 Good afternoon. I'm Joe Rogers, the president and CEO of the Texas Heart Institute, and it's a real pleasure today to have the opportunity to spend a few moments with Dr. Rania Provenza, who just gave grand rounds at the Texas Heart Institute, exploring the issues of type 3 or type B aortic dissections. Dr. Provenza is a professor of surgery at Baylor College of Medicine, a member of the Texas Heart Institute professional staff, and is the current president of the International Society for Endovascular Specialists. Rania, thanks so much for taking some time after grand rounds just to explore a couple of other topics that I think we should discuss and kind of round out what I thought was a really good grand rounds. Thank you so much and it's really a pleasure actually to be here and be with you. So one of the things that you explored were the number of different therapeutic options that this difficult patient cohort has. You know, you've talked about the fact that the vast majority of these patients are treated with medical therapy, but some of them go to open repair and some are treated with endovascular repairs of their dissections. If you're in the emergency room and you have a patient come in with an acute type 3 or type B aortic dissection, how should we be thinking about the best therapy for that patient? How should the presentation impact our decision making? This is very important because a lot of times we're getting these phone calls from the emergency room with patients that they think the emergency room physician thinks that maybe they have a dissection. So the first thing first of all is to establish the diagnosis and the way that we establish the diagnosis is by having something a good imaging study and a good imaging study is what most of the years they have these days maybe all of the years is a CT and actually a CTA. You need to give contrast to make sure that you see this dissection because what is a dissection? Dissection is a tear that happened on the inner layer of the aortic artery wall and goes through the mid layers. So basically what it does is separates the layers and cause and dissect the layers. So this dissection can actually start from the ascending aorta that comes off the heart, can involve the coronary arteries, can go through the arteries that goes into the head and can cause stroke or can cause into the back and cause what we call malprefusion. Like somebody has a severe back pain or a belly pain because the arteries that goes into the kidneys or the arteries that goes into the bowel they get dissected. So the blood flow is not good enough. So the first thing is we do a diagnosis. We establish the diagnosis, we know what we have. If we know that this is distal dissection meaning anything that supplies the bowel, the kidneys but does not interfere with the ascending aorta because the aorta is like just for whoever is listening there is really like a cane. You have a short cane, long cane and starts from the heart, short cane, you have the vessels, you supply the blood, the head and then you have the long cane. So if we're talking about a dissection that really goes into the distal aorta, the first thing is medical therapy. These patients are very hypertensive. They come to the emergency room with a systolic pressure of 200, sometimes to 10 or 190. So there are patients that they have long standing high blood pressure which one word or another is don't been treated well or they haven't been addressed. So you see that because you see the patient said my back hurts, the pain is very is a lot and you see on the monitor the blood pressure is 190. This is really like a red flag there that we need to have an imaging study to say does this patient has a dissection. So imaging is important. In the meantime it's almost like I remember even from my early days being an intern or being a resident or being in the emergency room you do a lot of things parallel meaning you order the imaging study but at the same time you have to make sure that the blood pressure is under control. So you have to start at the hypertensive therapy and you have to take care of the DP, DT that we use you know to talk about and what kind of hypertensive therapy that but usually like a better block is a very good way of starting it because you need to control the heart rate and you need to control the blood pressure and at the same time you want to ensure that you have adequate flow. So you want to drop the blood pressure but not to the point when it's like you become hypotensive in a way. So you want your blood pressure to be around like 120, 110 systolic which actually for these patients is already hypotension right because these patients are actually get used to 190 but you don't want for them to be at this point 190 because you can have a what what we call uncomplicated dissection that because of the continuous high blood pressure can actually be converted to quote or complicated dissection. So you take something that you can treat medically to something that most likely you have to intervene sooner than later. So you control you take the imaging you control the blood pressure you make sure that the patient when you do the physical exam is very important to make sure that you have good pulses. So you always say say this to the residents all the time does the patient has good pulses it's like oh we have to check I'm like no that's important you do need to check because this is if somebody has good femoral pulses good palpable pulses in the leg if