Penn cardiac surgeons Joseph Bavaria, MD, and Nimesh Desai, MD, provide an overview of the Penn Aorta Center, a new, comprehensive model of care for patients with aortic diseases. As co-directors, they outline the collaborative infrastructure, research functions, and educational opportunities in the Center. Additionally, Dr. Bavaria and Dr. Desai describe optimal pathways of lifelong care for patients and families with aortic diseases as well as review innovative approaches to the treatment of aortic diseases.
Twitter @PennMDForum Dr. Bavaria’s physician profile Dr. Desai’s physician profile Endovascular Repair of Complex Aortic Aneurysms Carotid Artery Stenosis in Cardiac Surgery And without further ado, let me introduce our speaker. So today we're very excited to have Dr Joseph Bavaria and Dr Domestic Side very briefly. Dr. Bavaria is the Brook Roberts William Almazy, professor of surgery, vice chair of the division of cardiovascular surgery and surgical director of the Heart and Vascular Center at Penn. He received his empty from Tulane, followed by many years of training here at Penn and Chop before joining the cardiothoracic surgery division. And since that time, he's built one of the most innovative programs, focused on many uh, cardiothoracic disorders, principally disorders of the aorta and the aortic valve. And he's widely published past president of the Society Thoracic Surgery and is a riel national and local treasure here. Dr Name Estes. I is associate professor of surgery director of Thera Sick Surgery Research and co director of the Aortic and Vascular Disease Center of Excellence at Penn. He received his medical degree from the school. It's School of Medicine in Ontario, Canada, as well as a PhD from the University of Toronto in in epidemiology. Then he completed an integrated cardiac surgery, residency, uh, in Canada and then an advanced surgical fellowship, a pen with an emphasis on complex aortic surgery and vascular surgery of many other techniques. What you may or may not know about the masses. He is also an expert health services, the researcher and is a associate director of pens, cardiovascular outcomes, quality and value of research center. So this is a real dream team here, and we're gonna have an exciting lecture about a new comprehensive model of care for patients with aortic disease, the pen aorta center. So without further ado, I'm going to ask whoever is going first the mesh or Joe toe overtake the screen and and we'll get going. Right? Um, all right. Can you guys see my slides? Okay. Here. Yes, Perfect. Good. Eso. Thank you, Uh, Tom and, uh to, you know, the faculty and students, residents and, you know, from from all of our referring Z and everyone around the world who is watching this today, um, it's a privilege to come and talk to you about something that is very close to our hearts. And the order is very close to the heart. By the way, Andi eyes, you know something I think is going to really bring some change and innovation to the field that is constantly evolving and innovating to begin with. So the penny or two center eyes are is our topic today. And it is, uh, a Riel live living entity. And, uh, something that one of the goals that Joe and I have this morning is is not to show you something, but to start a conversation about how we can build something together. Right? So that's actually what this is about. On DSO we want, Ah, a riel involvement and, uh, interaction with multiple specialties in particular, cardiology to work with us in developing and building the center on Do what we do with it going forward. Mm. Eso in terms of what we're gonna talk about today. First of all, I'm going to start by saying we don't know is much a Z we need to about the ferocity Orta on, um and and and so, ah, lot of what we're gonna be building the center around is trying to understand that which we don't know and also improve care for patients. Um, we are going thio present our vision of the future of care for the Arctic patient, which is the penny Orta, Translational Center of Excellence shortened to Penn Aorta Center. Um, we're going to give some examples of key considerations, uh, at the Penny Orta center, things that we're particularly interested in and want to talk about today. But obviously there are a lot of things in the order that we won't be able to get Thio in the limited time frame on, then room for some questions and discussion a T end. So I wanted to start off with a case. And this case illustrates in so many ways so many things about thorough ski Arctic disease and why we need to develop models of comprehensive care that go really way beyond, you know, even the multidisciplinary team approach and things that we've developed in tavern and in other areas because of the longitudinal nature of the disease a 57 year old man presents with acute Taipei dissection has Lin Mao profusion. Um, it comes to the operating room emergent. Lee has surgery. You can see this. The actual post surgical picture here. There's a graft here, but there's this residual dissected aorta down here is actually a stand in the iliac that was needed to be put into try and preserve flow down there at the time of the dissection s a very complicated case. Um, but the person survived it. Um, the aorta wasn't very big at the time of the dissections. Less than five centimeters. The route was not aneurysm all, um, otherwise healthy. No family history of aneurism disease or anything like that. So this is something we see every day. I think in the last two weeks, I think we've seen this picture similar to this about 14 times