Deborah Howell (Host): Aortic dissection is a dangerous condition of the heart and must be treated quickly and effectively to ensure survival. The comprehensive aortic program, part of the Memorial Care Heart and Vascular Institute at Long Beach Medical Center, is dedicated to early detection, monitoring, and treatment of various aortic diseases using evidence based treatments. We'll delve into all this and more on today's podcast. Our guest is Dr. Mark Sakwa, Chief of Cardiovascular Surgery, Memorial Care Heart and Vascular Institute, and Medical Director, Adult Cardiovascular Surgery, Memorial Care Heart and Vascular Institute at Long Beach Medical Center.

Welcome back, Dr. Sakwa.

Marc Sakwa, M.D: Thank you, glad to be back.

Host: Always a pleasure. Let's jump right in. What is aortic dissection?

Marc Sakwa, M.D: An aortic dissection is actually a very serious problem. The aorta is the main blood vessel which exits the heart right after the aortic valve and actually gives the blood supply to the rest of the body, traversing all the way down across the head vessels, down and bifurcating into the leg vessels.

When that blood vessel dissects, what happens is that the inner layer and the outer layer separate. And then blood, instead of going into what we call the true lumen, where it's supposed to be, can then dissect and go into the false lumen, which is the layer between the inner and outer layer. So that blood is now going into an area that it's not supposed to go.

Host: Got it. And why is aortic dissection so dangerous?

Marc Sakwa, M.D: So what happens is, when blood now traverses into this false lumen. The outside of that area, the outer wall, is not as strong, and what can happen is, as the pressure elevates, it can rupture, and if it ruptures into the chest, you'd have free flow of blood into the chest, which would take somebody's life very quickly, or it can rupture into the sac around the heart called the pericardium.

And when blood gets into the pericardium, it'll constrict the heart so that the heart can't beat fully and eject blood, causing severe hypotension, meaning low blood pressure. As well, the dissection and the inner layer can go down and block off the blood supply to the heart, which would cause an immediate heart attack.

So it's a very dangerous condition that needs to be diagnosed quickly and treated quickly.

Host: Understandable. What are the two different types of aortic dissections and how do they differ?

Marc Sakwa, M.D: So when we talk about aortic dissections, we're basically, classifying them where their location is within the aorta. So a dissection that occurs in the first part of the aorta, we either call it type A or a type 1 and if it occurs in what we call the descending aorta, the part that's going down through the chest towards the abdomen and the legs, we call that either a type B or a type 2 dissection. The difference is that they're treated differently in the sense that they are, the type A, the 1 in the ascending portion of the aorta is more dangerous than the one that occurs in the descending aorta or the type B.

Host: So, how are type 1 and type 2 aortic dissection cases treated?

Marc Sakwa, M.D: So a type 1, which is the more dangerous one, is usually treated with emergent surgical intervention, where we will go in and replace the ascending aorta and sometimes a portion of what the, we call the aortic archwhere the blood supply to the brain comes out. So that requires emergency treatment surgically, whereas the type B can often be treated with medical management.

Medical management will consist of really good control of the patient's blood pressure, and then close follow up, and potentially surgery down the line.

Host: So does that outer wall repair itself then, in some cases?

Marc Sakwa, M.D: No, it won't repair itself. So what we do is we take and we remove the dissected portion of the aorta in the ascending aorta and we put a piece of Dacron, a graft made out of Dacron, that will now be a replacement for that diseased portion of the aorta.

If it's in the descending aorta, and we treat them initially medically, then we can go in and do a less invasive repair, which is called an endovascular repair.

What that is, we take a graft, a Dacron graft, or a Gore Tex material graft, we mount it on a catheter. We go up into the true lumen, and we blow up, we're using a balloon, this graft, to now go inside the true lumen, push the wall back together, and stabilize the aorta.

