The newly established Vassar Aorta Program based at Health Quest’s flagship, Vassar Brothers Medical Center, and led by Jason Sperling, MD, is a regional destination for the diagnosis, long-term management and surgical treatment of thoracic aortic disease.
Jason Sperling, MD, FACS, Chief of Cardiovascular Surgery at Vassar Brothers Medical Center, meets with an aortic dissection patient six weeks post-op to discuss his progress.
Dr. Sperling joined Health Quest Medical Practice and Vassar Brothers Medical Center in January as Chief of Cardiovascular Surgery. He came to Health Quest from HealthONE in Denver, where, as Director of Cardiac Surgery, he established the Rocky Mountain Aneurysm and Bicuspid Aortic Valve Program. Prior to his time in Colorado, Dr. Sperling directed the Thoracic Aneurysm and Bicuspid Aortic Valve Program at The Valley Hospital Heart and Vascular Institute in Ridgewood, New Jersey, until 2014.
At Vassar Brothers Medical Center, Dr. Sperling saw an opportunity to establish a program for individuals with dilated aorta or aneurysm that would encompass much more than just leading-edge surgery.
“A small minority of thoracic aortic disease patients needs surgery,” says Dr. Sperling, who is fellowship-trained in thoracic and cardiovascular surgery. “Most need comprehensive, long-term medical care, which includes more than the skill to perform a handful of surgeries. The impetus for this program is to prevent aortic catastrophe, which is emergent surgery or death due to aortic dissection or rupture. In 90 percent of patients, we do that by providing long-term surveillance and counseling them on how to prevent rupture.”
The Genetics of Thoracic Aortic Enlargement
Unlike abdominal aortic aneurysms, which are caused by atherosclerosis, thoracic aortic dilatation and aneurysms are largely genetically mediated, according to Dr. Sperling.
“Nearly every dilated aorta, or thoracic aneurysm in the ascending aortic position, has a genetic cause,” he says. “These aortas are missing some ingredient that has to do with their structural architecture on a microscopic level. There may be a modification of a building-block protein or something of that nature that makes the structure look like a normal aorta, at least early in life. However, because of that minute structural problem, the constant pulsation that occurs when the heart beats stretches the aorta, and it ultimately enlarges over time.
As the aorta becomes less elastic and enlarges, Dr. Sperling says, the aortic wall gets thinner, and the vessel’s tensile strength decreases, as does its burst-pressure threshold.
“The trick in aortic medicine is determining which of these dilated aortas truly represent risk — because they’re a minority,” Dr. Sperling says. “A normal aorta would burst at a blood pressure of about 800 mmHg, but humans are incapable of increasing blood pressure to that level. We can, however, get up to a blood pressure of about 450 mmHg, not because of hypertension, but due to straining. Aortic counseling involves discussing the activities that can elevate patients’ blood pressure to these extreme levels.”
It is assumed that all patients with a dilated aorta or aortic aneurysm have a lower-than-normal burst pressure. The quest to pinpoint each patient’s true risk is where the art and science of aortic medicine intersect. For patients of the Vassar Aorta Program, the journey begins with counseling.
Ellen Oehrlein, RN, BSN-BC, Vassar Aorta Program Coordinator, explaining the structure of the heart to a patient
Dr. Sperling and Ellen Oehrlein meet with a patient who has been newly diagnosed with a thoracic aortic aneurysm at Vassar Brothers Medical Center to explain treatment options.
The Ticking Time Bomb Myth
Most patients enter the program following incidental imaging findings of aortic dilatation or aneurysm. (See “Red Flags for Referral.”) Their first appointment includes an in-depth conversation with Dr. Sperling about what it means to have a dilated aorta or aneurysm and what causes them. One of Dr. Sperling’s most important tasks in these appointments is to disabuse patients of the notion that they are constantly one heartbeat away from disaster.
“Internet research can lead patients to believe they’re a ticking time bomb,” he says. “I explain that aortic aneurysms become infinitely less dangerous simply through the knowledge that they’re present. Once we identify them and counsel patients, the chances of experiencing rupture and catastrophe are nearly nil for individuals in my surveillance program. That’s a powerful thing to say to patients, and it reassures them.”
Dr. Sperling displays patients’ imaging studies on a large, high-definition monitor and explains their pathology. He talks with patients about the possibility they inherited thoracic aortic disease from their parents, as well as symptoms, which are uncommon. If he suspects a patient may have Marfan syndrome or a similar connective tissue disorder that can increase risk for aortic rupture, he conducts a standardized physical assessment for such conditions, in conjunction with Program Coordinator Ellen Oehrlein, RN, BSN-BC.
Dr. Sperling and Ellen Oehrlein discuss a patient’s imaging study.
A vital component of the appointment is patient education about activities that could elevate blood pressure enough to prompt aortic rupture.
“It is important for these patients to avoid heavy lifting,” Dr. Sperling says. “Extreme straining on the level of an expectant mother’s pushing during labor can increase rupture risk. Young patients might engage in that sort of straining as part of a recreational activity. For older patients, it could be due to constipation. We operate several times per year on aortic ruptures triggered by constipation, and those patients are usually older adults.”