that 11, 11, 12 times. Something like that. Um, there's been a lot of sections lately, actually, which is another, you know, shoe? Um, nine years later. So that person came in, did find I went home and and live their life. Nine years later, a different 57 year old man presented with an acute Taipei dissection with Luminal perfusion. Um, and they didn't have a large order at the time of the dissection. The route was an aneurysm, patients otherwise healthy. He had no known aneurysm, hot and successful repair when I saw him in the follow up clinic, and I actually don't think he mentioned this to me until years later he mentioned. Hey, by the way, you know, my brother had emergency surgery for dissection years ago as well, and in fact, thes two patients. These two cases Air two brothers and you know, two brothers dissecting at the exact same age with the same presentation. We're not syndrome is not bicuspid, not aneurysm. That's really the crux of what we're talking about. If they were to disease, this is really complicated and trying to understand why this happens. Three environmental factors. Genetics, other other elements of of, uh, biology, biochemistry, um, are things we still don't understand in so many people who have this disease. Uh, could we have prevented the second brother from having or dissection? Well, it doesn't sound like he actually would have ever met criteria for prophylactic surgery before he dissected. But that's something that again we don't really understand. Um, when these people undergo emergency surgery, can we improve the surgery to prevent late complications? We saw that both the brothers have severely dissected distal aortas, you know, and that's gonna be issued an issue in the future for them. And how do we care for them now in terms of, uh, follow up future interventions and also the social emotional factors that can be really hard on patients with aortic dissection and aortic diseases in general, because they are often presenting early in life and often have the feel of a chronic, uh, and somewhat frightening condition. So what do we need to take care of patients with aortic disease? And you know, we will start off by saying that our aortic program here is is already one of the largest Onda almost either guarded in the world. But, you know, I think we're just at the tip of the iceberg in terms of what we can do to optimize care, develop pathways, develop new information, research, collaboration and all the other things that can really make meaningful impact over the long term. On DSO we're really looking beyond just, you know, doctors working together of different specialties and really developing more detailed collaboration and a more detailed infrastructure, um, to take care of patients uh, and, uh, Kevin Mahoney and the leadership team at Penn Medicine. I saw this opportunity and provided us with funding through their translational center of excellence, um, mechanism, which is ah, large funding package that will allow us to actually build resources to develop self sustaining infrastructure through actually hiring, you know, long term, um, positions in for physicians nursing a PPS and at the scientist level. So really, building that infrastructure to have a self sustaining model that can go on on and actually achieve the things that we want to achieve over the long term. Um, the mission of the panty artist center is to provide integrated, multi disciplinary care for your patients to lead innovation in clinical and translational science. And two, very importantly, revolutionized carefully work patients That that is very important part of it. Discovery and then implementation of those discoveries on then finally educate future generations of clinical leaders in medicine imaging, genetic surgery, nursing on science to innovate for care in a right patients so really developing diaspora that the entire world will benefit from. And I'll hand it to you now, Joe. Well, thank you. Know, mesh. And also thank you to Tom for, um, you know, being a part of the initiation of this, uh, translational center of excellence, um, that the hospital and health system has funded. Um, So the first thing I wanted to go through was the focus on the T, C E and the Penny aortic center. Um, and I think that, you know, the one of the main reasons why Tom wanted to us to speak was to get a, you know, a some some discussion and some comments and some recommendations and from the cardiology division, because it zit needs to be an important part of this whole effort. Uh, and, uh, you know, this is truly a cardiology slash cardiac surgery, um, endeavor amongst other areas of multi disciplinary care. Um, so ah, obviously we have an advisory board steering committee directors and administrator. But really, what I wanted to focus on is some of our our boxes about what we're doing, what we need to do, where the funding is going and how everybody on this line, uh, especially the cardiology division can help out. So we have, ah, clinical arm to the vision. Uh, and, uh, as I always say, a vision, strategy, tactics, execution in that order. Go back. Yeah, on. And so we have a clinical emergency aortic emergency program, which is heavily involved with pen star, and, uh, it is well known that many of the operations and many of the problems associated with, as you just heard from the message A tale of two brothers, uh, you know, aortic dissection, etcetera. Advanced imaging is a part of the clinical paradigm. Black custom aortic valve, uh, clinic and and related diseases is a very, very large part of what we heard about this yesterday