JAPACVS Vol. 2, No. 1 by JAPACVS

VOLUME 2 •

NUMBER 1 •

WINTER 2020 •

www.japacvs.org

APACVS J

Journal of The Association of PAs in Cardiothoracic and Vascular Surgery

Official Journal of The Association of Physician Assistants in Cardiothoracic and Vascular Surgery

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

JAPACVS

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Editor-in-Chief David J. Bunnell, MSHS, PA-C Washington DC VA Medical Center Associate Editor Stafford Scott Balderson, BS, PA-C, FAPACVS Duke University Medical Center - Durham, NC Editor Emeritus Doug Condit, PA-C Montefiore Medical Center – New York, NY Editorial Board Anitha Chandrasekhar, BS, PA-C Fortis Malar Hospital – Chennai, India Steven Harrington, MD, MBA Henry Ford Macomb – Clinton Township, MI Marcus Hoffman, MD, President EuroPAC Stuttgart, Germany Kimberly Mackey, MPAS, PA-C Children’s Healthcare of Atlanta JoAnn Montecalvo, MPAS, PA-C Winthrop University Hospital—Mineola, NY Aaron Morton, MMSc, PA-C, ATC, FAPACVS Emory University Medical Center – Atlanta, GA Mitesh Patel, MSHS, PA-C Baylor Scott and White – The Heart Hospital – Plano, TX David Tecchio, MPAS, MBA, PA-C Vassar Brothers Medical Center Poughkeepsie, NY Publisher David E. Lizotte, MS, PA-C, FAPACVS Executive Director APACVS – Simpsonville, KY

EDITORIAL MISSION: The JAPACVS is the official clinical journal of the Association of PAS in Cardiothoracic and Vascular Surgery. The mission of the JAPACVS is to improve Cardiac, Vascular and Thoracic Surgical and CVT Critical Care patient care by publishing the most innovative, timely, practice-proven educational information available for the physician assistant profession. PUBLISHED CONTENT IN THE JAPACVS: Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Publisher or the Association of PAS in Cardiothoracic and Vascular Surgery (APACVS). The Publisher and the APACVS disclaim any responsibility or liability for such material, including but not limited to any losses or other damage incurred by readers in reliance on such content. Neither Publisher nor APACVS verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damage incurred by readers in reliance on thereon. Neither Publisher nor APACVS guarantees, warrants, or endorses any product or service advertised in this publication, nor do they guaranty any claim made by the manufacturer of such product or service. SALES OFFICE APACVS 1435 Taylor Wood Rd. Simpsonville, KY 40067 Phone (502) 321-6155 admin@apacvs.org JAPACVS/Journal of the Association of PAs in Cardiothoracic and Vascular Surgery is published quarterly (4 issues per volume, one volume per year) by APACVS 1435 Taylor Wood Rd., Simpsonville, KY 40067. Volume 1, Number 1, Spring 2019. One year subscription rates: $40 in the United States and Possessions. Single copies (prepaid only): $10 in the United States

© 2019 APACVS, INC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including by photocopy, recording, or information storage and retrieval system, without permission in writing from the publisher. 2

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Editorial Smoking cessation intervention during pre-operative history and physical.

David J. Bunnell, MSHS, PA-C â€“ Editor-in-Chief 7

In This Issue of JAPACVS Peer Reviewed Content Aortic Dissection in a Transcatheter Aortic Valve Replacement Patient with Uncorrected Severe Paravalvular Regurgitation

Edward Ranzenbach, PA-C, MPAS, CAQ-CVTS, FAPACVS, DFAAPA; J. Christian Cash, MD, FACS; Raymond C Lee, MD, FACS; Gerard Francisco, PA-C, FAPACVS Peer Reviewed Content Secondary Rupture of a Residual Type B Aortic Dissection Following Surgical Repair of an Acute Type A Dissection

Tiffany Worthington, MSPA, PA-C; Ali Khoynezhad, MD, PhD Department of Cardiothoracic Surgery, Memorial Care Long Beach Medical Center, Long Beach, California Questions and Answers 23

Five Questions for Steven Wilson, PA-C

APACVS is the only association representing Cardiac, Thoracic and Vascular Surgery and CTV Critical Care PAs. By PAs, For PAs!