A Better View of the Aorta
When patients enter the Vassar Aorta Program, they may require additional imaging to complement previous studies, and most will receive periodic surveillance imaging for years to come. A hallmark of the program is a specialized type of magnetic resonance angiography (MRA) that allows Dr. Sperling to view the aorta with a level of detail that conventional imaging modalities, such as CT angiography and echocardiography, cannot match. It provides other advantages as well.
To obtain the most useful images of the aorta with a commonly used study, CT angiography, Dr. Sperling notes, it is necessary to use a contrast agent, which exposes patients to more radiation than a noncontrast study and may be transiently toxic to certain organs. Echocardiography does not expose patients to radiation or use contrast, but it is a 2-D study that is unable to image enough of the aorta in adults. Conventional chest MRI and chest MRA may not be tailored to image the aorta. They can be lengthy, uncomfortable studies for patients, and MRA typically uses a contrast agent.
Over the years, Dr. Sperling has worked with radiologists to combine the best elements of MRI and MRA in one study, and minimize patient discomfort.
“We’ve created MRI protocols that provide MRA-quality imaging without the use of IV contrast agents,” he says. “We separate the wheat from the chaff by eliminating unnecessary sequences that are not related to the aorta. We are pursuing ever-shorter durations of the study. Historically, we’ve been able to do it in 30 minutes, and I think there’s a reasonable chance we can get down to 20.”
The Vassar Aorta MRA allows Dr. Sperling to see 3-D images of the aorta in real time, which gives him a more accurate sense of its dimensions.
“The software can use flowing blood as a contrast agent, which increases the definition and fidelity of the images,” he says. “We can also create moving images of the aortic valve opening and closing in cross section, which help us identify bicuspid aortic valve. That condition can change a patient’s status relative to what the published guidelines recommend for surgical intervention. In the future, we hope to use this technology to do even more, such as 4-D studies, which could help us get closer to pinpointing patients’ individual risk of rupture.”
Patients who are not candidates for surgical intervention or for whom surgery is not indicated receive long-term surveillance imaging at intervals determined by Dr. Sperling based on the rate of aortic growth; most thoracic aortic disease patients experience aortic growth of about a tenth of a centimeter in diameter per year, according to Dr. Sperling.
Ellen Oehrlein, the Program Coordinator, becomes a go-to point of contact for all patients as surveillance progresses.
“Ellen forms long-lasting friendships with our patients,” Dr. Sperling says. “We create a family in our program. Part of that is providing support groups for survivors of aortic dissection and rupture, as well as those living with aortic dilatation.”
Sophisticated Surgical Options
Few individuals with aortic disease require surgery. Dr. Sperling bases the decision to operate on a variety of factors, cited in published guidelines, including aortic size. In general, patients with an aorta greater than 5.5 centimeters in diameter, or who have an aneurysm that grows more than 0.5 centimeters in diameter annually, are surgical candidates. Certain individuals with aortic size of less than 5.5 centimeters in diameter may qualify for surgery, as well.
A distinguishing factor for the Vassar Aorta Program is Dr. Sperling’s proficiency with valve-sparing root replacement, also known as the “David” procedure. Dr. Sperling has performed approximately 200 of these complex surgeries during his career. Unlike the Bentall procedure — a more familiar operation to many cardiovascular surgeons that involves replacing the aortic root and aortic valve — the David procedure preserves patients’ native aortic valve. During the procedure, the surgeon disconnects the aortic valve from the aorta, removes the section of the vessel in which the aneurysm is located and replaces it with a graft, then reattaches the valve.
Surgical implants used during aortic surgery
Dr. Sperling scrubbing in for surgery at Vassar Brothers Medical Center
“The David procedure is a lifelong solution because the re-implanted valve is much more durable than a cow or pig replacement valve that patients receive in a Bentall procedure,” Dr. Sperling says. “David procedure patients are also able to avoid taking warfarin, which is necessary to reduce the risk of dangerous blood clots for patients who receive a mechanical valve. It’s special for our program to be able to offer the David procedure because it’s uncommon.”
Dr. Sperling performs several other procedures to treat aortic disease, including:
- Aortic valve repair
- Complex aortic arch and ascending aorta surgery
- Hybrid bypass-stent procedures
- Procedures for patients who have previously undergone open-heart surgery
- Re-operations for patients who have undergone surgery for aortic dissection or rupture
Dr. Sperling and his team performing surgery at Vassar Brothers Medical Center
“To replace the aortic arch, most patients have to have blood flow interrupted to part of the body, which involves special techniques and cooling the body,” Dr. Sperling says. “We now know that the old-fashioned way, deep hypothermic circulatory arrest, is associated with a higher incidence of stroke, so there’s interest in providing blood flow to at least part of the brain — regional brain perfusion — during these procedures. I nearly always find a way to allow the patient to have total brain perfusion during aortic arch surgery, which is not common in the U.S. That’s allowed me to have stroke rates for this surgery that are much lower than the national average.”
That innovative approach and unwavering commitment to patient safety and success make the Vassar Aorta Program a valuable addition to the healthcare landscape in the Mid-Hudson area.
“I’m beyond excited to partner with the expert, compassionate physicians of this region in caring for their patients,” Dr. Sperling says. “Individuals with aortic disease deserve to receive the most modern care from a comprehensive aorta program, and that’s what we offer.”
For additional information about the Vassar Aorta Program, visit healthquest.org/Vassaraorta.