Latest / UF Health MedEd Cast / Aortic Dissection: Symptoms, Diagnosis, Treatment Choices, and Prevention

Transcript

Aortic Dissection: Symptoms, Diagnosis, Treatment Choices, and Prevention · UF Health MedEd Cast

• 0:03
  Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with
• 0:05
  UF Health Shands Hospital.
• 0:07
  I'm Melanie Cole.
• 0:08
  And today, we're highlighting aortic dissections.
• 0:11
  Joining me is Dr.
• 0:12
  Eric Jeng.
• 0:13
  He's the Director of the UF Health Aortic Disease Center and an Associate Professor
• 0:18
  in the Division of Cardiovascular Surgery at the University of Florida.
• 0:22
  Dr.
• 0:22
  Jeng, thank you so much for being with us today.
• 0:24
  Can you explain how the clinical presentation of aortic dissections differ
• 0:29
  between classic and tearing chest pain and more subtle or atypical symptoms,
• 0:34
  especially in women, as we're learning more and more about that, older adults and
• 0:39
  patients with connective tissue disorders?
• 0:42
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: Thank you for having me, Melanie.
• 0:43
  Really appreciate being on with you guys.
• 0:49
  Dissection, sometimes they present in women a little bit
• 0:51
  differently, but they present with tearing back pain to the chest.
• 0:55
  One of the big things to differentiate is a DeBakey type I or type II
• 1:00
  dissection versus a type III dissection.
• 1:02
  Sometimes they're also classified as the Stanford A or Stanford B dissections.
• 1:08
  The Stanford A is a surgical emergency, and the DeBakey I or II, which is also
• 1:14
  Stanford A, is also a surgical emergency.
• 1:17
  And then, the DeBakey type III or Stanford B can be a surgical emergency,
• 1:23
  but it can also be managed medically.
• 1:26
  Melanie Cole, MS: Thank you for explaining that to us.
• 1:28
  So from your clinical experience, what are some of the common pitfalls
• 1:31
  or delays in diagnosis that you see?
• 1:33
  How can the frontline clinicians reduce missed or late
• 1:38
  diagnoses of aortic dissection?
• 1:40
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: You know, clinical suspicion
• 1:42
  is the key indicator.
• 1:44
  Everybody knows about strokes and everybody knows about having campaigns
• 1:47
  like FAST where you have them basically build all over the place and everybody
• 1:51
  knows, "Oh, let's look for stroke," but looking for dissections isn't
• 1:55
  as common Fifteen thousand aortic dissections happen in the United
• 2:01
  States alone and about almost half a million, so 400,000 worldwide each year.
• 2:07
  And so, the-these are real problems that cause real mortalities and having an
• 2:12
  index of suspicion is the key component.
• 2:16
  So, I mean, anytime anybody has chest pain, they start thinking heart attack
• 2:20
  or if you have some numbness on one side of your face or you can't move one side,
• 2:25
  you'd start thinking about a stroke.
• 2:27
  But patients, number one, and even providers don't always immediately
• 2:32
  think about a dissection happening.
• 2:34
  Melanie Cole, MS: Before we get into guideline-based approach to managing
• 2:38
  Stanford type, I would like you to speak a little bit about what you
• 2:42
  feel is important for providers and indeed patients to notice.
• 2:47
  As you said, we've got Be Fast, we've got these campaigns, but
• 2:51
  what would you like them to know about not missing these things?
• 2:55
  You mentioned the tearing back pain in your chest.
• 2:57
  You've mentioned a few, but expand a little bit on that,
• 3:00
  what you directly look for.
• 3:02
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: By the time they find me, usually,
• 3:05
  they have the problem already.
• 3:06
  So, I don't see these people on the front line.
• 3:09
  Where I see these patients are in clinic when they have an ascending
• 3:12
  dissection, a known ascending aneurysm
• 3:15
  Patients with ascending aneurysms, you know that that dissection is a possible
• 3:20
  sequelae of an ascending aneurysm.