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

David J. Bunnell, MSHS, PA-C, Editor-in-Chief

Smoking cessation intervention during pre-operative history and physical. “Do you smoke?” “Yes.” “How much?” “One pack a day.” “How old were you when you started?” “Sixteen.” As a PA taking a history you have a moment right at this point on how you react. You could keep going because you have obtained the information. You could make a face and tell them smoking is bad. Or maybe you could take a moment to engage in meaningful conversation aimed at acknowledging how difficult it is to stop smoking and suggest a pathway to smoking cessation. In that moment my choice has been to acknowledge quitting is hard and my suspicion is the companies who make the products know it. Together we are identifying a problem and uniting together against a common enemy.

I go on to give people credit for already knowing smoking is bad for them and they don’t need me to tell them. Patients are smart and can’t escape the message smoking kills people. Insulting someone’s intelligence is an odd way to change a behavior so I choose not to do it. However, some day they will decide they need to stop smoking for reasons of their own. People do not change because you tell them they should. They change because they tell themselves they must. Smoking cessation medications can be helpful but none of them make you change your mind to decide to stop smoking.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

We often discuss one method so they have an idea in mind. I talk about nicotine lozenges which gives them the power to get a dose of nicotine and perhaps the support to smoke one less cigarette that day. I choose to mention this one strategy at this time because it is easy to understand, gives control to them, provides a modest and achievable goal, and I am willing to prescribe it at discharge if they ask me. If I prescribe it then I ask for a commitment to follow with their primary care provider that I ask about when we see each other in clinic. We talk about how there is more than one strategy and if one doesnâ€™t work that another might. I really like to have this conversation if someone they love is standing next to them. I can see how desperate their loved ones are to take the cigarettes away. I hope I have given them something to talk about together which doesnâ€™t involve fear, guilt, or shame. I am aiming for empowerment.

The obvious push back I can imagine from busy PAs who have a task list a mile long is they just donâ€™t have time to do this. I understand your concern. However, this whole interaction generally takes me less than two minutes. Another skepticism about this conversation I can hear is my complete lack of presenting data. Guilty as charged. I do this because it enables me to engage with helping to remind a patient their smoking is killing them and having a sincere conversation about how I care about helping them find a way out. Practicing medicine is art and science. This is simply is part of my art. Feel free to use this, suggest an alternative, or maybe study this intervention and tell the world about it in JAPACVS.

JAPACVS publishes invited commentary and letters to the editor in response to published articles in which the authors are given the opportunity to respond

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

thank you JAPACVS is a community effort which is a vehicle to explore our specialties and learn from each other. It cannot succeed without the efforts of authors, peer reviewers, and editors. The Editorial Board sincerely thanks the following professionals who have volunteered their time to make us all stronger.

Genie Ball Dustin Bartlett Benjamin Burroughs Karen CalcaĂąo Nona Chen Albert Chin Casey Clements Melanie Cottone Stephen DeVries Michael Doll Danica Fascella Steven Gottesfeld David Lizotte Ed Lopez Kimberly Mackey Michael Magarakis Evan Markell Stephanie Mayberg Robert Molyneaux

JoAnn Montecalvo Jason Morrissette Aaron Morton Alvaro Montoya Amanda Murray Darrell Newmann Ryan Oâ€™Gowan Mitesh Patel Ed Ranzenbach Brendan Riordan Richard Sabulsky Rawn Salenger Leslie Schlachter Scott Schubach Amy Simone Shawn Sussman Kimberly Sweet Kendra Thomsen Tiffany Worthington

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

In this issue of JAPACVSâ€Ś PA Ranzenbach, et al. present a case study which highlights how complicated decision making can be in the era of transcatheter valves. After a patient underwent a transcatheter aortic valve replacement at another facility which was complicated by paravalvular regurgitation (PVR) and a valve-in-valve attempt to treat this problem the patient then, years later, presented emergently with an aortic dissection. The conversation about the consequences of PVR, the radiographic studies, and surgical images make for a thoughtful conversation about complex patients and decision making. PA Worthington and Dr. Khoynezhad present a case of aortic dissection with surgical repair where a secondary dissection occurred and was treated with thoracic endovascular aortic repair (TEVAR). The conversation about aortic dissection and subsequent ruptures are an excellent review of the topics. Both of these articles together illustrate the dynamic nature of cardiovascular disease. While the operations performed by our teams are a significant event, they are only one step along the path to recovery. Recognition of this helps us to place our part in their lives into perspective and also enables us to be on alert for ongoing complications. A successful operation does not end with incision closure. These cases also illustrate how catheter-based techniques have become integral to modern surgical practice. No longer can we relegate our understanding of these techniques as someone elseâ€™s specialty. We need to have a full understanding of the indications and complications of these techniques so we can quickly apply this knowledge in the moments where they can make a difference in outcomes. PA Steve Wilson answers our five questions. This long-time APACVS member reflects on his 46-years (and counting) in surgery. His clinical work and service to the profession is an example to all of us on how to give our all to patients and our profession.