on. And this part this this box is actually fairly mature at this point with a with a true, uh, center already established within the T. C um, complex endovascular therapies. We all know that the future of therapeutic aortic, uh, interventions is probably going to go. Maura, Maura, endovascular As time goes on. Ah, we feel that some of the clinical programs were so sophisticated And so um, uh, you know, specific that they actually deserve their own. Um, you know, their own approach both clinically and research wise, and that would be aortic dissection. The genetic conditions, um, what we call Gentex genetically triggered aortic conditions, late consequences of congenital heart disease, eyes becoming something that's important on the entire secondary prevention and proactive surveillance program. Uh, and, uh so that's kind of part of the clinical arm, and I'm sure there that we have, uh, opportunity for more than that. The research arm of the T. C is also very important. Were heavily involved with clinical trials more and more coming up along in all aspects of aortic disease from both medical management drugs, devices, therapeutic devices, um, and even things such as how things that are helping us actually do the treatment that are that are not quite specific to the actual device treatment device itself. Clinical outcomes research. Uh, this is an area that were that were pretty good at already, but we want to get even better. This is going to require the next, uh, the next, uh, bullet, which is a large data analytics on and, uh, development of very specific databases. Um, and, uh, one of the things I can just imagine here, for example, just as an example of this is, uh, we all know that that the guidelines for aortic valve insufficiency, for example, are pretty pathetic on, uh, the reason why they're pretty pathetic is because there's not a whole lot of data out there to inform the guidelines, which, by the way, are coming out in about four or five weeks s O That will be Ah, whole another topic. But, uh, the, uh we have basically a aortic valve insufficiency, you know, center here. I mean, the amount the amount and variety of aortic valve insufficiency that we have in our in our, uh, you know, in our aortic center in our aortic clinics is truly amazing. So we should be able to inform the guidelines and inform the the world about about that. That's just a particular, uh, you know, a component. But that will require us to kind of have a database that's specific to that to that entity which doesn't exist right now anywhere in the world. Translational research imaging research is huge. I mean, I could go on and on that you could take that whole a couple two words right there and give a whole grand rounds on that alone technology innovation with the new Technology innovation center. Uh, this includes you know, a lot of the of the device innovation that we have, as well as process innovation, also education. We wrapped around that with CMI events, patient education and events. Can't forget about the patient. Patient centered research is actually important. Patient centered outcomes are very, very important. Postgraduate aortic surgical fellowship. We have some of that post a Nordic medicine genetics fellowship. And, uh, and Dr Sylvester is on the line. And we've already started Thio. Think about that. And to actually, um, right out our vision for that. Hopefully for this next year Coming up, we have the money to fund it on dso I'm eso with Frank and I and the mesh and and And Tom will be reaching out to everybody, uh, younger fellows for that. Possibly aortic graduate. Postgraduate fellowship in an aortic imaging as well. Again, we have the funding for these things. Um And then, of course, a philanthropic development or development itself, uh, for professorships and genetics, Uh, in medicine and surgery. A swell as research, funding and patient support from the development side of things next life. Uh, so that's kind of our vision. Go. So this is the same thing, but really, what A in a different way. Which is Basically the order is the center of the universe for this t c e. Uh, and, uh, we're wrapping everything around, you know, the aorta, All the planets and the moon are circling around in the order is is our bright sun on. And so, uh, as we fill out this grid, this is the idea behind the translational center of excellence, the penny order center next slide. So key areas for immediate focus This is when the next 12 months is to develop and build a strong aorta Genetics core, uh, with embedded geneticists and genetics counselors in the order clinics training recruit, aortic expert cardiologists. This is in genetics imaging medical therapy, again like I was talking about with the fellowship is Well, uh, clinical research, clinical trials and data science research were actively recruiting. Uh uh, for this regarding PhD level scientists as well as masters level clinical outcomes, uh, experts and then and then further innovation with development of new technologies. Uh, in innovative devices who are through our innovation center, which we've already done, we have a number of patents on and, uh, and processes already next slide. Now, I think I'll have Dr Silvestri talked about this at during the discussion session. But one of the things that we want to dio is recruiting right now. I'm talking about as of today, uh, is the fellowship in the order diseases from a medical standpoint, and I don't need to go through all this, but this is something that we want to kind of create out of thin air. It's nothing. That is, uh it doesn't exist