• 3:23
  So, a dissection is just a tear of an aneurysm or even non-aneurysmal tissue,
• 3:28
  but it more often occurs when the tissue or the aorta is aneurysmal already.
• 3:34
  So, patients with a known history of aneurysms, patient with a known history
• 3:37
  of connective tissue disorders or known hypertensive problems where they
• 3:43
  present frequently with hypertensive issues, are on multiple medicines
• 3:47
  for high blood pressure, those are patients that, really, you should
• 3:51
  have a high index of suspicion for.
• 3:53
  Melanie Cole, MS: Can you walk us through the current guideline-based
• 3:55
  approach to managing Stanford type A versus type B dissections and where in
• 4:01
  the real-world practice sometimes that has to diverge from the guidelines?
• 4:05
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: Just to break it down from a standpoint
• 4:07
  of incidence, about two-thirds of patients present with a Stanford type
• 4:11
  A dissection, and that's that surgical emergency I was talking about before,
• 4:15
  where you have to have emergency heart surgery they usually talk about.
• 4:18
  And the Stanford type B is also a tear.
• 4:21
  It's just a tear in a different part of your aorta.
• 4:24
  Most of the time, a Stanford type B dissection can be managed
• 4:28
  medically, meaning impulse control.
• 4:31
  Impulse control means having your heart rate lower and then having
• 4:36
  your systolic blood pressure lower.
• 4:38
  Usually, the goals for heart rate are around 80 and a systolic
• 4:42
  blood pressure less than 120.
• 4:44
  That's called impulse control.
• 4:46
  If there is no what we call end-organ malperfusion, that could be malperfusion
• 4:52
  to the legs, malperfusion to the guts, malperfusion to the kidneys.
• 4:56
  If there is end-organ malperfusion, even those Stanford Type B dissections
• 5:00
  have to be managed surgically.
• 5:02
  In those same cases, usually, a stent or an endovascular procedure
• 5:07
  is enough to fix that problem.
• 5:09
  Type A dissection is that surgical emergency part.
• 5:12
  You have to go to surgery, otherwise half of those patients
• 5:15
  will die no matter what you do.
• 5:17
  A Stanford type A dissection means there's a tear in the aorta really
• 5:22
  close to your aortic valve or as close as your heart as it can get.
• 5:26
  The reason why that's a surgical emergency is because the tear can
• 5:31
  propagate down to your coronary arteries.
• 5:34
  So, it goes down to the level of where the blood vessels feed your heart,
• 5:38
  and therefore kill you like that.
• 5:40
  They can cause what you call tamponade, which is blood around the heart, around
• 5:44
  the pericardial sac, and then make it so you have tamponade physiology and die
• 5:48
  that way, or cause malperfusion to not only the brain, but the rest of the body.
• 5:53
  So, that's why a Stanford type A also categorized as a DeBakey type
• 5:57
  I or II, it becomes a surgical emergency where you have to go to
• 6:01
  the operating room and operate on those patients with a heart surgeon.
• 6:05
  Melanie Cole, MS: Dr.
• 6:06
  Jeng, what are the major advances in open surgical repair for acute
• 6:10
  Type A dissection, such as cerebral protection strategies, arch replacement
• 6:15
  techniques, valve-sparing procedures?
• 6:17
  Tell us what's exciting in your field for that.
• 6:20
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: There are so many exciting things
• 6:21
  that have happened in aortic surgery in the last fifty years.
• 6:24
  We have so many different types of hybrid technologies.
• 6:28
  At the University of Florida, we're a part of every type of hybrid technology there
• 6:34
  is in clinical trials in development.
• 6:36
  And a lot of our patients have the option of being enrolled in those same trials.
• 6:42
  We have stents, inside stents, and then even what we call
• 6:46
  dissection stents or AMDS devices.
• 6:49
  We have specialized hybrid stent/gel weave grafts.