Keep up With APACVS and Specialty News Every Friday. http:// www.multibriefs.com/ briefs/APACVS/

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Aortic Dissection in a Transcatheter Aortic Valve Replacement Patient with Uncorrected Severe Paravalvular Regurgitation Edward Ranzenbach, PA-C, MPAS, CAQ-CVTS, FAPACVS, DFAAPA; J. Christian Cash, MD, FACS; Raymond C Lee, MD, FACS; Gerard Francisco, PA-C, FAPACVS Corresponding Author Edward Ranzenbach, PA-C 20707 Anza Ave. Apt 244 Torrance, CA 90503-2913 ranz@earthlink.net (530)592-6869

Introduction The patient is a 78-year-old middle-eastern male who was found in March of 2015 to have a 4.9 cm ascending aorta during his pre-operative transcatheter aortic valve replacement (TAVR) evaluation. The patient has a complex set of co-morbidities including coronary artery disease with percutaneous coronary intervention and stent placement, Class IIIc heart failure, moderate to severely reduced ejection fraction, mitral and tricuspid regurgitation, pulmonary hypertension, and persistent atrial fibrillation. There is no history of connective tissues disorders or family history of aortic aneurysm or dissection. The patient has given his consent to publication of this report. In May of 2015 the patient underwent Trans-vascular Aortic Valve Replacement (TAVR) at a well-respected tertiary facility. At completion of placement of a 29 mm Medtronic CoreValve™ the patient was noted to have moderate to severe anterior paravalvular regurgitation (PVR). An Edwards Sapien 3™ valve was immediately deployed, valve-in-valve, in an attempt to correct this. On post-operative day one the patient underwent trans-thoracic echocardiogram (TTE) and again was found to have moderate to severe anterior PVR. At that time his sinus of valsalva was measured at 3.3 cm. He underwent seven serial TTEs over the next two years which continued to show significant anterior PVR and mild to moderate aortic regurgitation. In September of 2016 a TTE demonstrated the patient’s sinus of valsalva had grown to 5.2 cm and by July of 2018, the patient’s ascending aorta was shown to be 6.0 cm. This prompted a CT angiography (CTA) which confirmed the ascending aorta to be 5.7 cm when compared to 4.9 cm on a CTA done as part of the pre-TAVR workup. In April of 2019 a CTA showed the ascending aorta to be 6.1 cm and the patient was referred for surgical evaluation at the same outside hospital. The patient was seen by a surgeon and intervention was planned. On 08/19/2019 the patient called Emergency Medical Services and presented to our Emergency Department with complaints of acute onset of chest and back pain. 9

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

[IMAGE #1 – Caption – CTA of Stanford Type A Dissection] CTA Image #1 demonstrates a Stanford Type A Dissection at the level of the pulmonary artery. This dissection was found to extend from the root to the origin of the innominate artery. In Image #2, we can see the dissection slightly more proximal and a slight hint of the TAVR cage.

[IMAGE #2 – Caption – CTA of Stanford Type A Dissection More Proximal] In Image #3, we clearly see the TAVR-in-TAVR cages and the dissection.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

[Image #3 – Caption – Dissection with TAVR-in-TAVR Valves] Procedure

The patient was taken emergently to the operating room and, using the Samurai 1 technique, the patient was placed on extracorporeal bypass. Upon opening the aorta the entry tear was noted on the greater curvature of the aorta adjacent to the distal extent of the TAVR cage. The tear extended retrograde below the level of the sinotubular junction into the non-coronary sinus and the root appear dilated. The TAVR valves were carefully excised. The root was replaced with a 27 mm Edwards Magna-Ease™ bioprosthesis and 30 mm Hemashield Platinum™ graft in standard Bentall fashion. The patient recovered and was discharged to inpatient rehab and eventually home with family.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

[IMAGE #4 – Caption – “Open aorta with TAVR valves”]

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

[IMAGE #4 – Caption – “Explanted TAVR in TAVR Medtronic CoreValve™/Edwards Sapien 3 Valve”]

