Melanie Cole, MS (Host): [00:00:00] Welcome to the podcast series from the specialists at Penn Medicine. I'm Melanie Cole, and we have a panel for you today to highlight guidelines for surgical versus medical management of aortic dissection. Joining me in this panel are Dr. Melanie Freas, she's the Clinical Program Manager at the Center for Bicuspid Aortic Valve diseases at Penn Medicine; and Katelyn Rosemann, a cardiac surgery nurse practitioner and clinical coordinator at Penn Medicine. Thank you both for being with us. And Dr. Freas, I'd like to start with you. Can you briefly discuss the differences between acute and chronic dissection with regard to the guidelines for surgical versus medical management of each?

Melanie Freas, MD: Absolutely. So, this is a big topic and could indeed be a podcast all on its own. But just briefly, we'll talk about acute aortic dissection, it means it's happened [00:01:00] very recently, generally within the last two weeks. And this is a stage where symptoms come on suddenly with many patients reporting severe chest pain, back pain, or abdominal pain, or experiencing signs and symptoms of heart failure.

During the acute phase, the aorta is more fragile, and the body is in a state of shock, if you will, trying to survive. So, the medical team acts quickly to stabilize you, controlling your blood pressure, and deciding whether surgery is needed. During the acute phase, the mortality rate is very high, so timing is very important. Most patients presenting acutely with a type A dissection or tear in the aorta closest to the heart will need emergency open heart surgery to survive. On the other hand, most patients who present acutely with a type B dissection or tear in the aorta further down will be managed with medications at first.

[00:02:00] Some of these patients, however, will require surgery, which is typically done with stenting. When we reach the chronic phase, that's about four to six weeks, later, the body has adapted to the altered blood flow patterns in the tear and the aorta is becoming more stable. Many patients live with chronic dissections for years with careful monitoring. About 20% of these patients will require another surgery within 10 years of their initial dissection.

I will add that if you want more information on aortic dissections, I recommend a previous podcast with one of our surgeons, Dr. Kendall Lawrence. She does a wonderful job explaining more details.

Host: Well, thank you very much, Dr. Freas. So, as far as long-term follow-up and testing, we recognize that long-term follow-up care is a crucial component of post-event cardiac care. However, do these elements of care have a distinct objective for acute and chronic dissection? Who's [00:03:00] involved? Speak a little bit about the multidisciplinary involvement in the care of patients post dissection and the role that advanced practice providers play in that long-term surveillance of these patients.

Melanie Freas, MD: So, yes, acute dissections require closer followup than a chronic dissection. This is because, in the acute phase, the tear is fresh and more susceptible to change. All patients with acute dissection will be admitted to the hospital for surgery for closer monitoring. CAT scans are obtained of the aorta to monitor it closely.

Once the aorta stabilizes in the acute phase, we then go on to monitor these patients with CAT scans at one month, three months, six months, and then yearly. For our chronic dissection patients, we monitor the CT scans yearly.

Katelyn Rosemann: The long-term care of a patient with an aortic dissection requires a specialized team. Here at the Penn Aorta Center, the cardiac and vascular surgery teams are the primary aortic provider [00:04:00] to monitor the aorta carefully and assess for change. The surgery team consists of surgeons and advanced practice providers to ensure that the repairs to the aorta are healing well and the rest of the aorta remains stable.

Patients will typically see the surgeon for the first few visits after an acute dissection, and then transition to the dissection clinic to follow with a specialized team of advanced practice providers. In addition to the surgery team, our patients are also followed closely by cardiology and their primary care physicians to play a big role in the medical management side of the aortic disease with a strong emphasis on blood pressure management.

Other specialists involved in the care of patients after aortic dissections include geneticists, cardiac rehab providers, mental health providers, and other medical specialists. As far as the role of an advanced practice provider is concerned, APPs for sure play a central role in the long-term care of patients with aortic dissection. By serving as the expert in their care from an aortic dissection perspective, they [00:05:00] coordinate and independently interpret regular imaging, serve as the first point of contact for new symptoms or concerns. They spend time educating patients, offering reassurance, and helping them understand their follow-up plan.