• 6:53
  There's so many of these different nuances to the care in aortic surgery
• 6:58
  that we provide at the University of Florida that makes it so much so exciting.
• 7:02
  The reason for that really is because we happen to be the second
• 7:06
  busiest by surgical volume aortic center in the whole country.
• 7:10
  We do about a thousand aortic cases every year, and we're one of the few
• 7:14
  centers where our case mix index, which is how complex our patients are are
• 7:18
  among the top ten in the nation, our case volume is among top ten in the nation.
• 7:23
  And then, our mortality index, which is how well people do,
• 7:27
  is also top ten in the nation.
• 7:29
  So, not only do we do it at a high volume, we do it at high quality in very complex
• 7:34
  patients, and the patients survive.
• 7:36
  Melanie Cole, MS: That is amazing to hear.
• 7:38
  So, how have endovascular and hybrid approaches, you just mentioned one, like
• 7:43
  TEVAR and frozen elephant trunk, changed that treatment landscape for complex
• 7:48
  arch and descending aortic dissections?
• 7:50
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: Well, first and foremost, what
• 7:52
  that can provide is it provides a more comprehensive repair.
• 7:55
  So instead of simply replacing a segment of the aorta called the ascending
• 7:59
  aorta, maybe around 2 to 3 centimeters, we replace this large segment of the
• 8:03
  aorta that includes the entire arch.
• 8:06
  And what that does is it makes it so that there's lesser
• 8:10
  downstream surgeries you may need.
• 8:12
  In many community hospitals, the surgeons aren't as used to doing aortic surgery.
• 8:17
  What happens is that if given no other option, they save the patient,
• 8:22
  and that's a great thing, and they replace the ascending aorta.
• 8:25
  But there are sequelae to that.
• 8:26
  Sometimes the aortic root gets bigger, and then you have to operate on that.
• 8:30
  Sometimes the aortic arch gets bigger, and you have to operate on that.
• 8:33
  Sometimes the descending aorta gets bigger, and you have to
• 8:36
  operate on that separately.
• 8:37
  So, one problem can mean three, four, five operations later if you don't get a
• 8:44
  very comprehensive solution from the jump.
• 8:46
  Melanie Cole, MS: For patients with genetic syndromes such as
• 8:50
  Marfan, Loeys-Dietz, or those with bicuspid aortic valve, how has
• 8:54
  genetic testing do you feel, Dr.
• 8:56
  Jeng, and family screening changed your approach to prevention and
• 9:00
  timing of prophylactic surgeries?
• 9:02
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: We actually have several genetics
• 9:04
  counselors that we utilize all the time.
• 9:06
  We send out genetic testings all the time.
• 9:08
  We provide, again, a lot of the genetics component counseling
• 9:12
  to our families all the time.
• 9:13
  Does it change for the patient?
• 9:15
  Again, sometimes I meet these patients when they already have a dissection.
• 9:19
  So, not necessarily for the patient themselves, but a lot
• 9:22
  of times for their families.
• 9:23
  One time I met with a patient that I operated on with Marfan's.
• 9:26
  And the next clinic run, she brought about 20 family members
• 9:30
  in the clinic room with her.
• 9:31
  And each one of those patients eventually saw us.
• 9:34
  But this disease process travels in families, and understanding what
• 9:39
  everyone's relative risk is, is important.
• 9:42
  Because at the end of the day, with elective surgery, your outcomes
• 9:47
  are immensely better than if you have to have emergent surgery.
• 9:52
  I'll give you an example.
• 9:53
  In a patient that's followed with an ascending aneurysm, I generally quote
• 9:57
  them a 1% mortality, a 1% stroke risk.
• 10:00
  We know in a patient that presents with an aortic dissection, at
• 10:03
  some of the best centers, at best, it's 15% mortality in-house.
• 10:09
  Our mortality in those same patients happen to be around 8% or less.
• 10:13
  But again, that 8% or 10% is a lot more than one.
• 10:16
  So, treating these patients prophylactically when their aortas,
• 10:21
  when they're aneurysmal, they become a certain size, is very important.