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Discussion Moderate to severe paravalvular regurgitation (PVR) is present in 0% to 24% of patients undergoing TAVR. 2, 3, 4, 5 Athappan, et al demonstrated in their large meta-analysis that moderate/severe PVR following TAVR was associated with a 3-fold increase in 30-day mortality and a 2.3-fold increase in 1-year mortality. 5 In the PARTNER-IA (Placement of AoRtic TraNscathetER Valves) study, randomized TAVR arm, the impact of any PVR on survival represented a 2-fold increase in the risk of mortality. 2 Other studies have shown moderate to severe PVR has a significant impact on survival. 3, 6, 7 Toggweiler, et al specifically looked at the progression of uncorrected PVR in the patient population undergoing TAVR using the self-expanding the Medtronic CoreValve™. 8 They performed TEE at 1-month and 12-month intervals and computed PVR perimeter and area in addition to conventional measurements. They noted that in the first month after TAVR 48% of patients had mild-to-moderate PVR. At 12 months there were significant reductions in PVR perimeter and cross-sectional area by 43% and 45%, respectively. They also found a nonsignificant trend toward reduced number and size of PVR jets. In their editorial comment on Toggweiler’s study Ineid, et al noted that significant post-TAVR PVR occurs more commonly with the CoreValve™ compared with the Edwards Sapien XT™ valve. 4, 9 This was seen in a large meta-analysis inclusive of 12,926 TAVR patients. 5 This was re-enforced in a study by Abdel-Wahab, et al in which 394 TAVR procedures resulted in significant PVR in the CoreValve™ group and adversely influenced the success of the device. 10 Additionally, they note that the CHOICE trial demonstrated more than four-fold frequency of significant PVR (18.3% vs 4.1%; P<.001) with the CoreValve™ which largely drove its lower device success rate when compared with the Edwards Sapien XT™ valve. 11 Additionally, we must consider the question of why this patient did not originally undergo Surgical Aortic Valve Replacement (SAVR) rather than TAVR and why the patient was allowed to progress sans intervention for his severe PVR. The original TAVR was performed at a well-respected academic facility noted for their cardiology and cardiac surgery programs. The patient and family relate that he had been followed for some time prior to his TAVR and that the TAVR option, when presented, was more agreeable to the patient than SAVR. The patient then presented to our community hospital facility some four years later with an acute Stanford Type A dissection after numerous serial echocardiograms demonstrating continued significant PVR and worsening aortic dilation. Per the echocardiogram interpretations and recommendations, the patient was not referred for surgical evaluation until long after his aorta was a surgical concern. We do not have access to the original TAVR workup which would include an STS risk score and frailty calculation. Nor do we have access to the actual TAVR imaging, either pre- or post-op, other than the printed reports available through an electronic medical record link. While it may be difficult to fully understand the decision for TAVR over SAVR, other than the patient’s 14

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

preference, we did calculate an STS risk score for this patient using the pre-op data prior to his emergent repair but using the isolated SAVR model. At the time the patient presented with his aortic dissection, his overall risk for mortality, using the SAVR model, was calculated at 2.07%. Renal failure was calculated as a 2.3% risk, permanent stroke 1.5%, and prolonged ventilation at 9.6%. His risk of re-operation was 4.9%. His post-op course, even as an emergent intervention was not far outside the norm for a SAVR patient of his age and with his comorbidities. The patient was extubated on POD #1 but did require BiPAP and remained in the ICU until POD #3. He was subsequently discharged on POD #8. Though we do not have frailty data, the patient was seen in-house by physical and occupational therapy and had a fairly normal course and was noted to be independent of ADLs prior to surgery. Summary There can be no doubt significant PVR is associated with non-laminar aortic blood flow. Such turbulent blood flow has been shown to be a source of aortic aneurysm and dissection. 12 While it is true that some post-TAVR PVR will self-correct, continued, significant, uncorrected PVR, especially in the setting of expanding aortic aneurysm is cause for concern and early intervention may be needed. Finally, given the location of this patient’s aortic injury, additional study may also be needed to determine if the elongated nitinol stent may have contributed to this dissection injury.