the legs are warm or if the hands are warm that's to me means that the patient is getting perfused so the level of urgency kind of like gets a second seat now we are still alert but kind of okay the patient is stable because it's a different story if on the physical exam I have in my mind that maybe the patient has dissection and then I would during my physical exam I don't feel any pulses in the leg or the leg is is cold then I'm thinking that the dissection is not really simple I mean there's no real dissection simple but it's not uncomplicated but has some kind of mal perfusion and that those mal perfusion signs or symptoms or even radiographic characteristics would lead you to a an intervention rather than a medical therapeutic approach because we the newer I mean I mentioned this during the grand rounds but during the STS-SVS reporting standards in 2020 they came up with these high-risk features that the patient should have to more like prowners to guide us towards having endovascular therapy down the line and one of the features is radiologic mal perfusion where you have basically what you have you have a good lumen what I say to the patient you have the good and the bad and you know what we call the twin the false lumen but basically for the patients is really the good and the bad and sometimes the bad can be so dilated that if you have the two lumens here really squeeze the good lumen so you don't really have any flow through this good lumen so you have to find a way to really expand this good lumen and giving away life so can squeeze the bad I was struck by your the slides that you showed that describe the aortic event-free survivals in this patient population and I was was thinking to myself what actually happens to those patients and I think it has implications for us as treating physicians to be on the lookout for complications why are in this patient population that presents with an aortic dissection what are the most common causes of death and how should cardiologists in particular be thinking about those as we're following the patient's longer term? Great question one of the things that I didn't mention on the ground but I think is important to know and been down here at Baylor at Texas Heart I think is important is Dr. DeBake originally described the type one aortic dissection type three and type two and type three and Dr. DeBake also suffered from a type one dissection and he was actually operated from one of his colleagues but one of his original papers for the dissection he had a lot of patients and when he followed them he found that these patients they come back that they have the distal dissection because one word another they don't really treat their blood pressure well and the proximal part of the descending thoracic aorta is the one that gets dilated so in a way in addition to the dissection you create an aneurysm in the setting of the dissection down the line and the more your blood pressure is not under control the more this it's getting worse and then of course you need an open operation down the line so approximately one of one-third of these patients can end up with an aneurysm there's another equal number that this is some of these patients can die because they have the aneurysm and these raptures or they have what we call they get into the chronic phase but then because the pressure is not well controlled they get what we call acute event on the chronic phase so they they get the acute on the chronic event so they have another dissection in the existing dissection that they have that is almost like a second insult in the original and with the insult so but this is it's um this is important because these patients first of all the crofford also mentioned that a long time ago that if somebody has an aortic disease you really have to follow them forever because it's not something that you can say that okay you're fine now i'm done with you so you don't really need to have to have follow-up so to be very meticulous about how we do the follow-up in these patients and increase awareness that is something that in order to be on top you really have to have a very good follow-up i think for us as clinicians to emphasize the importance of having the follow-up so when you have patients that somebody they miss the first appointment they they miss the second one they miss the third one kind of needs to be an alert somewhere where is this patient are they are doing okay so somebody needs to do that follow-up somebody needs to have should be aligned somewhere like the infrastructure that help us because you're a very busy clinician so in a way you cannot really have in your mind all the time who missed the appointment why so the infrastructure needs to be in place that we really it's not about treat the disease it's about prevent potential adverse events that can happen if we don't treat the disease well and we don't follow the disease well you have a huge experience with this condition and i'm interested in understanding from your experience and from the registries what percentage of patients who are coming in with a type b dissection are known to have aortic disease before they show up that's a great question and i wish i would know the answer to that but so yes actually my experience is based on a lot of sleepless nights yeah taking care of these patients but for the registry for the registry what happened is from the patients that they end up treated with endovascular therapy approximately one third of them they have