• 10:25
  What that size is for patients with connective tissue
• 10:28
  disorders like Marfan's, Loeys-Dietz, is usually around 4.5
• 10:31
  centimeters.
• 10:32
  In the regular population, it's around 5.5
• 10:35
  centimeters.
• 10:35
  So, it's a centimeter less.
• 10:37
  So, you intervene a little earlier when you're dealing with those
• 10:40
  connective tissue problems.
• 10:42
  Melanie Cole, MS: Dr.
• 10:42
  Jeng, and this is such an interesting discussion that we're having.
• 10:45
  And as you talk about the pure volume that you're doing there at UF Health,
• 10:49
  when you think of training residents and future surgeons, and so much
• 10:55
  of today is robotics and learning, do you feel that there's this gap?
• 10:59
  Because you were talking about open repair and in emergent situations.
• 11:05
  What would you like to say to residents and trainees about being able to switch
• 11:13
  at the last minute, go in and do that open repair, and planning for that, training
• 11:18
  for that so that there's not that gap
• 11:21
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: So I am also the program director for
• 11:23
  the Integrated Cardiovascular Surgery Program at the University of Florida.
• 11:27
  The integrated program is a surgical residency where we take residents that
• 11:32
  come directly out of medical school.
• 11:33
  These are the cream of the crop, basically.
• 11:36
  The residents that have the most research papers have the highest
• 11:39
  USMLE scores, do the best in amongst their medical school class.
• 11:45
  We are able to recruit these same medical students.
• 11:48
  And in our center, they flourish.
• 11:50
  So, I'll give you an example.
• 11:52
  One of our fourth-year resident, me and him, we did emergent surgery
• 11:56
  on a mitrtal tricuspid yesterday.
• 11:57
  We did aortic surgery on a different patient the day before.
• 12:01
  these residents are getting to be trained out the gates.
• 12:05
  I am very confident that these same residents will be appropriately trained,
• 12:09
  not only to be certified, but independent aortic surgeons and complex cardiovascular
• 12:14
  surgeons when they graduate.
• 12:16
  From a standpoint of robotic surgery, I think robotic surgery, there are
• 12:20
  certain avenues that I believe that robotic surgery is best applicable.
• 12:24
  I think in gynecology, it's super applicable because you're
• 12:27
  working inside the pelvis.
• 12:29
  Same with urology.
• 12:31
  Also in thoracic surgery, where you're doing lobectomies, lung-related
• 12:36
  surgery, I think you get a little bit less time in the hospital because
• 12:40
  of the pain scores and whatnot.
• 12:42
  In cardiac surgery, I think robotics is a little bit different.
• 12:45
  There is no robotic application to aortic surgery.
• 12:48
  You can do minimally invasive or less invasive surgery with cardiac surgery.
• 12:54
  I think the robotic platform is probably best suited for mitral valve
• 12:58
  potential applications, sometimes aortic valve applications, and
• 13:02
  sometimes coronary applications.
• 13:04
  So, robotic surgery is not probably the best platform for
• 13:08
  minimally invasive cardiac surgery.
• 13:11
  I think there are other approaches endovascularly that are better suited
• 13:16
  for aortic surgery as opposed to robot.
• 13:19
  Melanie Cole, MS: Yeah, that's an interesting point that you made.
• 13:22
  So, how do you structure a multidisciplinary aortic program
• 13:26
  or aortic center of excellence?
• 13:27
  What impact does that specialized team you're discussing does that care have
• 13:32
  on outcomes compared with standard care?
• 13:35
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: It's super huge.
• 13:36
  I believe actually the multidisciplinary team—so, we have an aortic conference
• 13:40
  every other Tuesday, where the vascular surgeons ourselves and sometimes
• 13:46
  the cardiologist, and then also the interventional radiologist meet.
• 13:49
  We talk about all the cases that each one of our respective aortic surgeons
• 13:54
  sees, and then what they think about it.