1. Kitamura T, Torii S, Kobayashi K, et al. Samurai cannulation (direct true-lumen cannulation) for acute Stanford Type A aortic dissection. Eur J CTS 2018;54 498–503 2. Kodali SK, Williams MR, Smith CR, et al. Two year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012;366: 1686–95. 3. Gilard M, Eltchaninoff H, Iung B, et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N Engl J Med 2012;366:1705–15. 4. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 2014;370:1790–8. 5. Athappan G, Patvardhan E, Tuzcu EM, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol 2013;61:1585–95. 6. Van Belle E, Juthier F, Susen S, et al. Postprocedural aortic regurgitation in balloon expandable and self-expandable TAVR procedures: Analysis of predictors and impact on long-term mortality: insights from the FRANCE2 Registry. Circulation 2014;129:1415–27.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

7. Dworakowski R, Wendler O, Halliday B, et al. Device-dependent association between paravalvar aortic regurgitation and outcome after TAVI. Heart 2014;100:1939â€“45. 8. Toggweiler S, van Schie B, Zuber M, et al. Natural course of paravalvular regurgitation after implantation of the self-expanding CoreValve: insights from serial TEE measurements. J Invasive Cardiol. 2015;27:435-440. 9. Ineid H, Paniagua D, Kar B, et al. Paravalvular regurgitation after TAVR: time heals, or not?. J Inv Card 2015;27(10):E226-8 10. Abdel-Wahab M, Comberg T, BĂźttner HJ, et al; Segeberg-Krozingen TAVI Registry. Aortic regurgitation after transcatheter aortic valve implantation with balloon- and self-expandable prostheses: a pooled analysis from a 2-center experience. JACC Cardiovasc Interv. 2014;7:284292. 11. Abdel-Wahab M, Mehilli J, Frerker C, et al; CHOICE Investigators. Comparison of balloon expandable vs self-expandable valves in patients undergoing transcatheter aortic valve replacement: the CHOICE randomized clinical trial. JAMA. 2014;311:1503-1514. 12. Braveman AC, Hasan G, Beardslee M, et al. The bicuspid aortic valve. Cur Prob in Card. 2015;30-9:470-522

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Secondary Rupture of a Residual Type B Aortic Dissection Following Surgical Repair of an Acute Type A Dissection Tiffany Worthington, MSPA, PA-C; Ali Khoynezhad, MD, PhD Department of Cardiothoracic Surgery, Memorial Care Long Beach Medical Center, Long Beach, California, 90808

Corresponding author Tiffany Worthington, MSPA PA-C, 3828 Schaufele Av. Suite #340 Long Beach, CA 90808 tworthington@memorialcare.org 657-241-9052

Introduction We present a case of an acute Stanford type A dissection with a contained rupture that was followed by a secondary rupture of the descending thoracic aorta 24-hours later. Aortic dissections have a prevalence of approximately 2,000 cases annually in the United States. The rupture of multiple sites of the aorta in the nontraumatic setting is much less common. We describe a 76-year-old male who presented to the emergency department with chest pain with subsequent identification and management of ascending aortic dissection with rupture. On the first postoperative day the patient experienced a secondary rupture of the descending thoracic aorta. Thoracic endovascular aortic repair (TEVAR) was used to treat the rupture successfully. He recovered well, was discharged to home, and has resumed his usual activities. Clinical Summary An active 76-year-old male with a past medical history of hypertension was brought in by ambulance after experiencing sudden onset chest pain while at work. Field personnel performed electrocardiography (EKG) at the scene which was suspicious for ST-elevation myocardial infarction (STEMI), however, repeat EKG did not show elevation of the ST segment. He lost consciousness during transport and by the time he arrived at the hospital he had regained consciousness and continued to complain of chest pain. Vital signs upon arrival were BP 145/75 with HR of 99. The patient was tachypneic with oxygen saturation of 93% on room air. Cardiac markers and EKG remained normal in the emergency department and D-dimer was >5,000ng/mL. Computed tomography angiography (CTA) scan identified extensive dissection extending from the aortic root to the bilateral common and external iliac arteries (figure 1). Antihypertensive medications were initiated with esmolol and nicardipine drips to achieve SBP goal of less than 120mmHg and heart rate less than 60bpm. The patient was then taken emergently to the operating room. After transfer to the operating room the contained ruptured dissection progressed to frank rupture at the posterior aortic root. The aorta was emergently cannulated and cardiotomy suctions were used to return active bleeding back to the heart-lung machine. Subsequently a right atrial cannula was placed along with a left ventricular vent for decompression of both atria. The 17

