Aortic diseases

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Symptoms

Aortic aneurysms may occur asymptomatic or with a variety of symptoms.

Symptomless aneurysms that do not cause discomfort are usually detected by the cardiologist at routine examinations such as ultrasound or when diagnosing other diseases.
Symptomatic aneurysms are characterised by pain in the region where they occur; in the chest or abdominal cavity. Chest aneurysms sometimes cause pain that radiates to the back, often associated with hoarseness and haemoptysis, severe weakness and shortness of breath.

An aortic aneurysm of the abdomen is often manifested by pain in the lumbar sacral area, which radiates into the perineum area. When large aneurysms occur, the patient has a “pulsation” in the chest or abdomen, and the cardiologist can then usually feel a pulsating tumour through the skin. Most symptoms worsen after increased physical exertion and increased blood pressure.
Aneurysms are commonly divided into bag-shaped and spindle-shaped aneurysms. The former, which look like a small pouch from the artery wall, burst more often. Spindle glands are seldom a source of bleeding, rarely burst, form thrombi, which often lead to an ischemic stroke in the brain stem.

Regurgitation of the aortic valve may be asymptomatic over a longer period of time. Usually the patient complains of chronic, unfounded fatigue. An acute, chronic form of aortic valve outbursts usually manifests itself:

- frequent feeling of shortness of breath,

- difficulty breathing,

- poor physical performance,

- chest pain,

- Heart palpitations,

- dizziness and fainting due to temporary ischaemia of the brain,

- the large difference between systolic and diastolic blood pressure in blood pressure measurements.
Aortic valve stenosis leads to similar symptoms:
- Pain,

- Fainting, dizziness,

- Heart palpitations,

- pulmonary oedema, difficulty breathing,

- poor physical performance,

- visual disturbances as a result of insufficient blood circulation to the brain,

- Auscultation phenomena; Noises that the cardiologist may detect during a stethoscope examination

and others.
Unfortunately, the first and only symptom of an undetected disease is sudden cardiac death. This may occur in both ruptured aneurysms and other aortic diseases in which ventricular fibrillation or pulmonary oedema occur.

Reasons for occurrence

The main causes of aortic aneurysms are:

- the result of atherosclerotic processes,

- hypertension,

- aortic regurgitation,

- physical injuries,

- sudden, strenuous physical exertion,

- complication after chronic inflammation,

- congenital defects of the aorta of genetic origin (e.g. in people with Marfan syndrome),

- rheumatoid arthritis (RA),

- chronic obstructive pulmonary disease (COPD),

- syphilis.
The likelihood of aortic aneurysms increases with age, and it affects men more often. Cigarette smoking has a negative impact that may contribute to the appearance of aortic aneurysms.
A similar pathogenesis is found by a cardiologist in the case of aortic regurgitation or stenosis.

Reasons for aortic regurgitation:

- atherosclerosis, degenerative changes with secondary calcification,

- post-infection complications, especially in the case of endocarditis, rheumatic diseases such as rheumatoid arthritis (RA), rheumatic fever, ankylosing spondylitis,

- congenital defect (in about 1% of patients).

The causes of aortic stenosis are also usually age-related acquired defects, sometimes caused by rheumatic disease or infections. Genetic defects are found also rarely by a cardiologist, in 1% of respondents. Sometimes the causes of these diseases are not recognized.
Factors influencing the process of aortic valve degeneration include:
- untreated hypertension,

- cardiovascular diseases (dislipidemias),

- diabetes,

- hyperparathyroidism,

- kidney failure,

- overweight, sedentary lifestyle,

- smoking tobacco,

- advanced age.
Diseases of the aorta affect men more often, although they also occur in women and children.

Diagnostics

Very often, aortic aneurysms, especially small and asymptomatic, are diagnosed accidentally, during tests carried out in connection with other diseases and ailments.

