneurysm may continue to increase in size, along with progressive weakening of the artery wall, surgical intervention may be needed. 

The valve may become leaky (aka regurgutant) as a result of enlargement (or dilatation) of the aortic annulus.  This may also result from structural defects in the valve leaflets.  Conversely, the valve may become narrowed (or stenotic) resulting in the restriction blood flow.Either of these conditions may require treatment.

Preventing rupture of an aneurysm is one of the goals of therapy. The larger an aneurysm becomes, the greater the risk of rupture (bursting). With rupture, life-threatening hemorrhage (uncontrolled bleeding) may result. 
 

 

What are the symptoms of an aneurysm?

Aortic disease is often insidious. Most people with aortic aneurysms experience no symptoms, unless they are extremely large or an aortic dissection occurs. For most people, their aortic condition is discovered incidentally while being tested for other reasons.  

When present, symptoms may occur with different types of aneurysms may include, but are not limited to, pain in the jaw, neck, chest and/or back; wheezing, coughing or shortness of breath; hoarseness or difficulty swallowing.  The symptoms of an aneurysm may resemble other medical conditions or problems, including heart attacks, pneumonia, and digestive conditions. Always consult your physician for more information.
 

 

How are aneurysms diagnosed?

For most people, their aortic condition is discovered incidentally while being tested for other reasons.  For patients suspected to have aortic disease, selection of a type of diagnostic examination is related to the location of the aneurysm. In addition to a complete medical history and physical examination, diagnostic procedures for an aneurysm may include any, or a combination, of the following:
  • computed tomography scan (also called a CT or CAT scan): a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce cross-sectional images (often called slices). A CT scan shows detailed images of any part of the body, including the bones, muscles, fat and organs. 
  • magnetic resonance imaging (MRI): a diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
  • echocardiogram (also called echo): a procedure that evaluates the structure and function of the heart by using sound waves recorded on an electronic sensor that produce a moving picture of the heart and heart valves.
  • arteriogram (angiogram): A dye (contrast) will be injected through a thin flexible tube placed in an artery. This dye will make the blood vessels visible on the X-ray.
  • ultrasound: uses high-frequency sound waves and a computer to create images of blood vessels, tissues and organs. An ultrasound is used to view internal organs as they function, and to assess blood flow through various vessels.
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Aortic Root Aneurysm and Asceneding Aortic Aneurysm on CT Scan
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Aortic Root Aneurysm and Ascending Aortic Aneurysm on CT Reconstruction
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Aortic root aneurysm on echocardiogram
 

 

If my aneurysm is not causing symptoms, why do I need surgery?

The objective of surgical repair of an aneurysm is to treat or prevent potential complications related to the aneurysm. These include:
  • heart attack
  • aortic valve regurgitation
  • heart failure
  • hoarseness due to left vagus or left recurrent laryngeal nerve compression
  • diaphragmatic paralysis due to phrenic nerve compression
  • difficulty breathing due to airway compression
  • difficulty swallowing due esophageal compression
  • swelling of the head or arm due superior vena cava syndrome
  • blood clots
  • aortic dissection
  • rupture of the aorta

In addition, the risk of  aortic catastrophe, including dissection and rupture, increases dramatically after the aneurysm reaches 5 centimeters.Surgery is generally recommended when the proximal aorta is larger than 5 centimeters.  However, depending on other factors, including other vascular conditions or the need for additional surgery (particularly heart surgery), this threshold varies with individual patients.


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Specific treatment will be determined by your physician based on:
  • age, overall health and medical history
  • size and extent of the disease
  • signs and symptoms
  • tolerance of specific medications, procedures or therapies
  • expectations for the course of the disease
  • patient preference
 

 

What are surgical treatment options?

At RWJ, surgery on the proximal aorta is performed using antegrade cerebral perfusion (ACP) via axillary cannulation. Traditionally, surgery on the proximal aorta required complete circulatory arrest, which leaves the patients without blood circulation for a period of time. The method of ACP used enables surgeons to maintain the flow of blood to the brain and other part of the body throughout the operation. It has been shown to be safer than traditional approaches, specifically decreasing the risk of stroke and other neurological injury. 

Surgical Options for Aortic Root Aneurysms:
Valve-sparing root replacement: When the aorta is dilated but the aortic valve is otherwise normal, the aortic can be fixed while preserving the valve. This avoids the need for a valve replacement with an prosthetic valve as well as the potential need for blood thinning medication.

Biological composite aortic graft: The aortic root and valve is replaced with a bio-prosthetic valved conduit. This has a number of potential advantages, including the avoidance of the need for blood thinning medications.
aortic root replacement with tissue valve aortic graft and coronary reimplantation

Mechanical valve conduit: Also called the “modified Bentall” operation, this approach is often used in younger patients or in those patients who wish to avoid reoperation. The entire aortic root and aortic valve is replaced with a combination of a mechanical valve within a graft conduit.  However, anticoagulation therapy is required.  

Homograft root replacement:  The aortic root is then reconstructed using cadaveric human (homograft) aorta. This eliminates the need for blood thinning medication and may provide superior blood circulation and valvular function, thus providing a longer period of freedom from reoperation than animal tissue alternatives.