Host: Wow. That is just magnificent work. I'm sorry. When you said what you do to save people's lives, it's so visual when you describe it. It's truly amazing. What happens when a local community hospital doesn't have the required capabilities to treat a type 1 aortic dissection?

Marc Sakwa, M.D: Well, you know, that's a great question, because the majority of hospitals, particularly those that don't have cardiac surgery, cannot treat these problems. And even those hospitals that do have cardiac surgery, the overwhelming majority don't want to treat these problems because they're very difficult and it requires a significant amount of expertise.

So when these patients come into those emergency rooms and they're able to make the diagnosis, which is usually done with an emergency CAT scan; then they call and they try to transfer the patient to a center that can treat these types of problems. Fortunately, Long Beach is one of the major centers in Southern California treating these types of problems. And in fact, our program here at Long Beach Memorial is the fastest growing and one of the largest volumes in all of California.

Host: That leads me to my next question, which is, what sets apart the comprehensive aortic program at Memorial Care Heart and Vascular Institute at Long Beach Medical Center to treat emergency cases like type 1 aortic dissections?

Marc Sakwa, M.D: So we have established a program that has excellent surgeons who are actually experts in treating these problems. Our surgeons are trained to treat them both with open techniques, meaning traditional surgical techniques, but we also have the skill set to do these with those endovascular techniques.

Those that I described, the remount catheters. We mount the grafts on catheters, which is a less invasive way to treat it. We have a high volume program, and people who have these problems want to be at a program that does high volume, because there's no question that the more cases you do, the more expert you become, and the better outcomes you have.

So we have better surgeon capabilities, better trained surgeons who have both open and endovascular skills, and we're doing high volume.

Host: Here's the part that I'm really interested in. What happens to type 1 aortic dissection patients after they receive emergency treatment?

Marc Sakwa, M.D: So I want people to realize that this is a lifelong disease. We don't just stop treating them and following them after we do the initial procedure. It's lifetime control of your blood pressure. And lifetime follow up with surveillance CAT scans to be certain that there's no increase in size of other areas of the aorta, that there's no progression of disease in the aorta.

So it's a lifetime management and we follow our patients regularly, initially probably every two to three months, and then eventually every year with CAT scans and long term surveillance.

Host: That's wonderful. You know, one thing we didn't cover yet are the symptoms of aortic dissection.

Marc Sakwa, M.D: Right. That's very important for people to realize when they start having chest or back pain. And they start to get, perhaps, they start to get sweaty, they start to get anxious, their blood pressure is going up. Those are the signs of an aortic dissection, and they should go to the emergency room quickly for evaluation.

Very similar to the same signs people could have when they're having a heart attack. So, any types of chest pain, and particularly if you have high blood pressure. High blood pressure is associated with patients who have aortic dissection. So, onset of acute chest or back pain with high blood pressure in your history, something to consider in going to an emergency room for an evaluation.

Host: Yeah, don't mess around and try to contact your doctor. Just go right in.

Marc Sakwa, M.D: Right.

Host: Okay. Well, is there anything else you'd like to add to our conversation?

Marc Sakwa, M.D: Well, I think I'd just like to say that the good news is that with the evolving technology, the better blood pressure medications, that patients are having better outcomes. And if you go to a center that is expert in doing this, you really have a much better chance nowadays of surviving this problem.

There's about 2,000 or more cases a year in the United States that actually get to an emergency room. We don't know how many actually die before that. So it's not a totally uncommon problem. And if you get to a place that can handle it, that's your best chance of survival.

Host: Well said. Well, thank you so much, as always, Dr. Sakwa for your time and your expertise. We really enjoyed having you on the show again.

Marc Sakwa, M.D: I appreciate it, anytime. Thank you so much.

Host: You can learn more about the Comprehensive Aortic Program at Memorial Care Heart and Vascular Institute at Long Beach Medical Center by calling 844-662-6484 or visit memorialcare.org/lbheart. For more info or to listen to a podcast of this show, please visit memorialcare.org. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.