The aorta and aortic valve pose particular challenges for cardiovascular care. Subtle changes can eventually lead to significant problems, including ventricular scarring, heart failure, internal bleeding, stroke, and organ damage. The presentations of these disease states are heterogeneous, and conditions often overlap — it's not uncommon to find simultaneous aortopathy and valvulopathy.
Aortic disease also affects a wide population that includes both older, frequently frailer patients and younger patients (under 65 or so) affected by congenital and genetic components. Other considerations include the variability of anatomy, including the size and location of critical branch vessels, and the longitudinal charter of arctic disease — even with treatment, patients may need further intervention in their lives, sometimes just years later.
Specialists in the renowned aorta program at Penn Medicine have spent decades working on these challenges, developing the comprehensive model others follow. But several years ago, they came to realize that more can — and should — be done. Their effort evolved into the Penn Aorta Center, which today unites the range of disciplines essential to effective care: top cardio-aortic surgeons and vascular surgeons as well as experts in medical cardiology, imaging, genetics, and nursing.
"Our mission within the Penn Aorta Center is to have a more focused, 360-degree view around each patient," says Nimesh Desai, MD. "We make decisions on medical management, we make decisions on endovascular treatment, and we make decisions on open surgical treatment. It's about the total management of the aortic valve and the aorta."
The center will operate from both Penn Presbyterian Medical Center and from specially designed operating suites within the Penn Medicine Pavilion containing advanced imaging and true hybrid functionality for open surgeries, endovascular approaches, and combination procedures.
From the outset, the aorta program's expansion provided referring physicians an unparalleled resource and opportunity for partnership. Today, new clinical programs, extended patient support, enhanced research efforts, and a larger goal are transforming the way care for the aorta and aortic valve is conceived and delivered.
New vision for aortic care from a national leader
The Penn Aorta Center is one of North America's four largest aorta programs and the busiest in Greater Philadelphia (by caseload). High volume means that Penn surgeons have experience in the full range of aortic interventions and see the most complex presentations, including emergent cases.
Members of the Penn aorta team publish globally influential research (more than 600 articles to date), with contributions that have helped change guidelines for earlier interventions in aortic insufficiency and Marfan syndrome. Members also present at conferences worldwide and hold leadership positions with the Society of Thoracic Surgeons.
In addition to expertise, clinical excellence, and leading outcomes, Penn is known for innovation. The team continues to perform aortic root operations that can repair and preserve a patient's heart valve, reduce Type A dissection mortality through a trauma-oriented approach and employ branched endovascular stent-grafts (customized when needed) to make procedures less invasive.
In addition, the Penn team has used the weight of its expertise and influence to enhance its approach to comprehensive aortic care:
- Making procedures increasingly safer, more effective and longer-lasting;
- Ensuring patients get the appropriate procedure, with a comprehensive understanding of timing (too early may increase surgical risk; too late may cause irreversible harm and reduced options);
- Taking a nuanced view of when to intervene, moving beyond just aortic diameter to consider age, body size, valve configuration, family history, and any underlying genetic predisposition or connective tissue disorder;
- Using advanced imaging and interpreting expertise, not just to confirm diagnosis but also to carefully monitor the valve and aorta before and after surgery;
- Offering access to novel stents, stent-grafts and additional devices others don't through Penn-led clinical trials, special FDA exemption, and unique early-feasibility industry partnerships;
- Conducting leading genetics research and full testing and counseling support;
- Considering lifetime needs and quality of life rather than just the challenge of the moment.
Penn Medicine offers surveillance for nearly 2,000 aorta patients a year — patients who had an initial intervention for a bicuspid aortic valve, aortic dissection, or aortic aneurysm or may eventually need one. The Penn Aorta Center and the resources it entails mean that support becomes a clinical reality for every patient. It's an unprecedented, holistic approach that looks beyond just the original disease.
