The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology.

Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.

Aortic arch endovascular branch and fenestrated repair: Initial Canadian experience with novel technology.

Objective: The objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies. Methods: We performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes. Results: Eleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation. Conclusions: To the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.

A Systematic Review of Total Endovascular Aortic Arch Repair: A Promising Technology.

BACKGROUND: Total endovascular aortic arch repair (TEAAR) represents an emerging alternative for the treatment of aortic arch disease in patients at prohibitive risk for open surgery. A systematic review of TEAAR was performed to delineate early outcomes with this new technology. METHODS: All studies (excluding single-patient case reports) of CE-certified "custom made" or "off-the-shelf" zone 0 stent graft deployments were included. The primary search of Medline, Embase, CINAHL, and the Cochrane CENTRAL registry was supplemented with searches of Web of Science, ClinicalTrials.gov, and conference abstracts (within last 3 years), and a hand search of citations within relevant articles. Articles underwent 2-stage screening by 2 independent reviewers before inclusion. RESULTS: Fifteen relevant investigations were identified. Indications for TEAAR were chronic arch dissection with degenerative aneurysmal disease (54%, 148/273), pure arch aneurysm (41%, 112/273), penetrating atherosclerotic ulcer (2%, 5/273), and type IA endoleak from a zone 2 thoracic endograft (1%, 3/273). Double-branch (70%, 192/273), triple-branch (19%, 53/273), and single-branch (into innominate artery; 10%, 28/273) devices were used. Adjunct left carotid-subclavian bypass occurred in 90% of double- and single-branch procedures. Procedural success with TEAAR was 93% (95% CI 85.8%-96.3%). The proportion of all-cause mortality was 16% (95% CI 8%-26%), stroke 14% (8%-24%), peripheral vascular events 7% (1%-33%), and myocardial infarction 4% (2%-7%). Endoleaks were identified in 13% (7%-25%) of the study population. CONCLUSIONS: TEAAR represents an emerging option for the management of aortic arch disease wth high procedural success rates and acceptable early outcomes in a high-risk patient population.

The Aortic Team Model for the Management of the Distal Arch, Descending Thoracic and Thoracoabdominal Aorta: Appraisal at 3 Years.

BACKGROUND: This study aimed to assess feasibility, logistical challenges, and clinical outcomes associated with the implementation of an Aortic Team model for the management of distal arch, descending thoracic and thoracoabdominal aortic disease. METHODS: An Aortic Team care pathway was implemented in November 2019. Working as a unit, two cardiac surgeons, two vascular surgeons, an interventional radiologist, a cardiologist, and an anesthesiologist collectively determined care decisions via multispecialty presence at an Aortic Clinic. Cardiac and vascular surgeons operated in tandem for open procedures. Interventional radiology participated alongside cardiac and vascular for endovascular procedures. Cardiology aided in medical therapies for heritable and degenerative disease, and had a lead role for genetics and high-risk pregnancy referrals. The model spanned three hospitals. Clinical outcomes at 3 years were assessed. RESULTS: There were 35 descending thoracic and thoracoabdominal surgeries and 77 thoracic endovascular aortic repairs. Endoarch devices were used in 7 cases (Gore Thoracic Branch Endoprosthesis, 4, Terumo RelayBranch, 3) and an endothoracoabdominal device in 4 cases (Cook Zenith t-branch). The Aortic Clinic acquired 456 patients, with yearly increases (54 patients [year 1], 181 patients [year 2], 221 patients [year 3]). For surgery, mortality was 8.6% (3/35), permanent paralysis 5.7% (2/35), stroke 8.6% (3/35), permanent dialysis 0%, and reinterventions 8.6% (3/35). For endovascular cases, mortality was 3.9% (3/77), permanent paralysis 3.9% (3/77), stroke 5.2% (4/77), permanent dialysis 1.3% (1/77), and reinterventions 16.9% (13/77). CONCLUSION: An Aortic Team model is feasible and ensures all treatment options are considered. Conventional open thoracoabdominal procedures showed acceptable outcomes. Endoarch technology shows early promise.

Zone 0 Aortic Arch Reconstruction Using the RelayBranch Thoracic Stent Graft.

Endovascular therapies have had a considerable impact on contemporary management of thoracic aortic disease. Still, with the anatomic challenges of the aortic arch, endovascular experience with devices that traverse the arch and deploy in the Zone 0 position remains limited. We report the first Canadian experience with the RelayBranch Thoracic Stent Graft (Terumo Aortic, Sunrise, FL) with Zone 0 deployment for total endovascular aortic arch repair in a patient at very high risk for redo open surgery. We demonstrate safe deployment of the device and successful treatment of a type 1A endoleak. Features of the RelayBranch design that mitigate challenges of arch deployment are also discussed.

