Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties, as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and we have a thought leader panel for you today with Dr. Michael Popeck, he's a non-invasive cardiologist and the Medical Director of the AHN Center for Aortic Disease at the AHN Cardiovascular Institute; and Dr. Scott Halbreiner, he's the Director of the Center for Aortic Disease at the AHN Cardiovascular Institute. And they are here today to highlight aortic disease.

Doctors, thank you so much for joining us. Dr. Halbreiner, I'd like to start with you. Can you provide a bit of an overview of aortic disease, what you're seeing in the current trends. Please tell us the scope of the issue we're talking about here today.

Dr Scott Halbreiner: Thanks, Melanie, for the introduction. And yeah, aortic disease is pretty all encompassing, I think, of many different pathologies that we see involving any part of the aorta, whether it's the ascending aorta, the descending aorta, or even the abdominal aorta. And the trends are that a lot of patients are out there with these existing problems and don't even know it. And so, we have an increasing volume of patients with undiagnosed aneurysms that get discovered by a CAT scan that just happens to be done for some other reason. And what we find is that a lot of these patients and even some of the providers aren't sure exactly how to manage this or what the true risk of an aneurysm could be in terms of rupture or dissection.

As a center for aortic diseases, our goal is to kind of educate the community and not just our peers, but our patients as well as to what the true risks of aortic aneurysms and aortic dissections are, and whether we need to intervene upon them earlier or later, what we can do to manage these diseases throughout time because, truly, aortic disease is a lifelong disease. The patient's always going to live with the risk. And so, our job is to kind of limit and improve upon the patient's quality of life, but limit their risk of problems down the road, whether it be using medications that Dr. Popeck would look into, or whether it's to discuss surgical correction of some of the diseases, if it gets to that point.

Melanie Cole, MS: Thank you so much for that overview. And Dr. Popeck, why don't you give us an overview of the AHN aortic program itself?

Dr Michael Popeck: I think that was a wonderful introduction by Dr. Halbreiner. The thing I might add is that a lot of the aortic risk factors have a lot of overlap with other cardiovascular disease. So, what we offer being a multidisciplinary group is we kind of cover encompassing medical care from the medical aspect all the way through surgeries and recovery. Not only that is the psychosocial aspect of it. You know, somebody is healthy and gets a scan for another reason. And then, they come out of it knowing that they have an aortic aneurysm is a pretty jarring life event. And so, we pride ourselves on the education side of things for patients, giving them the most up-to-date information that they need to go about living their lives and provide reassurance when necessary. I think that's a major part of at least what I do on the medical side. And I know Dr. Halbreiner does the same one from a surgical perspective.

Dr Scott Halbreiner: I agree. If I can comment and piggyback off of that a little bit is that a good point that Dr. Popeck touched on is these patients, the key that has developed over the last couple of years in patients is that they get these diagnoses and everyone's very worried when they discover they have an aneurysm, even if it's a very small aneurysm with really minimal risk of any problems outside of the normal aorta. But it is a constant worry for many patients.

And one of the newer guidelines that came out in the recent years was the goal of shared decision-making. Our goal is to educate patients. But in the end, within reason, there is a shared decision as if the patient's anxiety level is high enough with this and living with this disease, and they just don't want to think about it anymore, and there is some degree of risk, even if they don't meet every criteria that we have, but they meet some risk factors or size criteria, then sometimes correcting it and intervening upon the aneurysm is appropriate. So, I think that that's the key there, is these patients have this worry of this burden of an aneurysm and that can actually drive up blood pressure and increase stress. All those things are bad for aneurysms in general. So, we sometimes find ourselves talking to the patients and then discussing surgery when they may not be quite large enough, but close enough.

Melanie Cole, MS: Thank you for mentioning shared decision-making, and we're going to talk a little bit more about the guidelines and the surgical options. Before we do, Dr. Popeck, I'd like you to speak about the genetic component as Dr. Halbreiner was mentioning and sometimes these are found incidentally or you mentioned that as well. And so, I'd like you to speak about some of the risk factors and the current guidelines. And do you feel that these guidelines need to be more strict? Or are those pushing us towards being more aggressive up front or more complex surgery? Speak about the guidelines and the risk factors and where those intersect.