When aortic aneurysm is suspected, the echo of the heart is usually performed first. Thanks to this examination, the cardiologist can diagnose aneurysms of the ascending aorta and the aortic arch, i.e. located in the thoracic area. Other tests to determine the presence and size of the aneurysm include:

- ultrasound,

- computed tomography,
- magnetic resonance imaging,

- angiography.

An abdominal aortic aneurysm is usually more easily diagnosed than a thoracic aortic aneurysm. If it is large, often a cardiologist can detect it during a palpation of the abdominal cavity.

When it comes to aortic regurgitation, a cardiologist usually first suspects during a stethoscope examination; if he finds characteristic abnormal diastolic murmurs. Also, blood pressure measurements showing a large difference between systolic and diastolic pressure may be the basis for further research.
The cardiologist then usually orders:

- electrocardiographic examination (ECG) - it may show features of left ventricular hypertrophy and overload, and ventricular arrhythmias,

- Chest X-ray - thanks to it, in the case of chronic aortic valve insufficiency, left ventricular enlargement, dilatation of the ascending aorta and aortic arch are observed, in a very serious condition - pulmonary congestion,

- Echocardiography (Echo of the heart) - allows you to determine the qualitative and quantitative condition of the heart defect; a cardiologist can assess the dimensions of the heart cavities and aorta, identify possible damage to the valve leaflets, and assess the overall systolic capacity of the left ventricle.

Aortic regurgitation can vary in size and therefore have different ranges of return waves. The size of the defect determines the choice of further treatment.

Similar diagnostic procedure; ECG, X-ray and Echo of the heart will be ordered by a cardiologist if there is a suspicion of aortic valve stenosis. The changes may be mild, moderate or severe, and the further treatment of the heart defect depends on their size.

Treatment

The cardiologist decides on the treatment of aortic aneurysm, taking into account its growth rate and size. The goal of treatment is to prevent the aneurysm from rupturing. In the case of an aneurysm with a diameter of 5 cm and larger and the observation of its rapid growth, there is a high probability of its rupture, then the doctor decides about surgical intervention. Sometimes with a smaller aneurysm, but with a high risk of its rupture (e.g. when the aneurysm is connected with a rupture of the atherosclerotic plaque in the aortic wall), the cardiologist may also decide on the procedure. Surgical methods available:
- traditional (classic) method - consists in surgical opening of the chest or abdominal cavity, excision of the aneurysm and implantation of a suitable plastic prosthesis. Most often it is performed as a planned procedure for aneurysms of the ascending aorta and aortic arch.

- Stent graft - a method involving the insertion of the prosthesis intravascularly, i.e. through the lumen of the femoral artery. The cardiologist fixes the prosthesis with a metal stent. It must be perfectly matched to the size of the vessels, it is made individually for each patient. Stentgraft is a more modern method; less invasive, shorter, with shorter hospitalization time, but at the risk of complications.
Occasionally, in the case of dissecting aneurysms, the physician may decide to suture the walls of the artery or to cut the septum between the two dissection channels.

In the case of aneurysms not qualified for surgery by a cardiologist, treatment is based on observation in imaging tests, elimination of factors causing cardiovascular diseases and possible pharmacological treatment. In this case, it is important to regulate and maintain the blood pressure and cholesterol at the correct level, mainly β-blockers are used in drugs.
In aortic regurgitation diseases, it all depends on the size of the defect as well. In its mild course, lack of bothersome symptoms and normal heart function, no treatment is necessary. In other cases, conservative or more radical, invasive treatment is used. Conservative and pharmacological treatment consists in administering vasodilators by a cardiologist in order to reduce the feedback wave. They are used especially in patients with normal left ventricular function, even with severe aortic regurgitation. It is also an indication in patients who need to normalize their blood circulation in the process of preoperative preparation, and permanently in patients for whom surgical procedures are excluded due to their general health condition.
Invasive, surgical treatment consists in replacing the damaged valve with an artificial one by a cardiologist. The so-called the Bentall method, during which the three parts of the aorta are replaced; the aortic valves, the ascending aorta and the aortic trunk. A mechanical or biological aortic valve is implanted in this place along with an ascending aorta prosthesis, to which the doctor connects the coronary openings.
If it is not necessary to replace all three parts, treatments are performed to a lesser extent. Artificial heart valves require the patient to take anticoagulant drugs for the rest of his life. It also happens that these valves wear out. Therefore, if possible, the cardiologist often decides to replace only the ascending aorta without disturbing the correct valve.