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

to 20 degrees and del Nido cardioplegia was administered for coronary protection. Resection of the proximal entry tear and replacement of hemiarch and ascending aorta were performed. Circulation was restored and rewarming began. Excision and subsequent reconstruction of the non-coronary sinus using a modified Dacron graft was performed (Yacoub aortic root remodeling). The left and right sinuses of Valsalva were repaired using felt and glue. Anastomosis was then performed to join the modified graft to the aortic annulus and repaired sinuses. Finally, anastomosis of the ascending aortic and aortic root grafts was performed to complete the intervention. There were no intraoperative complications and the patient was subsequently transferred to the ICU for further management including tight blood pressure control with mean arterial pressure (MAP) goal of 55-60 mmHg. The following day the intubated patient became hypoxic and chest radiograph identified increased consolidation in the left lung field which was not apparent on the first CXR after the surgical repair. Subsequent CTA imaging confirmed hemorrhage into the left chest without an obvious source of bleeding in the descending thoracic aorta. At this point the critical situation was discussed with the patientâ€™s family. Discussion included the high mortality rate associated with aortic rupture and emergent endovascular repair was recommended with the potential need for conversion to an emergent open repair. The family consented to proceed and the patient was taken to the hybrid operating room. An aortic angiogram was performed identifying the rupture of the descending thoracic aorta. Thoracic endovascular aortic repair (TEVAR) of entire descending thoracic aorta provided successful coverage of the culprit lesion. Again the patient was transferred to the ICU for standard postoperative care. After an uncomplicated hospital recovery, the patient underwent cardiac rehabilitation and, at three months post-operation, has regained all functional capacity without limitation. Discussion The incidence of aortic dissection is 3 to 6 per 100,000 people per year.1 Type A aortic dissection has a mortality rate of approximately 1% per hour over the first 48 hours. Aortic ruptures occur as sequelae in 9.4% to 15.3% of patients with dissection.2,3 Aortic rupture is a highly lethal complication and accounts for 47% of in-hospital deaths for patients with aortic dissection.2 First-line management for aortic dissection is to control pain and minimize sheer stress on the aorta with blood pressure and heart rate control.4 Several guidelines exist providing varying blood pressure and heart rate goals with the overall message of keeping these as low as possible while maintaining end-organ perfusion, usually with heart rate less than 60 bpm and systolic blood pressure under 120 mmHg.4,5 After medical therapy has been initiated, patients with Stanford type A dissection should be evaluated for surgical management. The goals for surgical management of a Stanford type A dissection are to prevent aortic rupture, pericardial tamponade, and to manage aortic valve insufficiency.5 These are achieved by restoring aortic valve competence by valve repair or replacement, obliteration of entry to false lumen, and replacement of dissected aortic tissue.5 In cases where the aortic valve is deemed repairable (without stiffness, calcification or sclerosis) there are valvesparing options to restore function including the Yacoub (remodeling) and David (reimplantation) techniques.6 In the Yacoub valve-sparing technique, the Dacron graft used for aortic root replacement is modified by trimming the proximal end to form scalloped edges to recreate one, two, or three sinuses of Valsalva as needed.7 Anastomosis is then performed affixing this modified graft to the aortic valve annulus.7 If affected, the coronary ostia of the left and right sinuses are then reimplanted to the Dacron graft. The David valve-sparing technique involves the implantation of the native aortic valve and annulus into the proximal end of a Dacron graft positioning the commissures at the level of the sinotubular junction (figure 3).6 One of the benefits of the David procedure over the 18