Dr Michael Popeck: I think I'll start with the genetic side of things, because that's another big implication for patients who are diagnosed with aortic disease, especially those who are diagnosed at an early age. There are generally two buckets of genetic factors that these patients fall into. Some of them are called syndromic, and have to do with connective tissue diseases, such as Marfan syndrome, Loeys-Dietz, or the vascular subtype of Ehlers Danlos. Those patients generally have coexisting physical Traits or musculoskeletal maladies that can kind of tip us off that something might be going on as well, which may then prompt us to look at their aorta or vice versa. So, there's that subgroup.

And then, there's what we call the nonsyndromic, which are people who just have genetic abnormalities or genetic findings that put them at risk for elevated aneurysm size, or even there's overlap with cardiovascular disease. And a lot of the times we don't find this until we ask and dive deep into the family history and say, "Oh, you know, I did have multiple family members that passed at an early age." It was always just called a heart attack, but until we start digging deeper, we find that some of these may have been related to aneurysms.

And then when it comes to the medical side of things, a lot of things that set people up for cardiovascular disease in general in terms of coronary artery disease, stroke, all that kind of stuff. There's a lot of overlap in the risk factors that need control. So from my standpoint, the biggest thing is blood pressure and heart rate control with beta blockade and angiotensin receptor blockers being the workhorses there. Knowing the nuances of cholesterol management, it seems like the guidelines for cholesterol is always a moving target. So, knowing what's appropriate for each individual patient is kind of an individualized approach. And then, things such as smoking cessation, counseling, and then we continue to follow the patient all the way through post-surgical care, really diving into whatever type of medical history they have that coincides with their aortic disease.

And in terms of the guidelines, when to intervene has kind of been a hot topic. Generally, it's been somebody with an ascending aortic aneurysm is five and a half. But the guidelines that came out, I think in 2022 from the AHA and ACC, they kind of left some leeway in terms of if you're at an experienced aortic center and you have experienced surgeons, such as Dr. Halbreiner and Dr. Tsukashita and the rest of our staff. They leave leeway to operate all the way down to five centimeters, or if you start to do some normalization to body surface area and that kind of stuff. And that's where I think Dr. Halbreiner was referring to is when to weigh the risks and benefits from not only an anatomic and physical standpoint, but also a psychosocial standpoint too.

Dr Scott Halbreiner: That's a great summary. And the thing about guidelines is they're guidelines, right? They're not strict criteria to say, "This is when you should operate, this is when you shouldn't," but they're the best we have to help guide therapy. And over the last years, comparing the 2022 guidelines to the last time they were updated, which is around 2010, there has been a push for being a little more aggressive in treating these patients. Like Dr. Popeck said, what used to be five and a half, we're now down to about five centimeters in centers of excellence like ourselves, where we do a lot of these cases because the risk of the surgery turns out to be less than the risk of a complication of having an aneurysm over five centimeters, especially when you're throwing multiple risk factors for the patient on top of that, whether it's high blood pressure, family history. And the more risk factors you have, the higher the risk is. Genetics plays a super important role. And for the most part, I think, my gestalt is anybody less than 60 diagnosed with an aneurysm, whether they have history or not in the family will get genetically tested. We are finding many, many different genes, not all related to a connective tissue disorder, but there's a slew of genes out there that correlate to thoracic aortic aneurysms in particular. And the data may not be sufficient to say you have that gene, you should have surgery, but it certainly counts as a factor that I weigh into consideration when I'm deciding to discuss surgery with the patients or not. But certainly, I believe the guidelines have gotten a lot stricter.

