Join Habib Samady, MD, and Bradley G. Leshnower, MD as they discuss further the Cardiovascular Grand Rounds presentation given by Dr. Leshnower at Georgia Heart Institute on cutting edge surgical options for aortic disease.
Good morning. This is from the Georgia Heart Institute and it's my privilege to be talking today with Dr brad Weston. Our from every university brad is associate professor of surgery at Emory University and runs the program there. So brad, Welcome to Georgia Heart Institute. Well listen, you just gave us a phenomenal uh Georgia grand rounds on cutting into therapies for diseases. And I'd love for you to share with us some of the messages from that. But we can just start off with physical edition. Let me ask you this talked about two or 3 pathologies that lead to your surgery. Okay, so, you know, our clinic is full of aneurysms that are normally found incidentally, particularly in the era of Covid, where people are getting cT scans when they come in with Covid and aneurysms from predominantly placed in the chest. Asymptomatic instantly found in prisons four cm in the chest. Our clinic. Um and that's most of the art elective planned surgeries. Then we move on to the emergency since the section which really encompasses most of our work there, treat the sections of both of the acute and chronic phases and those faces the section's lead to the development of, wow so, aneurysm dissection surgery. Now with respect to the actual path of physiology. Are we talking primarily hypertensive diseases, connective tissue diseases? Can you kind of stratified that for our viewers here, what's most of the aneurysms are probably hypertensive disease in the chest when we open the order at the time of surgery. There's not that much disease that we see. It's unusual for instance to have somebody who has also have disease. It's not, it's unusual, it happens. Um, and then for the uh, for the other patients, tissue disorders. However, I will say that genetic testing is becoming more and more frequent and you will hear more about it in the surgical space. Our national meetings, we talked about what we have found is seriously variants of unknown significance. When you, when you see it in person has an aneurysm, we're just learning about what that means that would probably fall under connective tissue disorder unless under the hypertensive. I mean, it's fascinating you and I were chatting earlier just before we get into the surgical techniques and some of it really innovative and vascular techniques you talked about just with respect to the order general. Right. But these disease processes whether it's hypertensive disease and connective tissue disorders, many of which have a genetic underpinning. Um, but because the presentation of the disease is so vastly different from completely symptomatic to presenting extremists. Um, you know, it seems like there's a big opportunity and understanding the genetics and risk stratify populations and patients. So you can decide who gets screened in the screening, just imaging or their genetic test or other identifying so, uh, what we missed. You every is a set of criteria that if someone comes in with an aneurysm or dissection based on the beach, usually 50 or younger with a large six centimeter aneurism there. Likely it's suspicious for a genetic component. Now it's more important actually to test them for their families and offspring than it is for them. We know what they need. And it will also then uh impact how we follow their It's here no genetic experience, your vote to develop and generation of further segments. Um And so it's a challenge. We have the nurse practitioners who do the bulk of this work for us. But what we do is we need to send a medical geneticist which we've identified as part of our multidisciplinary program. But we also do our own um in office uh genetic testing where the prospectus is actually sent a swab and send it off to the company. And um it's a relatively low cost but it's not free uh patients. And we're really opening up this happening. So there's there's various ways to get at it. Um genetic counselors are also very important. They are not at the positions but are vital uh developing a large genetic topic. Some sort of understanding of physiology. This is his states how patients present, how to screen them. How do you deal with the families? That's all part program? Well, let's now delve into kind of therapies. Uh let's focus on surgical and endovascular therapies. I love that. Your job. You basically use the atomic classification with you design your talk, you talked about the route maybe sending the order. The arch in descending order. Let's start with the root. So obviously the balance there often involved are sometimes involved. Um Tell us a little bit about what are the criteria for requiring surgery for the aortic root and what is it? Where did they go to procedures or operations? So open procedures still remain and will for a long period of time. The gold standard pathology for aneurysm disease, it's gonna be a 5.5 centimeters. Symptomatic that's lower to five centimeters. If you have a family history or you have a connective tissue disorder or if you have rapid growth consisting of five millimeters and 12 month period, that's also criteria for intervention. Now, if you have symptoms which is very hard to tease out because most security systems are