Cardiovascular surgery

Multidisciplinary teams at the heart of new guidelines on aortic disease management

Closer ties between cardiologists, cardiac surgeons and vascular surgeons will be a hallmark of the future treatment of diseases of the aorta, a leading figure behind new guidelines for the diagnosis and management of aortic disease tells Cardiovascular News

Jointly published by the American College of Cardiology (ACC) and American Heart Association (AHA) in November 2022, the new guidelines are intended to support decision-making around diagnosis, screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease.

Building upon an earlier version of the document, last updated in 2010, the new guideline incorporates latest evidence to reflect advances in care. Central among the latest additions is a focus on multidisciplinary aortic team care to determine appropriate timing and optimal medical, endovascular and surgical therapies.

“The important thing for these guidelines is the multidisciplinary approach that was not evident in prior guidelines,” Ourania Preventza (cardiac surgeon at The Texas Heart Institute and professor of surgery at Baylor College of Medicine, Houston, USA), vice-chair of the guideline writing committee tells Cardiovascular News. “There is a multidisciplinary aortic team that is determining the appropriate type of intervention and a shared decision-making approach between the patient and the providers.”

According to Preventza, this diversity of specialisms was embedded in the writing process from the offset, with the committee chaired by a cardiologist, Eric Isselbacher (Harvard Medical School, Massachusetts General Hospital, Boston, USA), alongside Preventza, a cardiac surgeon, and her fellow vice-chair, James Hamilton Black III (Johns Hopkins Medicine, Baltimore, USA), who is a vascular surgeon. Other spaces on the 26-strong writing committee were also taken, in addition to the cardiologists and to the cardiac and vascular surgeons, by cardiovascular anaesthesiologists, geneticists, and interventional radiologists.

“The thought process when we created this and assembled the committee was really to provide diverse perspectives. The only way to provide these diverse perspectives is when we include all these different specialties with specialist knowledge about therapy and diagnosis of patients with aortic disease,” Preventza adds.

Asked whether it was difficult to balance what may sometimes be differing schools of thought, Preventza comments that the writing committee was fundamentally led by evidence available to guide best practice, and says that the proof that they got this right is in the fact that the document has been endorsed by a number of societies in different fields, including the American Association for Thoracic Surgery (AATS), the Society for Thoracic Surgery (STS), the Society for Vascular Surgery (SVS), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Cardiovascular Anesthesiologists (SCA) and the Society of Interventional Radiology (SIR).

“The guidelines are there to give the physicians something to base their practice on, to help patients, and make sure that

Risk assessment tool “sets a high bar” when considering alternatives to surgery in mitral valve repair

A NEW RISK ASSESSMENT tool has been produced for assessing operative risk of mitral valve repair for primary mitral regurgitation (MR).

In an article published in The Annals of Thoracic Surgery and the Journal of the American College of Cardiology (JACC), cardiology and cardiothoracic surgical researchers analysed US data to assess outcomes and risk of mitral valve repair for primary MR.

the medical and cardiovascular community have the same or similar approach, which is safe and effective.”

Detailing what she sees as the formula for a multidisciplinary aortic team, Preventza says that there is no firm blueprint, rather the approach is guided by shared decision-making in the interest of the patient.

“It is really a collaboration between cardiology, vascular and cardiac [surgeons],” she comments. “For example, an abdominal aneurysm is very well treated by the vascular surgeons. Somebody with an abdominal aneurysm may also have a thoracic aneurysm, involving the ascending aorta, and this is something that has to be taken care of by a cardiac surgeon. Or, perhaps the annuli of the aortic valve or the ascending aorta is not at the size yet that needs intervention, so in this case the patient can be followed by cardiology.”

The patient-specific approach is important, she adds, commenting that it is not a one-size-fits-all approach.

Other important takeaways from the revamped document include new thresholds for surgical intervention for sporadic aortic root and ascending aortic aneurysms, an updated definition for rapid aneurysm growth rate, and adjusted recommendations on when to intervene in patients who are smaller or taller than average. These are in conjunction with new entries covering family screening to identify those at high-risk of aortic disease and consistency in the acquisition and reporting of computed tomography (CT) or magnetic resonance imaging (MRI) in the measurement of aortic size.

“The plan is that the guidelines are a living document, to be updated in the next three years,” adds Preventza. “Nobody has a crystal ball, but given how the field is evolving I think it is important for us to re-evaluate and see where we are.”

Important areas to watch will include the evolving field of genetics as it relates to aortic disease, developments in the evidence in the area of endovascular intervention, and research looking at sex and socioeconomic disparities in aortic disease. “These are things that as we evolve we hope to improve, with more inclusive studies, and with advancements in technology; all of which will help us and help our patients and that is why it is important that these guidelines will be updated,” she concludes.

Assessing information from The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, the team identified 53,462 patients who underwent planned surgical mitral valve repair for primary MR between 2014 and 2020.

The authors found that there was an increasing frequency of operations done in a minimally invasive fashion, including robotically, and that the rate of successful repair has reached over 90% in the USA. Researchers also found that risk of mortality after this surgery was rare across nearly all age ranges. These data were used to develop a novel risk model for predicting 30-day outcomes based on the patient’s health conditions, which formed the basis for a risk calculator to assist healthcare providers to estimate the risks for their patients, to be made available online shortly via the STS.

