Timely diagnosis of an acute aortic dissection is the first key step to saving a patient’s life. However, not all hospitals are equipped to handle the next critical step: administering timely treatment to reestablish true lumen flow in the aorta. In these cases, according to an invited expert review published in The Annals of Thoracic Surgery, rapid transfer of the patient to a center of excellence is advisable.
Ashraf A. Sabe, MD, a cardiac and aortic surgeon of the Brigham and Women’s Hospital Division of Cardiac Surgery, is lead and corresponding author of this summative review, which underscores “a trend towards decreased operative mortality for patients with prior cardiac surgery undergoing acute type A aortic dissection (ATAAD) repair at high-volume centers.”
“Studies have found high-risk patients fare better at a center that has the right expertise as well as the capability to take a multidisciplinary approach at any hour, day or night,” Dr. Sabe said. “That’s what we offer in our group at Brigham and Women’s Hospital.”
24/7 Access to Aortic Experts
To assist hospitals referring a patient with an aortic dissection, Brigham cardiac surgeons with aortic expertise are always immediately available to review imaging, advise on the diagnosis and facilitate an expeditious transfer. Dr. Sabe, senior cardio-aortic surgeon Tsuyoshi Kaneko, MD, and their team work in concert with vascular surgeons and vascular medicine specialists. The surgical team in the operating room (OR) also comprises specialized nursing staff, perfusionists and cardiac anesthesiologists. Also at the ready are neurophysiologists who perform EEG and peripheral neuromonitoring of patients during surgery to help determine the best treatment strategy in the OR on a continual basis.
“We can activate our OR multidisciplinary team at any hour and, in many instances, have a patient from another hospital come in via helicopter and directly into our operating room,” Dr. Sabe said. “There, we can restore true lumen vessel flow and aortic integrity, often within 30 minutes of arrival, which is very difficult to achieve. Providing this level of expert care 24/7 is quite rare not just in New England but also nationally and internationally.”
In addition to complex operations like total arch replacement and procedures involving aortic valve-sparing techniques, the Brigham has expertise in minimally invasive and transcatheter therapies including thoracic endovascular aortic repair (TEVAR).
“We are equipped to perform transcatheter procedures in a hybrid setting.” Dr. Sabe noted. “If we need to address a complex dissection, we can do an open surgical correction concomitantly with TEVAR. We can do that in our hybrid operating room in one setting or do the two procedures in a staggered fashion.”
Long-Term Management Includes Genetic Testing
Dr. Sabe stressed that whether or not surgery is required for aortic dissection or another aortopathy, long-term medical management is crucial. At the Brigham Aortic Disease Center, cardiac surgeons collaborate with vascular medicine specialists, vascular surgeons, aortic radiologists, cardiologists and geneticists on long-term patient care. This team meets regularly to discuss the most complex cases and has collaboratively established several innovative clinical protocols and pathways to facilitate patient care.
Keeping in mind that aortic dissection is often due to a heritable or congenital condition, follow-up at the Brigham also includes genetic testing for all patients. If testing shows that one or more genes related to aortopathies has been triggered, then genetic counseling will be offered to the patient and their family. Family members may also undergo screening tests with their primary care doctors and be referred to the Brigham for follow-up if an aortic problem is detected.
“The burden of aortic disease not only impacts our patients, but also can ripple out to their family,” Dr. Sabe said. “With genetic testing, we can give all parties the relief of knowing they have been genetically cleared or let them know there is an issue that needs to be followed and potentially treated early, often preventing disease progression or catastrophic events.”
Some investigators in the Division of Cardiac Surgery are conducting basic science research to look at the origins of aortopathies and the differences among these diseases, including the genetic components. Others are focused on clinical outcomes research. Dr. Sabe has been exploring risk stratification of ATAAD patients and found that advanced age alone should not be grounds for deciding against surgery. “We have had excellent outcomes offering surgical repair to appropriately selected elderly patients, well into their ninth decade and beyond,” he said
“Everything we do in our group starts with our mission of delivering state-of-the-art care and performing cutting-edge research,” Dr. Sabe added. “We are uniquely positioned to provide timely and precise care that patients need to survive these life-threatening emergencies and the expertise they and their family need long term.”