aneurysm disease and that's different than having the dissection okay but approximately one third of them they have somewhere in their body an aneurysm now this makes you more prone that if you have already an aneurysm in place something bad can happen if you don't take care of this the dissection patients can be a little different let's say if you come with the de novo dissection is more in patients that they have for long-standing untreated hypertension yeah where actually everything goes together you know you have very thick left ventricle your blood pressure you have kidneys you have kidney issue you have all these things that goes with untreated high blood pressure it strikes me that the this particular institution between baler and texas hard and baler st luke's medical center has really played pivotal roles in our understanding of aortic diseases and treatment and i think back to dr debakie sewing grafts on his sewing machine you know to treat abdominal aortic aneurysms and things the the progression of therapies is remarkable to the point that you're now doing a lot of this work endovascularly where does this go in the future what are the gaps that are left and where do you think the therapies for for aortic dissections will be moving you're absolutely correct the landscape have really changed tremendously and we have creating almost like a new paradigm in treating aortic disease and the first person first of all that put the stand graph was 1999 mike day he was an intervention radiologist and for the audience if you have the opportunity to go and hear his testimony how he started and how he did his first case actually is fascinating and he did this 1991 but the landmark that gave the opportunity to clinicians to use the stent officially approved by the FDA was not until 15 14 15 years later in 2005 until then everything was under the umbrella of physician devices of physician IDE so was nothing FDA approved was everything was off-label and after the 2005 of course we have the first test and graft approved and now we have multiple of them we're really very fortunate here to be part of a lot of trials clinical trials and really be on the forefront on the forefront of trying the different devices we actually we've been part regarding the ascending order for the type one day section we've been part of their eyes trial and the results recently came out in the general of endovascular therapy the devices not get approved but the results came out we've been very fortunate to be part of the arts branch devices we are now we're able not only hybrid but totally endovastoid to perform some of these ethnic cases again these devices are not FDA approved yet but this is coming down the pipeline there's another device branch device that just got approved by the FDA and we hoping to have it here so we'll be able because we have some patients coming up so we're able to apply this technology to the patients and then with regards to the remaining order again devices are not FDA approved yet but definitely they're coming down the pipeline to how to revascularize and do completely photocop abdominal operations by just using these devices so and there is like so many other devices even though they've been used in Europe that we don't have here yet so I think the field is just evolving is the same way with the percutaneous heart valves when Alenque BDA did the first one in 2002 and then now we are like you know in 2022 and we have not one device but 15 devices and 10 different ways of doing things so I think all this by the end of the day knowing the indications and treating the patient for who what the patient has because this is one of these things that is not one size fits all is really what is better for the patient that you have that is sitting across you and looks into your eyes and said what do you think is the best thing for me and you can say you can do this you can do the other one but usually the patient said what is good for me and you have to think and this is when you have a thing as clinicians we have to take a step back and say what actually I would like to have my own family has because you know the data the patient doesn't really have the data you have the data I think it's remarkable that you've just outlined you know the treatment of the entire aorta exactly endovascular approaches and the ability with different kinds of devices to tailor the therapy to the specific pathology that you're looking at absolutely what an exciting space to work in I want to just thank you for taking the time today to share your knowledge with us at the Texas Heart Institute and really appreciate all that you do for our patients you provide wonderful care and Rania you're a great colleague thanks so much for taking the time thanks I think it's very important and I mean as a surgeon one thing that I didn't mention is for the residents is very important as they're learning these techniques not to forget how to do an open surgery because by placing these devices kind of we're creating other problems and right now we are in the phase to treating the disease creating problems and then trying to fix these problems that we're creating with these endovascular devices so it's very important at least for the surgeons in the audience to know that they have to keep the skills and for the other disciplines to know how well if we communicate we can really treat the patients so thank you so much for having me it's really great honor wonderful Rania thank you very much thank you