now in the United States or in the world. Maybe on, uh uh, But this is something that we wanna kind of start Andi, think out of the box about next. So I'll hand it back to the measures we go through this. All right? Thank you, Joe. And yeah. So, um, that fellowship is so key. You know, we wanna really, really develop, um, you know, the next generation of trainees and that, you know, the aortic, you know, it worked. Diseases, especially sub specialty of cardiology. I think it's something that will be a real thing in the next few years. Um, it's certainly developing very rapidly. So we get back to, you know, our brothers that I talked about at the beginning, you know, let's start working through some of the questions that we had raised about them and then where we're at and some of things that we're doing at our center that are gonna help it, understand? Explain. You know that going forward eso one of things I wanted to start with is just this Just to provide some background information on how frequent dissection is. Certainly it's been keeping myself and Joe on DWilson Zito over presby, um, up at night, almost on a routine basis these days. Um, but, you know, there's a lot of your dissection happening out there that in Japan it was a study that actually showed 8% of the hospital race are due to Taipei dissection. This is these are patients. They actually CT scan postmortem eso. Although that might be an overestimate, It still it still tells us how many people are actually, you know, dying. And they're from Taipei dissection. And, um, you know, our overall understanding of when to intervene on a type A dissection. A lot of it is based on some pretty old data and really based on old imaging techniques is well. But if we go back to the original papers that define the field, um, you know the initial hinge point of risk was defined at about six centimeters for, uh, aortic catastrophes in patients with a sending aortic aneurysms and you know, that Hinge Point kind of became 5.5 as a surgery became a little bit more standardized and safer. But if we actually look at this in a more granular way, this is data. It was just came out, like within the last couple of years that the rial hinge point doesn't happen at 5.5 or six. It actually happens. Probably closer toe five or 5.25 is really where the the hinge point is from the current it aeration of this Siri's from Yale on dso. You know, when we talk about whether or not we should be intervening on these aortas, I think, you know, size becomes unimportant element to it, but it's not the only element to it. Don't get into that in a second. Um, if we look at our sort of an algorithm, this is again from the Yale Group, um, of when to operate on aortas. This is really complicated. I'm not gonna walk through the whole thing, but essentially somewhere between five and 5.5 is where we operate on most aortas. Uh, and, um, just to put the size thing in context of 5.8 centimeter aorta is the size of a 355 millimeter cocaine. Uh, this is Dr Ralph Realities that yellow, which shows the slide. And it's, uh, it's always kind of puts it in context in terms of how pig 5.8 centimeter aorta actually is. It's huge. Um, we have a lot of recommendations based on specific gene aberrations. And again, this is era. This is an area that is replete with, um, confusion and one that I think we need to really work on a Z. We develop our centering on and recruit the faculty. We need to actually start answering some of these questions about went to interact and intervene in patients with genetic air top of thes. But the one thing we know clearly is that size is not the only criteria that determines risk on. And this is data from Iran and the International registry of aortic dissection that shows that the average order diameter the time of the type of dissection was 5.3 centimeters. And we actually have data that shows that the order grows about 20% or mawr, um, instantly. At the time, it dissect. So 5.3 is what it was after. Dissected. It was well under five, most likely before it dissected. Um, this is data from our own center where we actually modeled that, um, and found that 90% of the people that we actually end up operating on for acute Taipei dissection would never have met guideline based criteria for elective repairs. This is a disease we do not understand at this time. One of the things that has become more relevant lately is understanding the size of the Orta in reference to the size of the patient. So if the patient is large, expect them to the larger aorta. And if they're small, they expected of a smaller aorta. And so we can index the aortic size to the patient's size, either by DSA um, which is one technique. And there's no my grams. For all the different techniques by height or even by, uh, diameter to height or surface area are cross sectional area of the order to height ratio. These air all different ways that you can use to understand whether or not to operate on someone. The only sort of downside of some of these techniques is that you do get into the zone where you would operate on someone out of Europe. It's only four centimeters, which a nonsense dormant patient probably is not appropriate. But, um, they're things that we're using more frequently these days to understand other emerging areas like aortic length, like the actual length of the outer wall of the aorta. On more advanced imaging parameters like distance ability, onda, also, biochemical markers are all becoming more relevant in all areas that we need to explore a za. We develop the infrastructure to do this research in our