Melanie Cole, MS (Host): Welcome to the podcast series from the Specialists at Penn Medicine. I'm Melanie Cole. And today, our discussion focuses on the future of aortic care. Joining me is Dr. Jeremy McGarvey. He's a Clinical Assistant Professor of Surgery at Penn Medicine. Dr. McGarvey, thank you so much for joining us today. Can you start with some general aneurysm background, how common they are, and the scope of what we're discussing here today?

Jeremy McGarvey, MD: Thanks for having me. So, it's important, I think, for non-cardiac surgeons to understand that it's hard to pinpoint how common aneurysms are, because the definition of what we call an aneurysm has somewhat changed over time, particularly as it pertains to treatment within cardiac surgery and what our thresholds are for intervening on these individuals.

So, I think if you were to go back, say 10, 15, 20 years ago, the definitions for what an aneurysm was and what's normal was fairly black and white. And you would often see radiologists, for instance, call anything over a certain size an aneurysm and anything under that size not an aneurysm.

And I think what we've come to find in what we call an aneurysm is that it's really patient to patient. And our definition is really based on many factors, not just a singular measurement. So, with that in mind, when we see patients with aneurysms, it comes down to a lot of things, not just size. And because of that, it's hard to define or put a number on how prevalent aneurysms are in the broader population, if that makes sense.

Host: Dr. McGarvey, can you speak on the multidisciplinary management of aneurysm and other aortic disorders. Why is this so important for these complex patients?

Jeremy McGarvey, MD: Because the aorta is connected to everything. And so, when we're talking about aneurysms, whether it's chronic pathology or more acute pathology, it comes down to more than just a heart surgeon. Even for the most routine heart surgeries, it's not just a heart surgeon, it's a team. We have cardiac anesthesiologists, we have specialized nursing, we have specialized perfusionists.

But it even extends beyond that for aortic, in that we have to also lean on our vascular surgery colleagues because a lot of these procedures nowadays, as the technology advances, are being done through hybrid approaches where some of it's open surgical techniques and some of it's endovascular. It relies on radiologists that are facile with doing more complex imaging techniques in terms of three-dimensional reconstructions and magnetic resonance. And everyone else down the line from nephrologists that have to take care of these sick patients to our neurosurgical and interventional radiology colleagues that sometimes have to deal with downstream complications from just taking care of really sick individuals.

So, it's really a team approach. And I think that's important for having an aortic center, because if you don't have one of those individuals, eventually you're going to run into a problem. And so, it’s the whole team approach that I think makes a program run smoothly and is able to manage these patients and the occasional complication in a streamlined fashion.

Host: Dr. McGarvey, tell us a little bit about surveillance programs, changes to guidelines, how they've changed your surgical practice. When you get patients that are told mildly dilated aorta or moderately, tell us what you do with these patients and how they work through the program as far as surveillance.

Jeremy McGarvey, MD: The major societies’ guidelines are fairly nebulous in terms of what to do with these individuals. And I think that creates a lot of pause and confusion for primary care physicians, for cardiologists, and for ER doctors out there in the community in terms of what to do with people that have dilated aortas. Maybe they're not surgical yet, but they're not normal.

And so, I've spent a lot of time recently trying to develop a program that takes some of that confusion out of the equation for my primary care physicians and cardiology colleagues. What the guidelines would say is that if someone were to come in with a dilated aorta, they should be imaged every six to 24 months with some sort of modality that can measure the diameter of their aorta. I think that is somewhat confusing because we have providers on one end of the spectrum that will image these people every six months, and we have providers on the other end of the spectrum that will image them much less frequently. And then, you have the individuals that are coming in through the emergency department or something like that, that may incidentally find an aneurysm, and then they get lost to follow-up. And they never get it imaged again because they don't have a primary care physician.

So, we've developed a program to try to define an institutional standard of care when it comes to looking at these people. And what it does is it takes these people, it looks at their size, and it looks at other risk factors that these people have, whether it be family history, whether it be concerns for genetics. It takes their body size into consideration, and then it puts them on a pathway. And some of those individuals may immediately be at a size that warrants a discussion with a surgeon. Some of these people may be on a more frequent surveillance pathway. And some of these individuals may be on a less frequent pathway.

And so, it takes some of the confusion and thought out of it for those individuals on the front lines. And it also allows us the plasticity to alter those algorithms and those pathways if the guidelines change, and if we find new information. So, it's really been helpful for us here to have these people come in, get put into our thoracic aortic aneurysm surveillance program, and really have a very defined path for surveying these individuals down the road.

And I think it takes some workload off the frontline providers. It makes their life easier. It makes their office more efficient and makes my office more efficient. So, that's what we're currently doing. And that may change, but the nice thing is that the program can easily handle change in the future.

Host: Well, thank you for that. Now, speak about some of the novel treatment strategies for acute aortic pathology and speak about some of the strategies for elective aneurysm surgery. Speak about some of the treatment options that you have at your disposal there to help patients both in the acute phase and in the elective phase.