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Yacoub remodeling technique is the additional stabilization achieved by surrounding the aortic annulus with the prosthetic graft which may be preferable in younger patients with connective tissue disorders.7 There are three distinct phases during the recovery from an aortic dissection. These phases are acute (less than two weeks since onset), subacute (2 weeks to 3 months), and chronic (more than three months).8 During the transition from the acute to the chronic phase, aortic remodeling is actively occurring. Aneurysms develop in 34.5% of patients with descending aortic dissection within the first three years.9 There is a very rapid change in diameter which occurs in the early post dissection period and later stabilizes with a plateau after 88 days.10 A literature review by Peterss et al. noted a mean growth rate of 9.21mm/year in the acute phase, 1.30mm/year in the subacute stage, and slowing to 0.32mm/year in the chronic stage.10 This drastic change in growth rate underlines the importance of close follow up after the dissection event. One famous case of aortic dissection with subsequent rupture was Lucille Ball, who experienced catastrophic rupture one week after initial dissection.11 To our knowledge, this is the first report of successful treatment of a patient with acute type A dissection with two distinct ruptures. In addition to observed pathologic changes that occur in the acute period, the nature of entry tear patterns may have a role in aortic changes.10,12 In patients with several communications between the true and false lumens, obliteration of the primary entry tear in the proximal aorta during surgical repair may lead to pressurization of a re-entry tear distally.12 Especially in the setting of more extensive tears, this change in flow can lead to the equivalent of a new primary entry tear, putting the patient at increased risk for secondary rupture or aneurysm growth. The proximal descending thoracic aorta is the most common site for aneurysmal changes after aortic dissection.12 Rapid aortic remodeling after dissection can lead to further progression of the disease, or, in the case of the described patient above, rupture. It is during the acute post-dissection period that rupture, refractory pain, refractory hypertension, and ischemia are most often detected.10 Given the rapid post-dissection aortic changes, it is reasonable also to perform additional CTA imaging on hospital day five or prior to hospital discharge.10 Current guidelines recommend surveillance imaging of the aorta with CTA or magnetic resonance imaging (MRI) at 1, 3, 6, and 12 months post-dissection, and annually thereafter.4 Conclusion Aortic dissection has an incidence of 3 to 6 per 100,000 people per year.1 It is highly lethal if left untreated with an increase in mortality by 1% per hour for the first 48 hours. First-line treatment for aortic dissection is tight blood pressure and heart rate control along with pain management. 5 Surgical intervention for patients with Stanford type A dissection is recommended for all patients deemed to be surgical candidates.4 Continued close follow up in the acute and subacute phases of aortic remodeling are important to identify sequelae early and intervene as needed.10

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Figure 1: CTA of chest obtained prior to initial surgery showing extensive dissection of ascending and descending thoracic aorta, mediastinal hemorrhage, and hemorrhagic pericardial effusion.

Figure 2: Post-operative day one chest x-ray showing new left pleural effusion (left) and CTA scan showing interval development of large left hemothorax (right)

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Figure 3: David valve-sparing aortic root replacement with implantation of the native aortic valve and annulus into the proximal end of a Dacron graft positioning the commissures at the level of the sinotubular junction

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

References 1. Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM, Oxford Vascular Study. Circulation. 2013. May 21; 127(20):2031-7. 2. Afifi RO, Sandhu HK, Leake SS, et al. Determinants of operative mortality in patients with ruptured acute type A aortic dissection. Ann Thorac Surg 2016. 101:64-71. 10.1016/j.athoracsur.2015.07.007 3. Li ZD, Liu Y, Zhu J, et al. Risk factors of pre-operational aortic rupture in acute and subacute Stanford type A aortic dissection patients. J Thorac Dis. 2017;9(12):4979–4987. doi:10.21037/jtd.2017.11.59

4. Hiratzka LF, Bakris GL, Beckman, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol. 2010 55(14), e27-e129. 5. Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005 Dec 13;112(24):3802-13. 6. David TE. Aortic valve sparing operations: a review. Korean J Thorac Cardiovasc Surg. 2012 Aug;45 (4):205. 7. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg. 1998;115:1080–1090. 8. Authors/Task Force members, Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(41), 2873-2926. 9. Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). J Am Coll Cardiol Intv. 2013; 6:876-82 10. Peterss S, et al. Changing Pathology of the Thoracic Aorta From Acute to Chronic Dissection: Literature Review and Insights. J Am Coll Cardiol. 2016;68:1054–1065. doi: 10.1016/j.jacc.2016.05.091. 11. Spiegel C. Rupture of aorta called a result of extensive damage to critical vessel. Los Angeles Times. April 27, 1989 12. Krahenbuhl E, Maksimovic S, Sodeck G, et al. What makes the difference between the Natural course of a remaining type B dissection after type A repair and a primary type B aortic dissection? Eur J Cardiothorac Surg. 2012; 41:e110-5, discussion e115-6.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Steven Wilson, PA-C

Five questions for Steve Wilson, PA-C . PA Wilson is a long time APACVS member from Salisbury, Maryland who has provided distinguished service to the PA community through service to the Journal of the American Academy of PAs and through the AAPA. We were eager to hear how his perspective could inform APACVS members.