“We have two options to treat primary mitral valve regurgitation. The historical standard has been surgical repair, but we also have US Food and Drug Administration (FDA)-approved transcatheter devices for minimally invasive mitral valve repair that have encouraging results, particularly in high-risk patients with primary MR,” said Vinay Badhwar (West Virginia University, Morgantown, USA), lead author of the multidisciplinary study.

“Past perceptions of the risk of surgery and repair rates based on older risk models may have influenced the design of two clinical trials to explore transcatheter therapy in lower risk older individuals.

The finding of 90% successful surgical repair with less than 1% mortality now achieved in the USA sets the outcome bar fairly high when considering alternative therapies to surgery. We hope this information will help physicians and patients make more informed decisions regarding treatment, as well as to inform the optimal design of future trials in the field.”

Cardiovascular-aortic community comes together at CX 2023

From cutting-edge aortic interventions to consensus on revascularisation strategies in the peripheral arteries, the 2023 edition of the Charing Cross (CX) Symposium comes at a crucial time in the calendar for the cardiac, aortic, vascular and endovascular communities.

The three-day CX Symposium—taking place 25–27 April—returns to the Hilton London Metropole in central London for its second consecutive year, with attendees also tuning in virtually from across the globe. It is anticipated that the event will welcome more than 2,500 in-person attendees, with over 1,000 remote participants.

CX continues its three-year cycle of raising vascular and endovascular controversies in order to challenge the available evidence and to be able to reach a consensus after discussion with an expert audience. Sessions will explore routes to consensus in all vascular domains, spanning aortic, peripheral, venous, acute stroke and vascular access, punctuated by CX debates, live and edited cases and workshop demonstrations.

Running over the three days, the comprehensive aortic programme opens with aortic techniques and technologies on day one, followed by a full day focused on the abdominal and juxtarenal aorta, and finishing with debate centring on the thoracic aorta.

The sessions bring together worldleading experts in management and treatment of aortic disease from the cardiovascular, vascular and endovascular worlds, with faculty including Gustavo Oderich (University of Texas Health Science Center at Houston, Houston, USA), Joseph Bavaria (University of Pennsylvania, in the arch and thoracoabdominal aorta, and for me personally, to learn from colleagues in Europe and the UK on what is going on there, and what I should change in my techniques.”

Philadelphia, USA), Maximilian Pichlmaier (Ludwig Maximilian University Munich, Munich, Germany) and Marco Virgilio Usai (St Franziskus-Hospital Muenster, Muenster, Germany).

Commenting ahead of the symposium, Oderich, a member of the CX Aortic Executive Board, said: “We are all excited to see the latest advances

Handson Aortic Course

Highlights from day one include insights into advances in both open and endovascular thoracic aortic aneurysm (TAA) repair, options for the treatment of complex aortic pathologies, and a focus on the aortic dissection toolkit.

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A podium first presentation from Kevin Mani (Uppsala University, Uppsala, Sweden) is among the highlights from the abdominal aortic session at the start of day two, exploring the benefits of statin treatment after aortic repair. The following juxtarenal aortic consensus update session includes discussion on the impact of the ETTAA (effective treatments for thoracic aortic aneurysms) and UK-COMPASS (UK complex aneurysm) studies results with reference to National Institute for Health and Care Excellence (NICE) guidelines.

Thursday’s thoracic aortic consensus sessions close off the aortic programme with a debate on the conservative management of aortic intramural haematoma, featuring Michel Makaroun (University of Pittsburgh, Pittsburgh, USA) and Jean Panneton (Eastern Virginia Medical School, Norfolk, USA).

Treatment strategies for patients with chronic limb-threatening ischaemia (CLTI) have been firmly in the spotlight following the release of the first results from BEST-CLI in November 2022. CX will provide a platform to move the conversation forward, with firstto-podium results of the BASIL 2 randomised trial—comparing a ‘vein bypass first’ or a ‘best endovascular first’ revascularisation strategy—forming the centrepiece of a peripheral trial consensus update, taking place on the first day of the CX symposium.

During the session, BASIL 2 chief investigator Andrew Bradbury (University of Birmingham, Birmingham, UK) will deliver the first results from the trial, in a session that also sees participation from BEST-CLI investigators Matthew Menard (Brigham and Women’s Hospital, Boston, USA)—providing an update on the trial—and Alik Farber (Boston Medical Center, Boston, USA), presenting BEST-CLI quality-of-life data.

In-person attendees at CX 2023 will have the opportunity to attend a hands-on aortic workshop, led by Alexander Zimmermann (University of Zurich, Zurich, Switzerland), looking at the full range of fenestrated and branched endografts included devices that are physician modified. The Aortic Workshop will provide attendees with the opportunity to expand their knowledge and to test and improve their skills in a practical session taking place on Wednesday, 26 April. Offering a deep dive into physician modified stent grafts, this interactive session will explore the theory behind the history and indications of physician-modified grafts, and the technique to create fenestrations and branches.