There is also a two-stage treatment regimen for aortic stenosis. With a mild defect, when the narrowing (stenosis) is mild or moderate, the cardiologist introduces conservative treatment. With a severe defect, surgical measures are required, consisting in replacement of the entire valve or semi-invasive therapy, called valvutomy. During this procedure, the cardiologist, during a catheter with a balloon inserted through the skin, displaces or tears apart the fused valve petals. Valvulotomy is an effective and fairly safe procedure with very rare complications in the form of valve regurgitation. Sometimes, however, the patient has contraindications to perform this procedure, e.g. embolism or calcification of the subvalvular apparatus, then a full surgical procedure with valve replacement is necessary.

The effectiveness of treatment depends on prompt and correct diagnosis, the severity of the defect, and the experience and skills of the cardiologist.

Read more about diet and rehabilitation in aortic diseases.

Consequences of the lack of treatment

Untreated aortic diseases, unless they are minor physiological changes, usually have dire consequences. The most dangerous complication of an aneurysm is its rupture, which can lead to large blood loss, hemorrhage into the mediastinum or peritoneal cavity, and then death. If the haemorrhage takes place into the retroperitoneal space, sometimes quick surgical intervention is still possible. An aneurysm rupture is accompanied by severe pain in the abdomen, lumbosacral region and perineum. About 80% of aortic aneurysm rupture is fatal. Even if it does not rupture, the aneurysm puts pressure on adjacent organs and impairs their function. It also sometimes leads to aortic valve insufficiency and then to heart failure.
Sudden death can also be a result of ventricular fibrillation, caused by untreated or undiagnosed aortic stenosis. This usually occurs about 2 years after the onset of heart failure. Untreated aortic stenosis causes complications such as complications of blood pressure, strokes, aortic aneurysms, ischemic heart disease, and congestive heart failure. Infective endocarditis is also a common complication.
Aortic regurgitation can also have dire consequences. Over time, it leads to left atrial overload, morphological changes and heart failure.
The worst consequences are atrial fibrillation, which can cause a stroke by producing blood clots. In acute, chronic conditions, an infarction can occur, and is usually fatal.

Therefore, aortic diseases cannot be taken lightly and in case of any suspicions or symptoms, you should immediately consult a cardiologist.

Prevention

Not all causes of aortic diseases are fully understood. Prophylaxis against them is generally accepted as in the case of other cardiovascular diseases and it is of great importance. These include smoking cessation, a healthy, balanced diet, regular physical activity tailored to the needs and abilities of a specific person, fighting overweight, controlling and treating chronic diseases such as diabetes, hypertension, COPD, thyroid diseases and others.
It is especially important to maintain normal blood pressure and cholesterol levels.

It is influenced by diet and widely understood lifestyle.

Please read more about it here.

 Source:

• Michalak A, Michalak K, Bocian R i wsp. Jak zmienia się ocena stanu jakości życia u chorych po operacji z powodu tętniaka aorty brzusznej. Piel Chir Angiol 2009; 3: 93-109.
• Andrzej Szczeklik Choroby wewnętrzne. Kraków: Wydawnictwo Medycyna Praktyczna, 2010. ISBN 978-83-7430-216-6.
• Wojciech Noszczyk: Chirurgia repetytorium. Warszawa: PZWL, 2009. ISBN 978-83-200-3843-9.

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