Dr. Allan Stewart, director of aortic surgery at Mount Sinai Hospital
THE SPECIALIST: Dr. Allan Stewart
As the director of aortic surgery and co-director of the heart valve center at Mount Sinai, Allan Stewart is a cardiac surgeon who does all kinds of heart repairs. He performs about 300 heart valve surgeries a year.
WHO’S AT RISK
Aneurysms are balloon-like swellings or bulges in arteries that can occur anywhere in the body, but aortic aneurysms can be especially dangerous — they were the cause of death for beloved comedians Lucille Ball and John Ritter.
“The aorta is the body’s largest artery, and it should be a tube like a garden hose — but due to genetics and/or lifestyle behaviors, the tube can get stretched out,” says Stewart. “Eventually, the stretched-out aorta is likely to tear, or dissect, which can be fatal.”
In the past, many torn aortic aneurysms were mistaken for heart attacks. “When you hear about a healthy young person dropping dead of a heart attack while exercising, it may be due to an aneurysm,” says Stewart. “In general, aortic aneurysms affect a much younger patient population, due to anatomical defects of the heart valve and/or the aorta itself.”
A combination of genetic and lifestyle factors contribute to your risk. “Two percent of the population has a bicuspid heart valve that doesn’t function as well as the normal tricuspid valve, and 50% of these people also have a weakened aorta,” says Stewart. “How you live your life is also a factor — people who are weightlifters, have a history of high blood pressure, are smokers, or have a lot of stress are all at increased risk.” Lifting heavy objects is a factor because it puts tremendous pressure on the aorta.
While some aneurysms prove fatal if untreated, not all aortic aneurysms require treatment. “As the aneurysm grows, there can be a consequence to the aortic valve as the progressive swelling starts pulling the valve apart, which allows blood to flow backward into the heart,” says Stewart. “Over the course of time, the heart essentially gives up and starts to fail. This process takes a while, and sometimes the aorta will be stretched out and then hold steady.”
Many patients can opt for watchful waiting while the aorta’s diameter stays under the 5-centimeter range.
SIGNS AND SYMPTOMS
Most aortic aneurysms are asymptomatic, so they are picked up incidentally. “Either the primary-care physician can hear a murmur and calls for followup, or the patient gets a chest X-ray that picks up the aneurysm,” says Stewart. “Generally it takes about 10 years from the time when the aneurysm causes the valve to start leaking until the damage progresses to heart failure.”
In some cases, aneurysms can cause intermittent back and chest pain. “More often, symptoms develop not from the aneurysm but from the valve leaking enough that patients experience fatigue, reduced exercise tolerance, or difficulty breathing with exercise,” says Stewart. “Many people’s response to these symptoms is to stop exercising, to avoid symptoms, which delays seeking care and usually causes your blood pressure to go up even more.”
Many patients can get by with more conservative treatment. “Until the aorta stretches to a 5-centimeter diameter, you probably don’t need surgery — some patients’ aorta stretches to 4.5 centimeters and then stays there for 20 years,” says Stewart. “The progression doesn’t happen overnight, which allows patients the option of watchful waiting, along with some lifestyle modifications.”
Stress and lifting heavy weights are factors that can lead the already stretched aorta to tear. “If you have a small aortic aneurysm or know you’re at risk, the lifestyle recommendations are to reduce stress, limit what you’re lifting, stop smoking, maintain a healthy weight, and do cardiovascular exercise safely,” says Stewart.
“Because you actually want to limit adrenaline release — which places stress on the aortic root — I recommend taking a slow start, a good 10 minutes of warming up to get used to what’s happening,” says Stewart. “And yes, you can still have sex.”
Surgery can be indicated once the aorta has dilated to 5 centimeters or the patient is experiencing symptoms. “The goal of surgery is to fix what’s wrong with the valve and what’s wrong with the aorta. For some patients, the valve was leaking because it was being pulled apart by the aneurysm, even though the valve itself was perfectly good,” says Stewart. “We now advocate for a valve-sparing approach, that allows us to rebuild the leaky valve and fix the aneurysm all at once.” If the valve can’t be spared, the surgeon may replace it with a mechanical or animal valve.
Because aortic valve repair surgery is elective, you want it to be done by an experienced surgeon who has a mortality rate that is near zero. “This is a curative operation with very low complication rates,” says Stewart. “It can be transformative — I did this surgery for a guy in his mid-30s who ran a marathon with me on the one-year anniversary of his surgery.”
Like all surgeries, the cutting-edge valve-sparing aortic repair is continually being refined.
“Now we can do these procedures in ways that are safer and faster, without even completely dividing the breastbone,” says Stewart. “What we’re all looking for now is better genetic testing or a blood test that would allow us to diagnose earlier.”
QUESTIONS FOR YOUR DOCTOR
If you have a family history of early death that was assumed to be a heart attack, tell your doctor and ask him or her to listen to your chest. If you have a murmur, ask “Can I have an echocardiogram?” and followup with “Should I consult a specialist?” If you are diagnosed with an aortic aneurysm, ask “Am I candidate for valve surgery?” And be proactive about asking, “Can I have surgery that spares my valve?”
“Learning that you have an aortic aneurysm that calls for surgery can sound really scary,” says Stewart. “But patients find they feel a lot better with a repair. This problem that you’ve had since you were born is gone, so you can go on to live a better life than you had before.”
WHAT YOU CAN DO
Get informed. A superb patient resource is HeartValveSurgery.com, which was founded by a patient with a bicuspid heart valve who decided that patients needed better information.
Exercise safely. Continuing to exercise is crucial for your heart health, but it’s important not to lift very heavy weights and to warm up slowly to avoid a sudden jolt of adrenaline.
Avoid stimulant drugs. “Drugs like cocaine or amphetamines are out — they raise blood pressure, which leads to tearing — and avoid Viagra and Cialis unless you’ve cleared it with your doctor,” says Stewart.
See a specialist and get a second opinion. Stewart recommends that anyone with an aortic aneurysm seek a second opinion; if you’re a candidate for surgery, consult a Heart Valve Center of Excellence.