center. Right now, you know, our general indications were based on the guidelines are as follows. They're pretty standard that market and around five or otherwise in 5, 5.5, you know, smaller and my cousin golf are very uh okay. Every great oh ah, the as Joe was mentioning the bicuspid area, the bicuspid aortic valve in associating our top of the with is something that's a very significant interest, uh, from a research and clinical perspective to our team. Um, importantly, a large proportion of patients with by custody revolves will develop aneurysms within 10, 10 20 years of their valve diagnosis. Uh, and almost 80% will eventually develop before centimeter aorta in the rate of aneurysm formation in this group is 80 times higher than the general population. The mechanisms of it are not really well understood. Although there are hypotheses that is either a mediated by some kind of abnormal flow. Uh, that is putting, uh, excess tension on the wall of the outer wall of the aorta lateral, the order that causes the asymmetric aneurysm to form, or also various in real logic and other biologic hypotheses about why these aneurysms form because of our interest in it. Um, as Joe was mentioning the most sort of fleshed out version or element of the pen transitional aortic center, uh, is the bicuspid valve area. And we started the bike husband, uh, valve center, uh, almost two years ago now, uh, and it's really designed to provide a fully comprehensive on coordinated, uh, patient experience for all levels of bicuspid valve disease. Whether it's ah, patient who has an aneurysm and follow up, who has valve disease? Um, War has a bicuspid valve with no aneurysm and normal functioning valve that just needs lifelong surveillance, Um, or family members of patients who have, like Husband Valve. So it's a very robust program. Melanie Freeze, Who's our nurse practitioner who runs that with us, sees in addition to us a lot of patients for long term surveillance and repeat imaging. And it's something that we've really streamline to make of really satisfying patient experience and very, uh, sort of bespoke level patient education and resources for families in patients. So that's sort of the one area that we've actually really pushed ahead on. First through this transitional center concept, I'm not gonna go through the guidelines of went to operate on by custody or topic. But I will say this long controversy, Um, and it is that number five or 5.5 is a new area that I think is still up for a lot of debate. The surgical guidelines tend to recommend surgery earlier, the medical guidelines Central Mexico and surgery a little bit later on. A lot of it has to do with kind of the risk of surgery, the risk of the patient and the risk of actually developing New York catastrophe. Our understanding today is that my husband valve aneurysms in general and I'll give you some exceptions in a second are probably less likely to dissect or rupture than three leaflet. Um, aneurysms are so, uh, diaper size. Yeah, eso our understanding of it is changing on. I think we're again as Joe was mentioned. You know, we are just at the cusp of understanding aortic insufficiency and in an aneurysm in these bike husband patients. So there's still a lot of work to do on, you know, literally. I mean, our own project by itself, just as thousands of patients that weaken, uh, try to understand this. And, um, there are a couple of areas of bicuspid valves that we are more concerned about patients of the Rufino type. So if you have a very enlarged route with a bicuspid valve, they actually behave almost like Marfan patients. Typically, eso were a little bit more cautious in those as opposed to the A. Sending phenotype with the route is normal on the just. The standing order is aneurysm all. So you wanna take it from here? Sure. So one of the things I've always said is, uh is that we're actually, uh uh There's a lot more of this out there than we think. Which is one of the reasons why we're giving this talk to the cardiology community and setting up this T c. The center, uh, the the estimated number of aortas in United States over 4.5 centimeters is one million. This is maybe three million over the age over the size of four centimeters on This is actually, uh, data from how deeds done at Johns Hopkins. Eso uh, it is a massive problem. Uh, next and it's a It's a massive problem also because of the guidelines. So what's happening is that as the aortic guidelines, uh, for treatment kind of go down especially, and they become more nuanced on there's lots of exceptions. And as the mesh was talking about sizes, is is actually not the Onley criteria. As you saw from our tale of two brothers. It's just so we're getting more and more sophisticated slowly but surely, and there's lots of different factors playing, but it's not just size. So as a result of that, what's happening is that we're operating on aortas, a smaller levels in many patients, but their valves are, um not so bad because, uh, in many, many cases on and in the old days we would just take these valves and we would throw them in the bucket and do a composite graphs of mechanical valve tissue out. And and that's just becoming less and less reasonable on. This is just an example of that. So So I just wanted Thio talk, you know, a little bit about some of the stuff we're doomed. He just talked about, uh, the, uh, some of the, you know, syndrome issues. So let's talk about one other thing. Can we spare more complicated clinical aortic valve insufficiency, presentations and why it's so important? What's so important? Because because of what