Bigelow Lecture by John A. Elefteriades: “Thoracic Aortic Aneurysms: Reading the Enemy’s Playbook”

John Elefteriades

John Elefteriades is the William Glenn Professor of Surgery at Yale University. He is an aorticist who graduated from Yale Magna Cum Laude as a triple major in Physics, French, and Psychology. He serves as the Director of the Aortic Institute of Yale – New Haven, and editorin- chief of the journal The Aorta.

“Aortic dissection is the most common disease of the aorta. It kills by rupture, aortic valve insufficiency, myocardial infarction, and ischemia of critical organs. It was described as ‘the great masquerader’ by William Osler, who said ‘there is no disease that is more conducive to clinical humility than disease of the aorta’. People who have been felled by aortic disease include Lucille Ball, George C. Scott and Pulitzer Prize winning ‘Rent’ playwright Jonathan Larson.

“Aneurysms grow at 0.1 cm per year. When they reach 5.5 cm, they are generally judged appropriate for surgical treatment. The risk of rupture is 4% per year at 6 cm and nearly 10% per year when the diameter is greater than 6 cm. There are 5000 patients in the Yale Aortic Institute database. There is a 2% incidence of aortic disease in the population of patients with bicuspid aortic valves and 5% of them have aneurysms. The prevalence is much higher in Marfan’s disease.”

One day, John’s nurse Marianne pointed out that aortic rupture was frequently seen among weight lifters in their practice. John was a weightlifter in his youth. Weightlifters are said to experience a dramatic increase in blood pressure as they approach lifting 75% of their body weight. John carried out an experiment (that would never pass IRB/ REB review), using his healthy son, himself, and another subject to measure the blood pressure as they pressed progressively heavier weights in the weightlifting room: Aortas intact, they proved the correlation.

He feels that a snapshot echo should be available for athletes, especially those who engage in weightlifting. The cost of the echo is $200, whereas a pair of Nike’s sneakers cost $310. Nevertheless, it’s generally argued by health economists that performing echoes on young athletes is prohibitively expensive.

“A genetic predisposition - elevated metalloproteinases, and an emotional or physical challenge raising the blood pressure can lead to rupture. You can see the aorta thin out in systole. The wall stress goes up during weightlifting to greater than 800 kPa (kilopascals). The predisposition is an autosomal dominant and some of the genes, particularly ACT2MULK a CT predict early rupture. The silver lining in patients with aneurysmal disease is that they always have normal femoral arteries and a low calcium score. Their carotid intimal thickness is lower and their myocardial infarction rate is low. There is an RNA signature in a blood test that is 85% accurate in predicting aneurysmal disease. Intramural hematomas (IMH) often become dissections – IMH in the ascending aorta should be operated upon. They often have a tiny intimal tear. In contrast, IMH does not require surgical treatment in the descending aorta.

A spirited question and answer period followed the lecture. Question: “Does a person over 50 years of age, who starts going to the gym, need an echo?” Answer: “Yes, if they are doing strength training. Aerobic exercise is not a risk.”

Chris Feindel asked: “Isn’t configuration important, not just the diameter?” Answer: “The shape is important, especially bulging of the sinuses. Asymmetry and loss of the waist of the aorta above the sinuses or eccentric dilation are also important. Question: “At what age should we screen?” Answer: “The best referee in the NFL ruptured his aorta. We operated on him, and he was back refereeing in the Super Bowl. The bottom line is do echoes on athletes, even though it’s not cost-effective in life years. Think of those young athletes who die prematurely from rupture or hypertrophic cardiomyopathy.”

M.M.