Can an aortic aneurysm cause heart failure?

Aortic Aneurysms and Heart Failure

Yes, aortic aneurysms can cause heart failure through several mechanisms, primarily through aortic valve regurgitation when the aneurysm involves the aortic root or ascending aorta. 1

Mechanisms by Which Aortic Aneurysms Can Lead to Heart Failure

Aortic Valve Regurgitation

• Aortic root or ascending aortic aneurysms can cause dilatation of the aortic annulus, leading to aortic valve regurgitation which may result in heart failure 1
• The regurgitation occurs because the dilated aortic root prevents proper coaptation of the aortic valve leaflets 2
• Severe aortic regurgitation leads to volume overload of the left ventricle, causing left ventricular dilatation and eventually systolic dysfunction 2

Direct Compression of Cardiac Structures

• Large thoracic aortic aneurysms can compress adjacent cardiac structures, including:
  • Compression of the pulmonary artery, affecting right heart function 3
  • Compression of the left atrium, impairing left ventricular filling 3
  • These compression effects can lead to heart failure symptoms even with preserved ejection fraction 3

Rupture and Fistula Formation

• Rupture of an aortic aneurysm into adjacent cardiac chambers or vessels can cause acute heart failure 4
• Aortopulmonary fistulas resulting from aneurysm rupture can create severe left-to-right shunts, leading to high-output heart failure 4

Aortic Dissection Complications

• Aortic dissection, a complication of aortic aneurysm, can cause acute severe aortic regurgitation leading to sudden heart failure 5
• Aortic dissection may also be associated with myocardial contusion, which can lead to cardiac failure 1

Risk Factors and Associations

• Bicuspid aortic valve is strongly associated with aortic aneurysms, aortic regurgitation, and subsequent heart failure 6
• Hypertension is a major risk factor for both aneurysm formation and heart failure, present in up to 85% of patients with ruptured aneurysms 1
• Other common risk factors include smoking, hypercholesterolemia, and chronic obstructive pulmonary disease 1
• Inflammatory diseases affecting the aorta (vasculitis) can weaken the aortic wall, leading to aneurysm formation and subsequent heart failure 1

Clinical Presentation

• Many patients with thoracic aortic aneurysms are asymptomatic until complications develop 1
• When heart failure develops due to aortic regurgitation from an aneurysm, symptoms may include:
  • Dyspnea (NYHA class II-IV) 1
  • Signs of left ventricular dilatation and dysfunction 2
  • Acute pulmonary edema in severe cases 3
• The 10-year risk of congestive heart failure in patients with severe aortic regurgitation can be as high as 44% 2

Management Considerations

• Surgical intervention is indicated for:

  • Symptomatic patients with aortic regurgitation (dyspnea, NYHA class II-IV) 1
  • Asymptomatic patients with left ventricular ejection fraction ≤50% 1
  • Patients with severe left ventricular dilatation (end-diastolic dimension >70 mm or end-systolic dimension >50 mm) 1
  • Aortic root disease with maximal aortic diameter ≥45 mm for Marfan syndrome, ≥50 mm for bicuspid valves, and ≥55 mm for other patients 1

• Cardiac surgery for severe aortic regurgitation due to aneurysm markedly reduces heart failure rates (HR 0.23; 95% CI 0.08-0.68) 2

• Delayed surgical intervention in patients with traditional surgical markers (symptoms or ejection fraction <50%) is associated with excess mortality (HR 3.0; 95% CI 1.3-7.1) 2

Monitoring and Surveillance

• Regular echocardiographic monitoring is essential for patients with aortic aneurysms to detect early signs of:

  • Aortic regurgitation 1
  • Left ventricular dilatation 2
  • Decreasing ejection fraction 1

• Quantitative echocardiographic markers (regurgitant volume ≥60 mL/beat or orifice ≥30 mm²) provide better prediction of heart failure risk than traditional markers 2

• End-systolic volume index ≥45 mL/m² is an independent predictor of heart failure in patients with aortic regurgitation 2