I just said, because it's really common next. So, uh, should we should we should not consign young patients to mechanical valves with a bicuspid valve could be reliably repaired next. So this is a I just thought I'd show some of the biologist a little bit about what kind of what we see this. See these air? Ah, lot of patients will come in with a with a I. Most of them are our young On what I mean young. I mean under 50 or 60 on and they'll have a bicuspid aortic valve and we're going to take care of their of their or top of the. But we also just need thio, not take thes pretty reasonable valves and throw them in the bucket. And so this is an example of what we look at in the operating room with the valve analysis we're looking at the reference customers could see there were really good motion on whether we have ah, valve that has ministrations, whether it's degenerated, how asymmetric it is, things of that nature next. And one of the things that will well we look at, which is important for the cardiology community regarding tea and echocardiography, is exactly what is the commercial angle configuration of the of these bicuspid valves, mostly well, receivers, one bicuspid aortic valves, about 85 to 90%. Eso uh, the commercial angle between the two commissioners and as it is a ZA relates to the cafe, is quite important regarding our ability to treat the's on exactly what kind of procedures that we we do. They come between 1 81 80 which is a true bicuspid valve thio 1 21 20 Go forward again. Imaging is key here, so the first thing we do in the operations will treat the prolapse. As you can see here, the conjuring cusp is longer, uh, than the reference cusp on is, uh, about by five or six millimeters. And this will require equalization of the free margins next and so before that will take, the cafe will trim the cafe down. The Ralf A. Uh uh, We could get a better motion of the valve if we trim the ref. A. On the other hand, trimming the FAA can cause a little bit of billowing eso. There's a little bit of a of a debate about whether we should be doing the raft trimming or not next. So the next thing is the is the cleft repair implication of the Khan joined cusp so that you can see we'll have equality of the of the two leaflets along their free margins, very similar to mitral valve repair. Next, and you can see we have complete equality of the free Marge's. Now we have great motion of the reference custom. As you could see the mobility of the con joint customers a little bit less than it was before. But that's the reason why patient had severe ai next. And this is just a still frame. The same thing next. So presently in our practice, and this is something that we've pioneered on. This is actually on plenary presentation at the STS uh, that the mesh is going to do in a couple of weeks, but, uh, we start off with a black cast Nordic valve with insufficiency, look for calcification and administration and basically other an atomic criteria that make it difficult to repair. If that's yes, then we we go towards a bento procedure or New York group procedure with the valve. But if it's no can hit the buttons once at one of the time, yeah, next. So if it's no, we have a root aneurysm or dilation. Uh, then we go to a what's called a valve sparing operation with valve repair of the bicuspid valves. That's a combination route procedure with prepare of the B A V uh, Now, if there is no route, uh, aneurysm or dilation and the analysts is less than 27 millimeters, we go to a B A B repair directly with what's called a subcommission angioplasty in other words, will tighten up the annual is a little bit thio make it more robust and and stable. But if it's greater than 27 millimeters, will do a B A B repair on go towards a next total ring very similar to a mitral valve repair concept exactly with a ring and a repair of the valve next. So this is up through 2018, so we don't have the last two years here. But what I wanted to show in this slide real quick is we have a lot of behaviors that have come in. Most of them are A S cases or mixed essay I. But the whole point really is that there is a substantial minority and realized this is a surgical practice. But there's a substantial minority of these cases that have a I plus or minus a root aneurysm as a primary indication and for primary presentation, and we can go towards various repair techniques or even our mental operation next. Now, one of the things that we saw this is our one of our recent harvest of our data is to look what are our outcomes were from re operation but maybe more importantly, freedom from from greater than plus two ai. And what you see, this is looking at the three different repair types I just showed you. What you could see is that Green Line is the subcommission annual plastic as a whole on we saw that that was bad. We didn't have great results out to 10 years. And so we abandoned this, uh, and which is why, when we developed our algorithm that I just showed you next slide? Yeah. So we changed the algorithm. And now once we change the algorithms What? We're looking at what you saw. We have great results. So the the presentation that's gonna be presented is actually the presentation, not a bicuspid valve repair, per se, but bicuspid aortic valve repair in the setting of treatment of a treatment algorithm, a three pronged treatment algorithm on so far, so good since 2013. So the mess you want toe continue your tale of two brothers. Yeah, So thank you, Joe. So again, we you know, because we're surgeons, we have We have so few pictures of surgery, right? Um, the, uh so but