asymptomatic. And so if you have a patient that comes in and they have a 4.517 and they're having chest pain. Probably not the aneurysm that's causing. So you have to tease out and make sure there's nothing else because that's a relatively smaller size eight hours in which to operate. The other an indication is if you're going in for a different indication. So if you have for instance, superior insufficiency and the patient has commented your pathology of at least 4.5 centimeters, there is an indication to replace the at that time room replacement is typically involves valve and root replacement. As we discuss the talk with mechanical or bio prosthetic valve conduits. However, you know if you can save that valve for a number of valve sparing procedures, you've done the patient a great benefit. And Ambassador therapy as I alluded is very interesting. Hot topic for the route. There will be a single cases presented but as I mentioned, it's going to take the combination of the veracity of the extent graph technology married the trans catheter heartfelt technology with expertise and coronary stenting to make group replacement. So that's a really summary, essentially the criteria, the options. All right. So let's move up to I guess the arch uh you talked a little bit about the history of arch repair and Erica and circle rest. Give us still for us and about what are the options for patients with large arches. So I will include the ascending and aneurysms as well because they sending aneurysms usually involved the proximal arch. And so those that pathology of a sending an arch aneurysm is still largely open. But there have been great strides as I alluded to talk to creating a vascular solutions. There's now stent grafts that are currently in trial to treat sections and then arch pathology Branch arch technology have a single or dual branches to feed the great vessels While you place a step across the arch. Those trials are currently taking place, there will be a huge focus on stroke outcomes that will make or break this technology in the eyes of FDA. But I feel that it's very promising technology that will hopefully be available as an off the shelf solution that you can tailor your therapy. That's the tailor the therapy to the individual patient of whether they should get open surgery or should they get the. Now let's flip over to the dissenting um and talk about and I know you talked a little bit talked about dissections for a minute. So acute and chronic dissection each other challenges. You talked about trying to prevent all the logic and paraplegic complications with therapies. Um So what kind of patients with acute dissection require versus open? So patients come in with an acute dissection that starts distal to the left subclavian. Those are the type B dissection classification patients, the ones that have found profusion to the kidney, to the visceral organs, intestines, liver et cetera. Those patients are classified as uncomplicated type clearly thoracic aortic stent graft prepare is the gold standard. The results are far better than operating on patients in an open fashion. The real question is what to do with the uncomplicated type piece. So they come in. They don't have any help refused organs. They don't have rupture and you need to control their blood pressure and pain and that is an unanswered question in the field. There have been efforts to try and step uncomplicated type ease. It can be done safely and there's a good argument to do it. Um there are some downsides to it. You know, it's not completely risk procedure and also cost and then following the patients and potential some adverse effects on the heart, particularly young patient that's going to have a stent graft for 34 years. But that's where the question in the field is what to do with uncomplicated medical therapy versus stent right now. Answer what a what a tour, what a wonderful tour of you know, aortic pathology, symptom symptom pathology presentation and then all these various therapies. Alright, so final question for you um years from now. uh 10 years from now, where will let's focus on Why do you think a patient with a six cm 10 years from now? Um and let's put that into someone who's under 80 and relatively healthy and someone so free great question. As I pull out my crystal ball, it's always right, right. I think industry is gonna catch up and they will create what I described the talks as an endovascular valve conduit with pre made administration branches for the coronaries. And I think this is going to come online next couple of years and I think that The vast majority of patients, maybe even we can lower the age 75 depending on the results will benefit and be done with a master solution. I think that the younger patients will probably still be open because frankly open placement is done by most cardiac surgeons with excellent results. But the endovascular solutions as taverns showed us will start the age creep down and we'll have more data on how the valve works. But there's a lot of work to be done and is a different environment compared to the tubular ST. Yeah. The business of trying to maintain the skill sets to open procedures and they remain the gold standard for a lot of patients, right? Especially here, um, and the sinuses and the valves. And um, you know, we talked a little bit earlier about the challenge of mitigating skill sets.