Jeremy McGarvey, MD: Yeah. And this highlights the differences, I would say, in a more aorta center than one that's not. The acute pathologies, you know,  we have multiple tools at our disposal to handle these individuals. Each one's anatomy is going to be different. Each person is going to be different in terms of how sick they are. Some can be extraordinarily sick to the point that maybe they're not even a surgical candidate. And then, you have other individuals that are very, very stable and have no signs of malperfusion. So, there's a big spectrum. And so, having a bunch of tools in our toolbox to be able to deal with these acute pathologies is really helpful, because in a lot of cases we don't know what's coming through the door.

In the acute aortic realm, a lot of times these people are being transported directly to our operating room. Time is of the essence. We're trying to address their pathology as quickly as possible, particularly in situations where there's malperfusion. And, I think if you were to go back 10, 15, 20 years ago, the primary focus of surgical repair was to go in, find the tear in the aorta, cut out that tear, and replace that section of the aorta. That is still true today. We still have a very entry tear-focused treatment strategy.

But where I think it's evolved over the past decade or so has been that we are now more aggressive about valve preservation surgeries where, if the tear is down near the aortic valve, we do our best, particularly in a young individual to try to save those valves. That translates to benefits way down the road for those people. We're also more aggressive on the top end up in the aortic arch about really fixing the arch, and trying to set ourselves up for future surgeries or future treatments that need to be done because a lot of these individuals are going to need staged treatments, staged surgeries to address residual dissection in their descending aorta.

So, I think we're more aggressive with managing the aortic arch and having a little bit of foresight and making our lives easier in the future by doing a good repair that sets ourselves up for success down the road. And that has gone hand in hand with a lot of the newer devices that are available to us now that really make our lives in the operating room easier to do those things. So, we have more tools at our disposal and we're setting ourselves up for the future, particularly in the acute aortic scenarios.

In the chronic space are typically people coming to us through our surveillance program. Maybe they've seen a little growth. Maybe they're at a size where the consideration needs to be done. And as I mentioned very early on, there's not one answer that fits all these people. So, I'm going to give a different answer for the 4 ft 10 female that's 60 years old that has a family history of aneurysm with a 4.5 cm aorta than I am for the 5 ft 10 male with no family history that has the same size aorta. It's very patient-specific. It comes down to social factors. It comes down to family history. And ultimately, when the decision is made in these individuals to proceed with surgery, it's based on a risk-benefit analysis to the best of our abilities, where we're balancing the risk of elective aortic surgery to the risk of ongoing medical management and imaging surveillance.

And so, when we can see that the scales have tipped in favor of surgery, we'll offer these individuals an operation and we'll be able to cross the T's, dot the I's and do it under our terms. And what that translates to in the operating room is that a lot of times we're able to do it through smaller incisions. We can do it minimally invasive. Sometimes not cutting the whole breastbone, sometimes not cutting the breastbone at all, and do I think, fancier operations where we can address the entire problem, leave these people with no residual disease, and try to restore them to a fairly normal survival curve. And just like in the acute aortic space, set ourselves up so that when that future procedure does come, we have a really easy way to address it.

Host: Thank you for all this great information, Dr. McGarvey. As we wrap up, what's your vision for the program and how will the care model you've described improve the way patients receive their care, the journey outcomes, and receiving care for related conditions?

Jeremy McGarvey, MD: We have a fairly large catch net within central Pennsylvania, where we're looking to gather more people that want to enter into our surveillance program. And what that means is that those people are going to have, a more contemporary treatment strategy for their disease process, because that program is always going to be evolving with the technologies and the surgical standards that we have.

So, as the surveillance program takes hold, we're going to expand further and further out from where we are now to get these people to us. The surgical technologies that we have in the operating room are ever evolving. We're becoming better and better at aortic surgery.

And so, what we'd like to do is expand our surveillance program to the point that we can get these people in our doors, keep them up to date on the current standards. When the time comes that these individuals do need surgery, we offer them surgery with the safest possible outcomes and with the most up-to-date technology that we have that will set themselves up for success in the future. And if and when those people do have an acute aortic event, which fortunately, is very rare, we already are aware of those people. Our doors are always open. We have a treatment pathway that is already very streamlined. We can get them into the operating room quickly and try to correct this potentially devastating diagnosis.

So, I think from my standpoint, we have the acute aortic space, the surveillance space, and the chronic surgical management space. And I think that we're going to see growth in the surveillance in the chronic, more elective aneurysms, hopefully less acute aortic pathology. But we're always prepared when the acute aortic pathology walks in the door.

Host: What an informative episode this was, Dr. McGarvey. You are an excellent educator. Thank you so much for joining us and sharing your incredible expertise. And to refer your patient to Dr. McGarvey at Penn Medicine, please call our 24/7 provider-only line at 877-937-PENN, or you can submit your referral via our secure online referral form by visiting our website at pennmedicine.org/referyourpatient. That concludes this episode from the Specialists at Penn Medicine. I'm Melanie Cole.