But you know, again, this is actually the largest group of people we follow in our in our aortic practice. But getting back to our brothers who were not like husband or three leaflet, You know, the questions about how we care for these These, uh, guys now and how do we rent late? Complications is is a big deal. I think in our own clinics right now, we follow between 800 that pretty close to 1000 patients who have aortic dissection. Um, it's a lot of people out there and and, you know, the care pathways for them are pretty complicated. Um, so for those who don't know ah lot about aortic dissection, this is what type of deception looks like. So it's typically a tear in the ascending aorta. Um, and it can often damage the the aortic valve hinge mechanism by actually sharing the common shares off of the aorta. And here I hope you can see this on the zoom. But you can actually see the intimate flap like through this see through Advent Isha of the aorta. This is terrifying to look at when it's right in front of you. Because this thing, literally the patient could cough and that could, you know, rupture right in front of you. So that's when the aortic dissection looks like, um ah, and we use a classification system. There's a few out there. There's type A and type B. Uh, there's also the debate declassification. But the key thing to understand is that, um, the vast majority of aortic dissections, they're actually Taipei dissections that start in the A sending the order. Um, historically, this was, ah, very bad situation, and it still is. But, you know, we've made a lot of, ah lot of headway into making the operation safer. Onda um in particular, bringing down some of the preventable mortality of dissection surgery, which you know, 15 or 20 years ago, the mortality rate if you had surgery for your cat dissection, um was in the 30 percent range Atar Institution. Today it's down to a seven or 8%. So we've made a lot of headway in terms of moving away from the old techniques of bring the patient into the I. C u. Not having good blood products having long delays to treatment, those kind of things on learning how to actually operate on the arch and protect the brain while we're operating up. There are all really important. Um, you know, and and so we way kind of design operations that could deal with every single phase off or sort of cause of death from the aortic dissection on. Uh, you know, I think this is just a summary of it here, which is number one. And this is really important for the folks in the call who are at other sites and centers is you know, we treat this like trauma. Okay, so we don't need an I c u bed. We don't need a, you know, to make it a complicated situation to get the patient transferred that we're using our pen star helicopters the same we use for trauma. We get a call for emergency room, or CCU, or sometimes, you know, Cardiologist's Office of acute Taipei dissection that's been diagnosed that that patient can be, you know, kind of moved very rapidly. Um, that there's always a dedicated aortic surgeon on call at all times. Where your dick emergencies? Not so it's not just the regular cardiac surgeon on call, but it's actually someone who has dedicated their life to operating on the order is, um, we actually have the ability to to real time live image ing with referring emergency room so they're actually films could be uploaded as the patients being loaded onto the helicopter on we can look at them and try to understand what the next step is gonna be for them. Whether we need to go to the I c u the operating room hybrid sweet or that we need to get more imaging sometimes, um, that we actually use the operating room itself as a diagnostic and therapeutic sweet. So again, we're not relying on bringing this patient to and I see you or anything like that, they bring them to the operating room and sort everything out there as quickly as we can. We've done a lot of things in the surgery which I won't get into, but to try and make it safer and on and again, we've literally decreased the mortality rate for aortic dissection by about 70 to 75%. Um, by following these, you know these principles? Um, one of the things that is really relevant to these brothers is you know, now that there 10 or 15 or a five years out from their dissection. What's gonna happen to the rest of the aorta? And this is actually the the initial repair of one of the brothers, which had a 32 millimeter descending drastically. Order. This was taken, uh, maybe a year after the original surgery. Um, if we follow that person about 10 years later, that aorta has grown to about 50 millimeters, Right, So that's a that's a big change. I mean, there's a lot of things that I mean, that's not we wouldn't operate on that level typically. But, you know, you could imagine that there's just a lot of late consequences, um, to aortic dissection that we really don't have fantastic solutions right now on this is what we see very routinely. Um, you know, for the thousands of aortas that we follow dissected yours that we follow in our clinics. You know, pictures like these air very typical. And you know, these operate. These problems are extremely complex to fix, either with a combination of endovascular in open techniques or sometimes very, very major open surgeries to fix them. So there is a problem with the long term. Even when you get the patient quote off the table safely with the aortic dissection. And that's another major area focus of our program on this is, uh, this is one of Dr Bavaria's lines here. But, you know, acute DeBakey One dissection is a total aortic