Advanced practice providers can also refer for genetic evaluation when needed, and keep communication flowing between cardiologists, surgeons, specialists, and primary care providers. In many ways, we're the steady partner, guiding patients through lifelong surveillance and helping to ensure nothing's missed.

Host: So Katelyn, why is long-term follow-up care so important? And what distinguishes superior post-dissection care from routine care?

Katelyn Rosemann: Long-term follow-up care is probably the most important thing for patients to understand following an aortic dissection. One of the biggest misconceptions that we see is the idea that surgery cures the problem. When in reality, a dissection is a lifelong diagnosis. Even after a successful repair, the rest of the aorta still needs really careful monitoring.

In fact, as [00:06:00] Melanie had said earlier, about one in five patients will need another procedure within 10 years of their initial repair, which is why staying connected to a specialized clinic makes such a difference. Our dissection clinic keeps patients plugged in with their surgeon and care team and offers easier access to appointments, and provides extensive education so people truly understand their condition and remain plugged in.

At the Penn Aorta Center, we build a tailored lifelong surveillance plan for every patient supported by a dedicated team of surgeons, APPs, cardiologists, and genetics. It's proactive, highly coordinated, and grounded in the latest guidelines and emerging treatment options designed to keep patients safe for the long haul.

Host: Well then, Katelyn, at what point does follow-up care and surveillance transition to surgery or a progression of medical management.

Katelyn Rosemann: So, follow up care will be transitioned back to the surgeon at any point in the surveillance period if the aorta starts to enlarge or grow quickly, cause symptoms or affect [00:07:00] blood flow to the organs. The goal is always to act quickly before a problem becomes dangerous. So by staying plugged into the surgeon's clinic, since the dissection clinic is part of the surgeon's clinic, we can easily get patients plugged back in with the surgeon when the time arises.

Progression of medical management, so when patients come into the office and we notice that their blood pressures are running higher, we tend to really stress the importance of monitoring blood pressures at home and getting back to their primary care provider or cardiologists to be more aggressive about blood pressure management if we notice that the blood pressures have been out of control.

Host: Yes, that's so important. And Dr. Freas, when we think of the importance of genetic testing, what's the current status of genetic testing for aortic dissection risk? And where are we in the search for expanded genetic testing for dissection risk in the general population?

Melanie Freas, MD: [00:08:00] So, this is a very good question because I would say, in the last 10 years, we've come a long way with our genetic testing and our ability to identify certain variants. And genetic testing is very helpful for people who already have aortic disease or those patients who have a longstanding or strong family history. It helps us understand individual risks, and it helps protect their relatives and their loved ones. We're learning more and more every year, but we're not quite at the point where we want to offer genetic testing to everyone. We really want to focus on those patients who we know will benefit from it. We currently are offering genetic testing for any patient who has a history of a dissection, particularly those in the younger population of less than 60, if patients have a strong family history of aortic dissection or aortic aneurysm, and those patients who are suspicious for any syndromic diseases.

Despite these advantages in the area, though, we really can only [00:09:00] identify a few variants. And the yield remains very low at about 20-25%. I think one of the most important things for providers and for patients to know about genetic testing is that a negative genetic test does not mean that the aortic disease is not genetic. It just means it's negative for the known variants that we are able to identify. We have a long way to go. And certainly, Penn is really instrumental in doing a lot of research on genetic testing.

Host: Katelyn, thinking about the psychological effects of dissection, several years ago, the Cleveland Clinic did a survey among patients who'd been treated for dissection and found that 22% of them had PTSD years after the event. And one of the comments the researchers made is that, unlike the other events, there's no safe place to retreat to when the heart's involved. How do you counsel people living with a dissection to assuage their fears? Because I imagine that that has got to be scary [00:10:00] every single day.

Katelyn Rosemann: Absolutely. Living with an aortic dissection is very frightening. I take the approach to reassure patients that it's completely normal and expected to feel that way. One of the benefits to being followed in a specialized clinic of patients with aortic dissection is that patients feel that they're not alone in their diagnosis. So, they find it to be very helpful to be followed by a program that specializes in their condition, and that they have a dedicated team watching the aorta closely.

