Valvular Heart Disease in Dissection of the Ascendant Aorta and Abdominal Aortic Aneurysm
Short Summary

72-year-old male with a diagnosis of mitral valve prolapse and chronic severe mitral regurgitation, aortic root and ascending aorta dilatation and patent foramen ovale. On 06/2008 he had dissection of the descending aorta. The clinical course has been characterized by hemodynamic stability and the vascular surgeon decided on conservative treatment and follow–up by thoracic CT. Transesophageal Color Doppler and revealed severe mitral regurgitation due to bileaflet prolapse of the mitral valve, dilated ascending aorta, evident wall hematoma of the descendant thoracic aorta (probable thrombosization of the dissection).

Patient's Questions
1)         What, in your opinion, is the overall therapeutic solution that is the most appropriate to the case of this patient?
2)         Can you advise a center of excellence in Italy we can refer to?
Medical Background

Age: 72, Male
Diagnosis: Valvular heart disease in dissection of the ascendant aorta and abdominal aortic aneurysm.
 
Anamnesis:
Since 30 years known arterial hypertension in good compensation:
Smoker (at present 5-6 cigarettes daily);
Prostatic hypertrophy;
Abdominal aortic aneurysm (3,5 cm) at the thoracoabdominal junction known since 1995 (this lesion is monitored by periodic ecographies and abdominal CT angiography performed in August, 2007);
Hiatal hernia, diffuse gastropathy with petechial appearance and bulboduodenitis.
 
Case history:
In March 2008 diagnosis of mitral valve prolapse with flail of the posterior flap and severe failure; modest aortic root and ascending aorta dilatation; patent foramen ovale
A cardiac surgery visit was, therefore, performed that gave indication for a mitral valve defect repair surgery and for an aortic valve and ascending aorta replacement. In expectation of the cardiac surgery operation fixed on June, 2008, the patient underwent, on 05/2008, a cardiac catheterism and coronarography that gave evidence of “severe mitral failure (3+/4); bulbar and ascendant aorta moderately dilated: bulbar 44 mm, sinotubular junction 39 mm, tubular 47 mm; EF (ejection fraction) 60%; no alterations of the regional kinetic. AD (anterior descendant) slight ostial stenosis 20%, 40% at I and II segment; CX (circumflex branch) with slight irregularities; atheromasic dominant right coronary artery (DRCA); at the abdominal aorthography evidence of abdominal ascending aorta dilatation (32 mm), diffuse atheromatosis and moderate tortuosity on the aorto-bisiliac axis”.
On 06/2008 the patient went to the Emergency Room at Abano Terme for a thoracic and interscapular pain; after a closer examination with complete abdominal and thoracic CT scan there are proofs of a distal thoracic aortic dissection with probable origin slightly at the top of the thoracoabdominal junction. The patient was, therefore, hospitalized at the intensive care ward of Padua Hospital from which he was moved to the hospital department on 06/2008. The clinical course has been characterized by hemodynamic and breathing stability; during hospitalization a follow up thoracic CT angiography was carried out that turned out to be unchanged and that was then followed by a visit performed by the Vascular Surgeon who gave indication for a conservative treatment monitoring the lesion by a follow up thoracic CT angiography after 30-40 days.
Medical therapy at discharge still current:
NEOLOTAN 100 mg           1 tablet daily
LASIX 25 mg                                    2 tablets daily
NORVASC 5 mg                  1 tablet daily
CARDURA 2 mg                  ½ tablet twice a day
METOPROLOL 100 mg     ½ tablet twice a day
LIMPIDEX 30 mg                 1 tablet daily
On 08/2008, a transesophageal Color Doppler Echocardiography was carried out with the following medical report:
aorta:
fibrotic cusps; presence of fine calcifications; uncompromised systolic opening. Moderate ascending aorta dilatation (45 mm) with endoluminal hyperecogenic linear image poorly movable not visible at the transthoracic echocardiography and with full filling at the color-Doppler (image consistent with the reverberation). No proof of images ascribable to endocardial vegetations at valvular level. Evident wall haematoma of the descendant thoracic aorta (probable thrombosization of dissection already described). No alterations of the aortic arch are noticed.
Left atrium:
slightly dilated, interatrial septal mobility
Mitral valve:
prolapse of both flaps, more marked in the posterior flap with flail at the level of distal edge. Lack of appearances ascribable to endocardial vegetations.
Left ventricle:
regular left ventricle dimensions. Normal systolic function.
Tricuspid:
Redundant tricuspid flaps.
Doppler:
Light aortic regurgitation; severe mitral regurgitation directed towards the interatrial septum”.
On 10/2008, an Aorta CT scan was carried out with the following medical report: “severe parietal atheromasia of the thoracoabdominal aorta complicated by the descendant thoracic segment for the presence of amputating ulcers, one near the exit site of the left subclavian artery and the other one at the thoracoabdominal junction. An intrawall haematoma of chronic type is associated, it seems clearly reduced compared with a previous CT scan follow up (June, 2008) making, at present, the ulcers that show limited dissection at the left subclavian artery exit site and at the thoracoabdominal junction more notable.
Dilatation of the Valsalva sinuses (max. diameter = 42 x 48 mm for asymmetry in cusps), of the ascendant aorta (max. diameter = 44 mm) and of the descendant thoracic aorta, particularly at the thoracoabdominal junction (max. diameter = 45 mm).
Normal dimensions of the abdominal aorta and of the iliac-femoral axis.
Common origin of the brachiocephalic artery and of the left common carotid and origin of the left vertebral artery straight from the aortic arch”.
With regard to the heart problem the two cardiac surgeons, who were asked, agree on the need of surgical operation even if they disagree on timing (one requests it immediately, the other one in Spring 2009) and on the evaluation on the advisability to replace the heart valve too.
With regard to the vascular problem two vascular surgeons were asked:
The first one thinks that it is possible to perform an operation (surgical/endoscopic) simultaneously to the valvular operation;
The second one excludes every kind of operation thinking it is unsuitable and even potentially dangerous.
The questions are asked in the light of the above-mentioned opinions.

Expert's Opinion

There are no details given on the clinical status of this patient. It is very important to know the patient's functional capacity and whether he suffers from shortness of breath during exercise and does he have arrhythmias such as atrial fibrillation.
Recommendations:
1. Regarding his valve problem: According to the data presented I am not sure this patient need surgical intervention at all. If the patient is asymptomatic and his left ventricular size and function are normal, and he has no atrial fibrillation or significant pulmonary hypertension than the valve problem is not urgent and I wouldn't replace or repair this valve at this time. In 73 old patient with chronic dissection of the descending aorta and dilated ascending aorta the risk of surgery is quite high.
2. Regarding the ascending aorta: I do not think that there is indication to operate the patient due to dilation of his ascending aorta. In a patient with tri-leaflet aortic valve the indication for operation is aorta diameter of 50 mm or more. This patient has ascending aorta of around 45-48 mm.
3. Regarding the chronic dissection in the descending aorta- the patient should consult vascular surgeon regarding the possibility of treatment with stent. This is not my area of speciality .
4. The patient needs good medical treatment for high blood pressure including ACE inhibitors and Beta blockers because of his dilated aorta. He needs regular echocardiography follow-up every six month and occasionally CT.
So in summary if the patient is truly asymptomatic I think conservative treatment with careful follow up by echo of LV size and function and aortic diameter is all is needed at this stage. Every surgical intervention in this patient carries a significant risk. 

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