I just came from a meeting, our national society's meeting, two weeks ago, maybe less, where they all were on board with we think patients should have a higher risk than we thought before, and we should be more aggressive. In fact, I look back at some of our data from last year and, you know, the acute aortic emergency, which is an aortic dissection, most of these patients usually have an aneurysm. At baseline, most of them never knew they had it. But a few, about five or six of the dissections we did last year have actually been seen in the outpatient setting with aneurysms between four and a half and five centimeters, which makes the case that maybe we need to be a little more aggressive in treating these patients, because just because you have a five-centimeter or less aneurysm doesn't mean you don't have an increased risk of a problem like a dissection.

Melanie Cole, MS: Dr. Halbreiner, and this is such an interesting conversation that we're having today. And after you've decided with shared decision-making that contributes to choosing that best therapy for the patient and weighing the risks and benefits of surgical options, tell us about some of the exciting advances in technologies that help in conducting these more complex surgeries. And while you're telling us that, does the research show that more surgeries completed, the more successful the outcome?

Dr Scott Halbreiner: So for the first question, yeah, technology has been growing and growing. And what we have seen is that starting 20 years ago when endovascular therapies became the hot item in aneurysmal disease for the abdominal aorta, it slowly progressed proximally into the descending aorta. And now, we have pretty good data to show that aneurysmal and aortic dissections within the descending thoracic aorta can almost usually get treated with some sort of minimally invasive endovascular therapy, where we put a stent inside the aorta. In some cases, it may still not be ideal, but in many cases, it is.

And in the recent 5, maybe to 8 years, we're pushing that envelope even further and working with companies designing devices that are made to encroach into the arch with a stent. So, the arch is a very complex portion of the aorta with the head vessels coming off of it. So, putting a stent up there, you really have to design devices that branch stents into those arch vessels. So, that has kind of been where we're at now, where there are some FDA-approved devices on the market. And then, things that have been talked about in recent years in the meetings are moving that stent into the ascending aorta and even into the root into something called an Endo-Bental procedure. But these are still off-label type procedures that haven't become mainstream yet. But definitely, we see the future of this heading down, the road entirely almost endovascular therapies. But for now, a true aortic dissection, type A dissection, involves open heart surgery to correct and true aneurysms of the ascending aorta are surgical as well.

And the other thought process advancing this is we think about the patient and not just what we're fixing now, but what we may need to do down the road when we think about surgical planning. And so, I may see an aneurysm in the ascending aorta with maybe smallish aneurysm in the arch or in the descending aorta. And I'm thinking this patient may need further surgeries down the road. But if I only do an ascending aortic repair right now, I'm not really setting them up for a minimally invasive procedure down the road in the descending aorta. I have to do some other modifications to my surgery the first time so that the second time they can get a much simpler, straightforward procedure. So, there is a lot of talk. There is no true center excellence for aortic diseases, but it has been talked about at different national meetings where this will be coming in the next couple of years, where to be a center for aortic disease of excellence, you need to have good outcomes and high volume. And there's a lot of data out there to show that not just the center that does a lot these types of surgeries, but also a surgeon that does a lot of these types of surgeries. The more you do, the more successful and better your outcomes are going to be, especially when it gets to complex surgeries.

Most of us can do an ascending aortic aneurysm repair. But not all of us are very comfortable doing a complicated ascending total arch repair or a frozen elephant trunk. And those are certain procedures that you have to do enough of to really feel comfortable and to not put the patient at risk for complications, because it's not a common procedure, but doing one a year is something probably most people shouldn't be getting into, but doing six to 12 frozen elephant trunks a year is a good volume for a center or a single surgeon even to have good outcomes and show that.

Melanie Cole, MS: Dr. Popeck, as we've mentioned a few times about the multidisciplinary management and Dr. Halbreiner just gave us an excellent comprehensive overview of the surgical options as we look at all of the different people that are involved in monitoring and following these patients. And you've mentioned psychosocial, the worry factor that goes into it. Can you speak about your team and all of the different people that are involved, including genetic counselors and psychologists, because as you both have said, this can be kind of a devastating, very scary diagnosis.