Over time, most dissections become stable. And regular imaging and check-ins give us plenty of warning if anything changes. So in the clinic, I try to stress that our goal is to restore quality of life for our patients and teach them not only how to survive a dissection, which they've already done, and then kind of flip into starting to live with a dissection. So, this is something that takes time, and we recognize that.

We [00:11:00] also provide patients with an extensive list of trusted resources to explore after their visit, including organizations like the John Ritter Foundation and Aortic Hope. These groups offer reliable information about aortic disease, and they also have a really deep supportive community where patients can connect with other patients who share similar experiences by way of support groups or educational platforms in order to help them feel at ease with living with an aortic dissection.

And along these lines, I just wanted to take a minute to highlight an upcoming event we're really excited about here. On April 17th, 2026, the Penn Aorta Center is hosting the inaugural AortaDelphia event, which is a special educational meeting, held in collaboration with the John Ritter Foundation, bringing patients, families, and clinicians together in one space to educate and bring awareness to aortic disease. This is a pretty unique platform. It's not often that [00:12:00] there are educational events out there offered to both patients and clinicians. And it's really going to be a chance to build the community, hear from national experts and local experts at Penn and allow people to feel supported by people who truly understand the journey. This event is completely free and open to anyone impacted by aortic disease. So, we're really excited about that.

Host: Thank you for telling us about that, Katelyn. And Dr. Freas, when we talk about moving forward with activity and exercise, what lifestyle modifications are necessary in people who've had a dissection? What sort of precautions do they need to follow in order to best prevent a worsening of their condition? And can lifestyle modification reverse any of the sequelae or make it better, or does it make it worse?

Melanie Freas, MD: This is a topic that I spend a lot of time on with my patients. [00:13:00] Lifestyle changes are very important; however, they're not going to reverse what has already happened. Our goal is really to protect our aorta from becoming unstable or enlarging in diameter, or an event that would require our patients to move on to surgery or additional surgeries.

So, we talk about keeping your blood pressure well-controlled. And we work with cardiologists very closely to do this. We want patients to be active, we want them to exercise. We are asking that they try to enjoy and encourage good quality of life as much as possible for our younger patients. We can offer them an appointment with our sports medicine if they're very active and want to get back into very high intensity type of exercises. Or we can offer a cardiac rehab for our older patients or patients who are not doing a lot of high intensity.

Importantly, we stress that patients want to avoid activities [00:14:00] that will cause straining or sudden changes in their blood pressure. Healthy changes are always very important. Limiting your alcohol, not smoking, maintaining a healthy weight through your life. These are all things that are going to help you in the long run. Again, it's important to say that these choices can't heal the tear. We're just trying to prevent any further problems with the aorta down the road, and it allows patients to live more confidently and more safely with this chronic disease.

Host: Such important information we're giving out today. And Katelyn, last word to you. How does the clinic-- and I feel this is so important, personalized followup and monitoring for each patient. As we've gone through the psychological factors and exercise activity, lifestyle modification, how do you followup with patients and monitor them for these things to help them have a better quality of life?

Katelyn Rosemann + Melanie Freas: Yeah, this is a really [00:15:00] important topic. So, one of the biggest challenges with chronic aortic dissections is that no two dissections are alike. Every patient's anatomy looks a little different after a dissection. Everyone has had a little bit of a different spin on their aortic repair or their medical management, and they all come in with their own baseline health and functional ability.

So, our clinic takes a really personalized approach. I spend a lot of time talking to patients about what their life looked like before a dissection, what their life is like currently, and what they're hoping to get back to. And then, we work in the restrictions from there and try to find a plan that works best for their life and what's going to be safest in the long run.

I also think it's really important and I spend a lot of time showing patients their CAT scan images that have oftentimes been reconstructed in 3D format and educating them about their disease so they understand the importance and, you know, the background and where all of our restrictions and our [00:16:00] recommendations come into play.

So once we established kind of where they were, where they are, and where we want to be, then we talk about their goals. And we build a plan that's safe, realistic, and tailored specifically to their condition to help them get back to a meaningful life again.

Host: Thank you both so much for joining us today and sharing your expertise on this topic. And to refer your patient to Dr. Freas or Katelyn 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/refer. I'm Melanie Cole. Thank you so much for joining us. That concludes this episode from the Specialists at Penn Medicine.