Les traitements endovasculaires ont eu un impact considérable sur la gestion contemporaine des pathologies de l'aorte thoracique. Pourtant, en raison des contraintes anatomiques de la crosse aortique, l'expérience endovasculaire avec des dispositifs qui traversent la crosse et se déploient dans la zone 0 reste limitée. Nous rapportons la première expérience canadienne de l'endoprothèse thoracique RelayBranch avec déploiement (Terumo Aortic, Sunrise, FL) en zone 0 pour une réparation endovasculaire totale de la crosse aortique chez un patient présentant un risque très élevé de reprise de chirurgie ouverte. Nous décrivons le déploiement en toute sécurité du dispositif et le traitement réussi d'une endofuite de type 1A. Enfin, nous examinons les caractéristiques du système RelayBranch qui limitent les difficultés liées au déploiement du dispositif dans la crosse aortique.

Development of Quality Indicators for the Management of Acute Type A Aortic Dissection.

In an effort to further improve surgical outcomes in patients with acute type A aortic dissection (ATAD), the Canadian Thoracic Aortic Collaborative (CTAC), with the support of the Canadian Society of Cardiac Surgeons (CSCS), endeavoured to develop quality indicators (QIs) for the management of patients with ATAD. After 2 successive consultations with the CTAC membership, 11 QIs were selected and separated into 5 broad categories: preoperative (time from presentation to diagnosis, time from presentation to the operating room), intraoperative (use of hypothermic circulatory arrest and antegrade cerebral perfusion), 30-day outcomes (30-day rates of all-cause mortality, 30-day rates of new postoperative stroke), 1-year outcomes (1-year rates of follow-up imaging, 1-year rates of all-cause mortality, and 1-year rates of surgical reintervention), and institutional (institutional surgical volumes, individual surgical volumes, and presence of institutional aortic disease teams). The purpose of this article is to describe the process by which QIs for the management of ATAD were developed and the feasibility by which they may be collected using existing clinical and administrative data sources. Furthermore, we demonstrate how they may be used to evaluate success following surgery for repair of ATAD and ultimately improve clinical outcomes.

The Many Care Models to Treat Thoracic Aortic Disease in Canada: A Nationwide Survey of Cardiac Surgeons, Cardiologists, Interventional Radiologists, and Vascular Surgeons.

BACKGROUND: Several specialties treat thoracic aortic disease, resulting in multiple patient care pathways. This study aimed to characterize these varied care models to guide health policy. METHODS: A 57-question e-survey was sent to staff cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons at 7 Canadian medical societies. RESULTS: For 914 physicians, the response rate was 76% (86 of 113) for cardiac surgeons, 40% (58 of 146) for vascular surgeons, 24% (34 of 140) for radiologists, and 14% (70 of 515) for cardiologists. Several services admitted type B dissections (vascular 37%, cardiology 31%, cardiac 18%, other 7%), and care was heterogeneous. Ownership of disease management was overestimated relative to the perspective of the other specialties. Type A dissection admissions and treatment were more uniform, but emergent call coverage varied. A 24/7 aortic specialist on-call schedule was present only 4% of the time. "Aortic" case rounds promoted attendance by a broader aortic specialty contingency relative to rounds that were specialty specific. Although 89% of respondents felt an aortic team was best for patient care, only 54% worked at an institution with an aortic team present, and only 28% utilized an aortic clinic. Questions designed to define an aortic team derived 63 different combinations. CONCLUSIONS: Thoracic aortic disease follows a network of undefined and variable care pathways, despite its high-risk population in need of complex treatment considerations. Multidisciplinary aortic teams and clinics exist in low volume, and the "aortic team" remains an obscure construct. A multispecialty initiative to define the aortic team and outline standardized navigation pathways within the health systems hospitals is advocated.

CONTEXTE: La prise en charge de la maladie de l'aorte thoracique peut faire appel à plusieurs spécialités, ce qui a pour effet de multiplier les trajectoires de soins des patients. Cette étude visait à caractériser ces différents modèles de soins afin d'éclairer l'élaboration des politiques de santé. MÉTHODOLOGIE: Un sondage électronique de 57 questions a été envoyé aux chirurgiens cardiaques, aux cardiologues, aux radiologistes interventionnels et aux chirurgiens vasculaires membres de 7 associations médicales canadiennes. RÉSULTATS: Sur un total de 914 médecins, le taux de réponse a été de 76 % (86 sur 113) chez les chirurgiens cardiaques, de 40 % (58 sur 146) chez les chirurgiens vasculaires, de 24 % (34 sur 140) chez les radiologistes et de 14 % (70 sur 515) chez les cardiologues. Plusieurs services avaient admis des cas de dissection aortique de type B (chirurgie vasculaire 37 %, cardiologie 31 %, chirurgie cardiaque 18 %, autre 7 %) et les soins étaient hétérogènes. Les spécialistes surestimaient leur responsabilité de la prise en charge des cas par rapport à celle des autres spécialistes. Les admissions de cas de dissection de type A et leur traitement étaient plus uniformes, mais la présence de spécialistes de garde pouvant traiter les cas urgents était variable. La présence continue d'un spécialiste de l'aorte de garde n'était observée que pendant 4 % du temps. Les séances de discussion de cas « aortiques ¼ favorisaient la participation par une gamme plus large de spécialistes de l'aorte que les discussions axées sur une spécialité donnée. Si 89 % des répondants estimaient qu'une équipe « aortique ¼ était la meilleure option pour les soins aux patients, ils n'étaient que 54 % à travailler dans un établissement disposant d'une telle équipe et 28 % à utiliser les services d'une clinique de l'aorte. En réponse aux questions portant sur les éléments constitutifs d'une équipe aortique, 63 combinaisons différentes de spécialités ont été proposées. CONCLUSIONS: La prise en charge de la maladie de l'aorte thoracique emprunte un dédale de trajectoires de soins non définies et variables, alors que sa population à haut risque a besoin de traitements complexes. Les équipes multidisciplinaires et les cliniques spécialisées dans le traitement de l'aorte sont rares, et la notion d' « équipe aortique ¼ demeure un concept obscur. Nous préconisons une initiative réunissant des spécialistes de différents domaines pour définir les éléments constitutifs d'une équipe aortique et établir des trajectoires de navigation normalisées au sein des hôpitaux du système de santé.