Dr Michael Popeck: I think being part of a multidisciplinary team, I mean, between myself, my partners in General Cardiology and Interventional Cardiology along with the surgical side, we're all pretty well versed in what the restrictions are, what timing intervals are for the monitoring of, when to obtain the next set of imaging, what to do if we're progressing, you can read the guidelines for that, I think. But where we all kind of excel here at the AHN Center for Aortic Disease is that we all have seen this before, we know how to talk to the patients. A lot of these people, there are physical limitations we have to put on them, which could be pretty jarring from a life perspective. So, knowing just how far they can push it, knowing when to restrict them, knowing how this may affect their livelihoods, I think that's something that we get into pretty well. And then, having access with the primary cares in the community and having access to mental health services are something that we could definitely get them in touch with through the AHN network.

In terms of the joint decision-making of, when to, intervene upon these things, whether it's from my perspective, from Dr. Halbreiner's, or from an abdominal perspective, from the vascular perspective side of things, all of this stuff kind of gets worked together and there's frequent communication needed to determine, "Hey, is this patient doing okay? Hey, is this somebody that we should be taking a look at more closely?" And we even have an excellent coordinator here at the center. Her name is Kylie Barnes and she is a direct point of contact for people. And then, she is also well-versed in all this stuff and can answer questions by phone, by email, by text. We're very available and we'd like to be big resource to all of our patients.

Dr Scott Halbreiner: That's a great point and summary. And I'll reiterate that, you know, our aortic coordinator has added so much more to our program and been a blessing to patients. I think the key with our center is that we're not a center where you just go see a doctor once a year for five or 10 minutes and that's it. But we provide access to the patients where they have direct contact to Kylie, and they have ways to get in touch with us. We have an email just for our center that any patient can just email any questions they have that myself and Dr. Popeck and Kylie can all get into and respond to.

We have educational pamphlets. We work with charitable organizations like Aortic Hope, which was developed by John Ritter's family after he suffered the death of an aortic dissection. And we get educational materials from them that we give to patients and I think go a long way in helping patients feel comfortable with this disease process. Because like Dr. Popeck said, a lifelong problem, that talking to somebody for five to 10 minutes every year isn't always enough. And we try to bridge that connection by giving them education and ways to reach us. And there are support groups locally and also national support groups like Aortic Warriors that I know some of my patients belong to as well, just to talk it over with other survivors of aortic dissection.

Melanie Cole, MS: Thank you both. This has been a very enlightening episode. Dr. Popeck, I'd love to give you a final thought here about the benefits to a cardiologist referring to an Aortic Program like AHN. What features should prompt a referral? And summarize this for us today.

Dr Michael Popeck: So, a lot of the referrals are coming from the primary care network that we're associated with, but we've had people self-refer themselves to our service and for the general cardiologists who aren't as familiar with imaging guidelines, when to obtain them, how to do it, or for that subset of syndromic familial aortic diseases with the Marfans and the Loeys-Dietz, those patients tend to take a little bit more involvement and familiarity with all of the maladies that can come along with their disease, not only their connective tissue, but their aorta as well. So, I would encourage anybody who may have a suspicion or needs genetic testing, anything like that, if you need a subspecialty service between myself and Dr. Halbreiner, we are pretty well-versed and happy to help manage your patients.

Dr Scott Halbreiner: We kind of see ourselves more as a resource for not just patients, but our peers. So, I know all cardiologists are perfectly capable of managing, blood pressure, that's their job. But I think, even reaching out to surgeons out there and other hospitals and other settings that do heart surgery, we're here as a resource to bounce questions off of or to provide your patients with more education and connections to resources that they may not otherwise get from their primary cardiologist or PCP. So, we're here not just for the patients, but for our peers.

Melanie Cole, MS: Thank you both so much for joining us today and sharing your incredible expertise in this thought leader conversation. To learn more or to refer a patient, please call 844-MD-REFER or you can visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. Please remember to subscribe, rate, and review AHN MedTalks on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.