• 13:57
  Sometimes, there's an open solution.
• 13:59
  Sometimes there's an endovascular solution to a complex problem.
• 14:02
  And sometimes there isn't a surgical solution, and we look to our
• 14:06
  interventional radiology colleagues for a plug or somehow to embolize something.
• 14:11
  There are so many ways to tackle these problems.
• 14:15
  I think being in silos prevents a comprehensive solution for each patient.
• 14:20
  And the aortic center for us, what it does is it brings together all
• 14:24
  these specialties, and enhances the care for the patient because
• 14:28
  it breaks down these silos.
• 14:30
  And because of that, I think the patients get optimal care, the
• 14:34
  best care they can in the nation.
• 14:36
  Melanie Cole, MS: And looking ahead 10, 15 years, how do you envision the care
• 14:39
  pathway for patients at risk or living with aortic disease changing, particularly
• 14:45
  with advances in genetics, endovascular technology, AI-driven prediction models?
• 14:51
  What do you see happening?
• 14:53
  What do you hope will happen?
• 14:54
  And please offer your best advice and final thoughts.
• 14:58
  Eric Jeng, MD, MBA, FACS, FACS, FACC, FCCP: The AI part is exceptionally huge for us.
• 15:01
  And the reason for that is we know that computing power is more than
• 15:05
  any human can do, the artificial intelligence computing power.
• 15:08
  Especially with, all the resources we have, including the HiPerGator
• 15:11
  at the University of Florida, we've been able to leverage all of these
• 15:15
  resources, and we've created AI models, especially for our sepsis
• 15:20
  prediction in our cardiovascular unit.
• 15:23
  Aortic surgery and cardiovascular surgery inherently go hand in hand.
• 15:27
  Sometimes it's complex cardiovascular surgery that includes the aorta.
• 15:30
  Sometimes it's aortic surgery that includes the heart.
• 15:33
  And so, these go hand in hand for us.
• 15:35
  I think with a center like ours, where we have very little silos, we
• 15:40
  have all of these subgroups working together hand in hand, in addition to
• 15:45
  having prediction models, not just of sepsis, but also aneurysmal growth, and
• 15:50
  having all of the capabilities, either endovascular, open, hybrid technologies,
• 15:56
  to utilize all these approaches in combination, you really get what I like
• 16:00
  to call a precision model of medicine that is important for every patient.
• 16:05
  That way, you get a customized approach to what you . As opposed
• 16:08
  to a blanket one type of solution for every problem, you get a very
• 16:12
  customized solution for the patient.
• 16:16
  And I think that is what will be different going forward.
• 16:19
  Everybody will get a customized approach to what they need.
• 16:23
  I think an individualized precision model medicine is the key to the future.
• 16:27
  And utilizing AI to help with that.
• 16:30
  And AI, sometimes we believe that, you know, AI is the solution to everything,
• 16:34
  and everybody's probably put in something in ChatGPT and realized it's wrong.
• 16:39
  So, there is the human component that really standardizes everything
• 16:42
  and the checks and balances between that and ensuring that we're not
• 16:47
  just believing whatever's input.
• 16:49
  That these models where real surgeons, expert clinicians take into account
• 16:53
  the real-world changes and how that affects the modeling of this and
• 16:57
  adapting to the different changes that you're seeing is going to be key.
• 17:01
  Melanie Cole, MS: Well, it certainly is very exciting time.
• 17:04
  Thank you so much, Dr.
• 17:05
  Jeng, for joining us today.
• 17:06
  And to learn more about this and other healthcare topics at UF
• 17:09
  Health Shands Hospital, please visit innovation.ufhealth.org.
• 17:13
  And to listen to more podcasts from our experts, you can always
• 17:17
  visit ufhealth.org/medmatters.
• 17:20
  That concludes today's episode of UF Health MedEd Cast with
• 17:23
  UF Health Shands Hospital.
• 17:25
  I'm Melanie Cole.