"We are trying to take one of the world's best models of aortic care and make it more sophisticated and comprehensive than we have ever been able to in the past," says cardiac surgeon Nimesh Desai, MD, the center's director. "We are looking not just at the current problem that the patient has, but actually trying to understand all the elements that we are going to need to support that patient and their family through their lifetime of aortic disease."
Supplementing medical and surgical care, patients will have access to psychological support under the center — crucial for conditions like aortic dissection that can still pose a risk after initial treatment. The team will also work with neurologists to monitor the impact of interventions on the brain, extending the focus beyond operative and postoperative stroke to consider a range of potential long-term changes and how to prevent them.
Meeting a Growing and Significant Need for Aortic Disease Care
Estimates place the number of enlarged aortas in the U.S. in the hundreds of thousands, a figure likely to increase as improved imaging leads to more incidental findings (the most common way aortic disease gets discovered) and a large segment of the population transitions into old age.
Not all these aortas will need an intervention, but they may still benefit from evaluation and possible surveillance at a multidisciplinary center. Experts can watch for possible progression and, should that occur, work to prevent future rupture or dissection. (Ruptures and dissections affect 30,000 Americans a year)
Enlarged aortas may also warrant aortic valve examination, given the interconnected nature of the two structures and the frequency of valvulopathy: Up to 30% of the population has some degree of aortic insufficiency and up to 2% a bicuspid aortic valve. Left ventricular decline can result from these valve conditions, as well as aortic remodeling.
In addition to lifetime disease management, the Penn Aorta Center will meet these needs by continuing to improve interventions. Penn's cardiac and vascular surgeons are:
- Using investigational stent-grafts, often branched, to extend endovascular treatment into the ascending aorta, arch and thoracoabdominal segment
- Accounting for the fact that downstream complications often follow Type A dissection repair, by preparing for later stent-grafting or potentially avoiding reintervention altogether
- Extending valve-sparing procedures into more complicated anatomy, with the ability to repair both tricuspid and bicuspid aortic valves
- Leading the reinvigoration of the Ross procedure, when they cannot save the aortic valve
"That's what makes Penn such a special place," says cardiac surgeon Wilson Szeto, MD, who will oversee the center's efforts at Penn Presbyterian Medical Center.
"We're continuing to challenge ourselves to be better. We're continuing to push the boundaries to improve the care of our patients, while asking the question of how do we embrace technology and innovation in doing so."
Conducting Groundbreaking Research to Inform Aortic Care
A final key element for the Penn Aorta Center is research, both in immediate clinical application (outcomes and more than 15 clinical trials) and translational work. As part of the program's transformation, we're hiring additional researchers to partner with physician-investigators.
Many questions remain about how aortic disease forms and progresses, unknowns the team plans to address. The center will feature a new aortic tissue bank, to determine how aortic-related genetic changes manifest and how care might need further adjustment.
The Penn aorta team also has years of data from interventions and surveillance, a rich resource for addressing shortcomings in national and international treatment guidelines. Given the limitations inherent in the field to date, those guidelines often lack strong backing data, Dr. Desai says.
The analyses will potentially provide the field with a greater understanding of risk and a more nuanced stratification, to determine at what point to step in for each patient, and with what care. "We are just at the tip of the iceberg in terms of what we can do," Dr. Desai says.
Refer a Patient to the Penn Aorta Center
To make a referral to the Penn Aorta Center, call 877-937-7366.
Whether you're in Greater Philadelphia or elsewhere in the country, the Penn Aorta Center welcomes inquiries. The team is equipped to handle complex needs, including reinterventions after previous surgeries. Other reasons to inquire about possible referral include:
- Aortic insufficiency
- Bicuspid aortic valve or related repair/replacement
- Diagnosed connective tissue disorder
- Dissected aorta
- Enlarged thoracic aorta (4 centimeters or more)
- Family history of thoracic aortic aneurysm or dissection or known, related mutation
- Repaired congenital heart defect
Additional Resources from the Penn Aorta Center