catastrophe that, you know, it involves the entire order. And surviving the surgery is really step one of a journey that's 20 or 30 years and multiple re interventions for most people who survive it. One of the things that we've done eyes both the brothers had this operation, which is a standard hand marriage operation. It's to get the patient off the table operation. But we've actually moved to do too, both using sort of techniques that we've developed but also technology that is now coming to the clinical realm. Still experimental. What comes to the clinical realm? Um, actually, uh, developed operations try and prevent late erotic catastrophes. So one of the things we've really made an effort to instead of doing the simpler operation at the beginning, to do a more complex operation at the beginning on give ourselves landing zone to put a stand graft later so that we can actually do this, which is treat the entire aorta in the chest the entire through. Rosky Orta, Um, at the you know, either at the index operation or in a stage stage fashion within the first few months of the original dissection occurring so that you're not left with, ah, massive descending aneurysm, and that is going to become extremely hard to fix. And one of things that we've been doing to facilitate this is using Branch Brause, Andi zehr new. They're not commercially available United States yet. Um, but we actually have had the most experience in the world with, uh, some of these techniques and devices. Andi, they're they're becoming commonplace for these complex, uh, aortic arch reconstructions. And this is a case example of any order that, uh, we operated on. This was kind of a first in man type scenario of a gentleman who came in with a horrific aortic dissection. You can see all the tears and things there, um, and dissected. Correct. This is a very standard dissection, actually. Dissected, corroded, dissect, actually. Bad pulses, huge aorta, huge and dominant. Big tear down here, tears everywhere. Just really, really, really awful. A order of it. What we see all the time. That's a very difficult aortic dissection that we see. And, um, you know, fixing these could be pretty complicated. But one of the things is, you know, how do you get on bypass with an operation like this? Even. How do you There's no artery that isn't dissected in this. A person's body on dso how to even put a line into the order to go on bypass it. These are things that all techniques that you know we've developed here, this is the ace. And your candidates will actually use T e and EP aortic ultrasound to put the wire into the true Lumen. Um, this is when we're actually operating on the arts here in circulatory arrest with cool the patient down toe room temperature. I had to show a gory dissection video just because you know everyone. We've seen this, um, on here. We're actually protecting the brain while we're operating on it. So we have the aortic arch open patients at room temperature, 18 degrees Celsius. Um, and we have blood flowing into their brain. There's no no blood flowing in the body, and we're actually reconstructing the holy order here. Uh, and eventually. Um, we're gonna put this special graph that we designed, uh, at our place, um, into the aorta with the idea that we have a place to put a stamp. So we're not just gonna treat the a sending were actually treat the Holy Orta, and then we actually put a branch graft into it at the end that we did. There's a few days later, but the amazing thing about this is this person has no more dissection in their chest at all. Not in there. A sending arch or descending order down to there visceral segment. So, you know, in a young person that can make a huge, huge difference for them. Prognostic Lee, Um, there are other things about dissection, that air. Really? Uh, you know, difficult. And we're just, uh um uh, you know, depression. The long term understanding of all the residual problems that patients dissection have fear the actual fear of of living your life for exercising or having sexual activity or all these other things are riel. And you know, part of the goals of one of the goals of the center is actually to really work on developing infrastructure to provide patients and their families with the support they need in this realm as well. So that's all work to do. We have a lot of innovation in the pipeline, I think just for the interest of time, I'll probably skip over it. But we are currently enrolling in a trial. So Joe mentioned that it was all sort of observational evidence for Went operate on in order. We're actually in a randomized clinical trial was going to definitively answer the question of whether the number is five or 5.5, both for bicuspid and for three leaflet valve. So we're actively recruiting into that trial. Um, Andi Ah, lot of innovation on the on the end of vascular side as well. This is ah, the aortic dissection that we actually treated. Uh, almost completely endovascular little the operation. The neck with a five centimeter incision. Just thio rewrote the head vessels a little bit. And then we actually use this device that's designed for Taipei dissection in the ascending aorta. Uh, not totally ready for prime time yet, but really, uh, amazing piece of technology, Onda. We actually treat the a standing dissection. Treat the tear here. Um, and uh, and then with the rerouting that we did, uh, we actually can replace their entire aorta. Now, eso we're going to put another stent in the descending here. And then, most importantly, we put a branch graph to bridge the two. Uh, what's going in here? Mhm.