Lack of Equity in the Cardiology Physician Workforce: A Narrative Review and Analysis of the Literature.

The gender and racial diversity in the cardiology workforce in Canada does not reflect that of the population we serve. As social awareness of the principles of equity, diversity, and inclusion rises, our profession must rise to meet the challenges they present. We detail contemporary examples of publication bias in the cardiac sciences literature and describe the factors that led to oversight in the peer-review process. We performed a narrative review to summarize the published literature on equity and diversity among cardiac physicians. We also summarize the challenges faced by women and racial-minority physicians when pursuing and thriving in a career in cardiology, and the systemic barriers to their success. In the past decade, social justice movements have advanced. Professionalism standards are changing, and awareness and understanding of these advances in terminology is imperative for all physicians. In this review, we summarize key language and concepts, with cardiology-specific examples, and propose a new paradigm of professionalism.

Au Canada, la diversité des genres et des races au sein de la main-d'œuvre en cardiologie ne reflète pas celle qui existe dans la population que nous servons. La prise de conscience sociale des principes d'équité, de diversité et d'inclusion gagne du terrain, et notre profession doit se montrer à la hauteur des défis qui s'y rattachent. Nous abordons des exemples contemporains de biais de publication dans la littérature cardiologique et décrivons les facteurs qui ont mené à des omissions dans le processus d'examen par les pairs. Une revue narrative de la littérature publiée sur l'équité et la diversité parmi les cardiologues nous a permis de résumer l'information publiée sur le sujet. Nous résumons également les difficultés auxquelles sont confrontés les femmes et les médecins issus des minorités raciales qui choisissent et mènent avec brio une carrière en cardiologie, de même que les obstacles systémiques à leur réussite. Au cours de la dernière décennie, les mouvements de justice sociale ont progressé. Les normes de professionnalisme évoluent, et tous les médecins doivent connaître et comprendre les avancées terminologiques. Dans le présent article, nous résumons les termes et les concepts clés, en y adjoignant des exemples propres au domaine de la cardiologie. Nous proposons aussi un nouveau paradigme de professionnalisme.

Development of Microbiome Biobanks - Challenges and Opportunities.

The microbiome research field is rapidly evolving, but the required biobanking infrastructure is currently fragmented and not prepared for the biobanking of microbiomes. The rapid advancement of technologies requires an urgent assessment of how biobanks can underpin research by preserving microbiome samples and their functional potential.

Economic Burden and Healthcare Resource Use for Thoracic Aortic Dissections and Thoracic Aortic Aneurysms-A Population-Based Cost-of-Illness Analysis.

Background Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost-of-illness analysis was performed. From a single-payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (P<0.0001) and $13 M to $18 M for TAAs (P<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (P=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (P=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.

Repetitive transcranial magnetic stimulation for the treatment of postpartum depression.

BACKGROUND: Postpartum depression (PPD) is a common and gravely disabling health concern. Repetitive transcranial magnetic stimulation (rTMS) is an FDA approved treatment for major depression and may be a valuable tool in the treatment of PPD. The treatment effect of rTMS is rapid, generally well tolerated, without systemic effects, and without medication exposure to a fetus and/or breastfed infant. METHODS: Six women with PPD received 20 sessions of 10 Hz rTMS over the left dorsolateral prefrontal cortex (DLPFC) over a 4 week period. Psychiatric rating scales (BDI, EPDS, STATI), cognitive assessments (MMSE, Trails B, List Generation) and breastfeeding practices were surveyed at baseline and post rTMS treatment. BDI and EPDS were obtained weekly, as well as 3 months and 6 months post study conclusion. RESULTS: Average BDI, EPDS, and STAI scores declined over the 4-week duration of rTMS treatment. Of the six patients, four achieved remission as assessed by EPDS and one achieved remission and two responded as assessed by BDI. Mean BDI and EPDS scores at 3 and 6 months follow-up remained below levels at study entry. No evidence of cognitive changes or breastfeeding disruptions. LIMITATIONS: This was an exploratory study with small sample size with no sham control arm. Daily administration of rTMS provides potential for confounding of behavioral activation in the otherwise often isolative postpartum period. CONCLUSIONS: rTMS was safe and well tolerated among participants with evidence of sustained improvements in depression and anxiety scores. This study supports rTMS as a promising non-pharmacologic treatment modality for perinatal depression.