JAPACVS PA Wilson thank-you for your perspective and for your work to drive the profession forward. How did you get your start in cardiothoracic surgery? PA Wilson When I left school in 1974 my first position was at the Shock Trauma Center at the University of Maryland Hospital in Baltimore. It was almost an overwhelming opportunity, but I learned so much. After 2 years of +80 hours/week I needed a break. I became the Clinical Coordinator of the combined Hopkins/Essex Community College programs. After two years there one of the surgeons I had worked with at the Trauma Center asked me to join him in a general surgery and trauma practice in Greensburg, PA. It was a great eight years but I was missing some of the intensity of the Center and the surgeon was thinking of leaving the area. I applied to a CV practice in Harrisburg Pennsylvania in 1985 and one of my former students from the PA program was working there, saw my resume, and told them to call me up. The teacher became the student.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

JAPACVS What changes have you seen in the profession during your career? PA Wilson So, you are asking me about over 50 years of PA history? I must refer you to the PA History Society web site. In my position on the Board there I am trying to emphasize the CV surgery side of our history. As for my personal experience, I must look to the changes that I personally experienced in clinical practice. I must say that I was blessed of working with surgeons that recognized the capabilities of PAs and were secure enough in their own capabilities to allow and promote my own capabilities. I remember deciding to leave the Trauma Center and meeting with the Clinical Director/Surgeon there. He said he understood and pulled a document out of his desk drawer and told me that this was a memo he had received a year previous informing him of things that PAs could no longer do in the Trauma Center. He “forgot” to give it to me. A pathologist in Greensburg worked tirelessly to restrict my privileges. One restriction was that after 5pm another physician had to be present for any surgery performed by my supervising physician. During the first late night case we performed a designated physician arrived and was asked to have a seat in the corner of the OR suite while the surgeon and I completed the case. The first CV surgeon with whom I worked batted heads constantly to increase my privileges, encouraged my work with the state society, allowed me to attend state board of physician meetings, and embraced my desire to obtain new skills like EVH. Today, my colleagues and I enjoy a relationship with the medical staff that has only been accomplished by the efforts of individual PAs, knowledgeable physicians, and PA organizations like APACVS. JAPACVS Tell us about your leadership and service experiences in the profession? PA Wilson My reason for being involved in leadership is twofold: 1 - the profession has given me so much in terms of professional and personal satisfaction that I feel obligated to promote it. 2 – I believe in our profession’s capability to better address the needs in healthcare. I have served in multiple capacities in state, national and specialty organizations. I have served as chapter president, national director at large and chairman or committee member of committees that do or do not still exist. Leave it at that. It has been 46-years of experience for which I can’t quite abandon and for which I still feel passionate. Today I serve on the Board of Trustees for the PA History Society and having left the Editorial Board of JAAPA I continue to review papers for cardiac, thoracic and vascular surgery.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

JAPACVS How did you get involved with the Journal of the American Academy of PAs? PA Wilson First off, I was very pleased to be a part of a group of very dedicated PAs and staff that slowly but surely brought JAAPA to be an indexed Journal which has received multiple publishing awards. The Journal was looking to make it a recognized Journal in medical literature. They saw the need to better include and educate the specialties in which PAs were involved. I was asked to try to welcome the surgical specialties to what had previously been considered a “primary care publication”. Efforts were made to establish a surgical specialty section of the Journal. Unfortunately, we were never able to accumulate enough interest from the surgical specialties to maintain a monthly specialty section where the papers were acceptable to a peer reviewed journal. However, I have seen an increase in the number of surgical articles that are reviewed each year. I think that surgical PAs understand that they have a base of knowledge that should be shared with their primary care colleagues. It is an effort to help them recognize problems earlier and appropriately refer them as well as helping the primary provider better understand the surgical issues their patients face after surgery. JAPACVS What advice do you have for PAs interested in writing for scholarly journals?

PA Wilson If a case has a particular interest to you then it is probably of interest to others. A well written case report is a great leaning/teaching tool. An in-depth review of a particular disease process provides the opportunity to bring the most up-to-date information of a subject to your peers. If it is of special interest to you then you are able to provide that information that is more current than any textbook. Whichever paper you begin to prepare be sure to do the appropriate research. Look at other peer-reviewed journal articles that have been successfully published and see which style is best for your manuscript. Always start with an outline. Use credible references. Read the “author’s guidelines” found on the webpage. Finally, don’t become discouraged if you submit a paper and your peers that review it offer questions and suggestions. If you consider them it will make your manuscript better. I have never seen a manuscript make it to publication on first pass. These reviewers want you to succeed in having your paper published. It is their job to help you as well as protect the integrity of the journal they represent.

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery