IRAD Investigator Meeting American College of Cardiology 2012 { [PDF]

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IRAD Investigator Meeting

American College of Cardiology 2012

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Agenda

{

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I.

Database Update

II.

Notes on Variables

III.

Participating Sites

IV.

IRAD Expansion

V.

IRAD IVC

VI.

Patient Education

VII.

Dynamic Imaging

VIII. Publications Update

IX.

Manuscripts in Preparation

X.

ACC 2012 Presentations

XI.

Upcoming Meetings

XII.

2011 in Review

XIII. Future Directions

Agenda

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Database Update

{

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Type A Type B

Total Patients

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100 200 300 400 500 600 Michigan

Mass. Gen.
U. Penn.
S. Orsola

Vall d'Hebron RBK San Donato Tromso

St. Michaels

Brigham & Women's Minneapolis Heart Tokyo Eppendorf-Rostock Calgary Mayo

Wash. U.

Vienna Hadassah

U. Mass.

San Giovanni e Ruggi 12 de Octubre Duke Dartmouth

U. Colorado
U. Chicago

Bichat

U. Virginia

Graz

U. Pittsburgh
U. Minnesota
No. of Cases by Hospital

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500 1000 1500 2000 2500 3000 3500 4000 Total Survived Followed Up

Total Follow-up

3867 3086 (79.8%) 1592 (51.6%) Follow-up defined as a patient having at least one completed follow-up form.

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Type A Dissection

500 1000 1500 2000 Survived Followed Up

Type B Dissection

500 1000 1500 2000 Survived Followed Up 1205

Follow-up by Type

1881 908 (48.3%) 684 (56.8%)

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50 100 150 200 250

Mass. Gen.

Michigan RBK

S. Orsola

Vall d'Hebron San Donato Tromso

St. Michaels

Eppendorf-Rostock Calgary Minneapolis Heart Brigham & Women's Vienna

U. Mass.

Tokyo

Wash. U.

12 de Octubre Hadassah Mayo Duke

U. Penn.

Dartmouth

U. Chicago

Bichat Graz San Giovanni e Ruggi

U. Colorado
U. Pittsburgh
U. Virginia
U. Minnesota

Follow-up by Hospital

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0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% RBK

U. Mass.

12 de Octubre Tromso Eppendorf-Rostock Calgary Vall d'Hebron

Mass. Gen.
St. Michaels

San Donato

S. Orsola

Minneapolis Heart Michigan Vienna Duke Hadassah Brigham & Women's

Wash. U.
U. Chicago

Tokyo Mayo

U. Penn.

San Giovanni e Ruggi Dartmouth

U. Colorado

Bichat

U. Virginia

Graz

U. Pittsburgh
U. Minnesota

% Follow-up by Hospital

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Type B Follow-up

20 40 60 80 100 120 140 160 Michigan

Mass. Gen.

Vall d'Hebron

S. Orsola

Tromso Eppendorf-Rostock RBK San Donato

St. Michaels

Calgary Tokyo

U. Mass.

Minneapolis Heart Mayo

Wash. U.

Brigham & Women's Duke Hadassah 12 de Octubre

U. Penn.

Vienna San Giovanni e Ruggi Dartmouth

U. Colorado
U. Chicago

Bichat

U. Virginia

Graz

U. Pittsburgh
U. Minnesota

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0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 12 de Octubre RBK Tromso

S. Orsola

Vall d'Hebron Eppendorf-Rostock

St. Michaels
U. Mass.

Calgary

Mass. Gen.

Michigan San Donato Hadassah Brigham & Women's Duke Minneapolis Heart Mayo Tokyo

Wash. U.
U. Penn.

Vienna San Giovanni e Ruggi Dartmouth

U. Colorado
U. Chicago

Bichat

U. Virginia

Graz

U. Pittsburgh
U. Minnesota

% Type B Follow-up

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0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% RBK Tromso

S. Orsola

Vall d'Hebron Eppendorf-Rostock

St. Michaels

Calgary

Mass. Gen.

Michigan San Donato Brigham & Women's Minneapolis Heart Mayo Tokyo

Wash. U.
U. Penn.

% Type B Follow-up

Sites with >100 Cases

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20 40 60 80 100 120 140 RBK

Mass. Gen.
S. Orsola

San Donato Michigan Vall d'Hebron

St. Michaels

Minneapolis Heart Tromso Calgary Brigham & Women's Vienna Eppendorf-Rostock 12 de Octubre

U. Mass.
Wash. U.

Hadassah Tokyo Duke Mayo

U. Chicago
U. Penn.

San Giovanni e Ruggi Dartmouth

U. Colorado

Bichat

U. Virginia

Graz

U. Pittsburgh
U. Minnesota

Type A Follow-up

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0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% RBK

U. Mass.

12 de Octubre Tromso Calgary Minneapolis Heart

Mass. Gen.

Eppendorf-Rostock San Donato Vall d'Hebron

St. Michaels
S. Orsola

Vienna Michigan Duke Hadassah Brigham & Women's

Wash. U.
U. Chicago

Tokyo Mayo

U. Penn.

San Giovanni e Ruggi Dartmouth

U. Colorado

Bichat

U. Virginia

Graz

U. Pittsburgh
U. Minnesota

% Type A Follow-up

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0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% RBK Tromso Calgary Minneapolis Heart

Mass. Gen.

Eppendorf-Rostock San Donato Vall d'Hebron

St. Michaels
S. Orsola

Michigan Brigham & Women's

Wash. U.

Tokyo Mayo

U. Penn.

% Type A Follow-up

Sites with >100 Cases

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Notes on Variables

{

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Only diagnostic imaging studies should

be included in the imaging studies section

 No data from intra-operative or intra-

procedure studies should be listed.

Acute Form Variables

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Participating Sites

{

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Active IRAD Sites

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IRAD Expansion

{

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Interested Sites

33 Sites

Have inquired about joining the IRAD registry.

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New IRAD Sites

Centers in the Process of Enrolling

 University of Osaka, Osaka, Japan  Royal Prince Alfred Hospital, Sydney, Australia  Henry Ford Hospital, Detroit, Michigan  University of Sao Paulo, Sao Paulo, Brazil  Cedars-Sinai Medical Center, Los Angeles,

California

 Advocate Christ Medical Center, Chicago,

Illinois

 University of Maryland, Baltimore, Maryland  Methodist Hospitals of Memphis, Memphis,

Tennessee

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New IRAD Sites

Centers in the Process of Enrolling

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Interested sites that are recommended

by a current IRAD member may join, if they agree to do the following:

 Establish a dedicated study coordinator at

their site

 Commit to pay ~$5,000 annually, to cover

expenses incurred from managing a larger database

Adding New Sites - Requirements

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{

Publications Update

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I.

Ascending Thoracic Aorta Dimension and Outcomes in Acute Type B Dissection (from the International Registry of Acute Aortic Dissection [IRAD]).

 American Journal of Cardiology. 2011.

II.

The Role of Preoperative Coronary Angiography in the Setting of Type A Acute Aortic Dissection: Insights from the International Registry of Acute Aortic Dissection.

 American Heart Journal. 2011.

Recently Published Manuscripts

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III. Sensitivity of the Aortic Dissection Detection

(ADD) Risk Score, A Novel Guideline-Based Tool for Identification of Acute Aortic Dissection at Initial Presentation.

 Circulation. 2011.

IV. Descending Aortic Diameter of 5.5 cm or

Greater is Not an Accurate Predictor of Acute Type B Aortic Dissection.

 Journal of Thoracic and Cardiovascular Surgery. 2011.

Recently Published Manuscripts

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V.

Type-Selective Benefits of Medications in Treatment of Acute Aortic Dissection (from the International Registry of Acute Aortic Dissection[IRAD]).

 American Journal of Cardiology. 2011.

VI. Correlates of Delayed Recognition and

Treatment of Acute Type A Aortic Dissection: The International Registry of Acute Aortic Dissection (IRAD).

 Circulation. 2011.

Recently Published Manuscripts

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VII. Acute Type B Aortic Dissection in the

Absence of Aortic Dilatation.

 Journal of Vascular Surgery. 2012.

VIII.Clinical Presentation, Management and

Short-Term Outcome of Patients with Type A Acute Dissection Complicated by Mesenteric

Malperfusion. Observations from the

International Registry of Acute Aortic Dissection.

 Journal of Thoracic and Cardiovascular Surgery. 2012.

Recently Published Manuscripts

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Manuscripts in Preparation

{

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1.

Medical vs. Endovascular Tx in TB AoD

2.

Age and Complications in TB AoD

3.

Aortic Dimensions and Body Size

4.

Marfan Syndrome in AoD

5.

24 Hour Mortality

6.

Trends in AoD: 3000 Patients

7.

Medical Management of TA AoD

8.

BAV in AoD

9.

Stroke in AoD

10. New Time Classification
11. Left Renal Artery Involvement in Type A
12. Normal Diameters

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13. Non-Operative TA Patients
14. False Lumen Thrombosis in TA AoD
15. Spinal Cord Ischemia
16. Mortality Models for TA AoD
17. Young Women with AoD
18. Renal Insufficiency
19. Intramural Hematoma
20. Predictors of Aortic Growth
21. Medications in Marfan Patients
22. Pre-Procedure Neurological Deficits
23. Size and Dissection Risk in Marfan and BAV
24. Differences in Cannulation Strategy

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25. Imaging Over 15 Years of IRAD
26. Racial Differences
27. Aortic Regurgitation on Follow-Up
28. Type A Dissection with Myocardial Infarction
29. Iatrogenic Aortic Dissection
30. Redissection on Follow-Up
31. CXR Sensitivity
32. Patient Education Surveys
33. Long-Term Follow-Up in Marfan Syndrome
34. Pregnancy in Aortic Dissection
35. Surgery in Elderly Type A Patients

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Invasive Treatment Cohort

IRAD-IVC

{

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Cases Enrolled to Date

668

cases enrolled

100 200 300 400 500 600 700 800 AHA 2010 ACC 2011 AHA 2011 Current 284 462 616 668

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Cannulation Abstract

First IRAD submission

using IVC data

Submitted to the AATS

Aortic Symposium conference

Compared axillary vs.

femoral cannulation in Type A dissection repair

Findings:

 Cannulation strategy did

not affect survival or malperfusion-related morbidity

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Mortality

Mortality by Site of Cannulation Right Axillary Femoral

p=non-significant

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 Pre-op stratification of Type A patients  Pre-op stratification of Type B patients  Variation in outcomes among IRAD site following

TAAoD repair

 Fate of aortic valve following TAAoD  Is EEG monitoring mandatory during circulatory

arrest in TAAoD?

 Outcomes following aortic valve sparing operation

in patients presenting with aortic valve incompetence in TAAoD

Open repair vs. closed repair

Future Project Ideas

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 Comparing antegrade cerebral perfusion, retrograde

cerebral perfusion and deep hypothermic circulatory arrest without brain perfusion

 Limited resection versus aggressive resection of

descending dissection

 Use of glue as a risk factor?  Elephant trunk repair vs. standard ascending aortic

replacement in TAAoD

 Long-term outcome of un-operated root in patients

< 60 years of age?

 Long-term outcome of un-operated arch in patients

< 60 years of age?

Future Project Ideas

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Survey Results

Patient Education

{

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Patient Education Surveys

26 responses 50% use some sort of guidelines to determine

appropriate patient activity

Majority recommended avoiding weight lifting

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Aerobic Recommendations

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Isometric Recommendations

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{

Survey Results

Dynamic Imaging

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Imaging Survey

 Distributed to AHA

attendees and emailed to IRAD investigators

 Most expressed a

desire to work with imaging specialists at their site

 Ultimate goal: develop

standardized imaging protocols

 Echocardiography and

CT imaging capabilities varied

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ACC 2012 IRAD Presentations

{

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Poster Presentations:

 Temporal Trends in Imaging in Acute Aortic

Dissection

 Aortic Dissection During Pregnancy  Acute Type A Dissection Causing Acute

Myocardial Infarction

 Long-Term Follow-Up in Marfan Patients after

Successful Surgery for Acute Type A Aortic Dissection

ACC 2012 IRAD Presentations

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Poster Presentations (continued):

 Mortality and Outcomes of Patients Presenting

with and without Iatrogenic Aortic Dissections

 Acute Renal Failure and its Early and Late

Implications in Acute Aortic Dissection

 Is Size a Good Predictor of Dissection Risk in

Patients with Marfan Syndrome of Bicuspid Aortic Valves?

ACC 2012 (continued)

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Upcoming Meetings

{

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Attendees Confirmed: 33 Chair:

 Kim A. Eagle, MD

Co-Chairs:

 Santi Trimarchi, MD  Eduardo Bossone, MD  Patrick O’Gara, MD  Joseph Bavaria, MD

Charing Cross Aorta 2012: April 12-13, London, England

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 Joseph Bavaria  Eduardo Bossone  Lori Conklin  Nimesh Desai  Marco Di Eusanio  Kim Eagle  Arturo Evangelista  Mark Fillinger  Alberto Forteza  James Froehlich  Dan Gilon  Martin

Grabenwoger

 Lisa Hackbarth  Eric Isselbacher  Frederik Jonker  Eva Kline-Rogers  Amit Korach  Sheila McGreal  Emil Missov  Franz Moll  Dan Montgomery  Truls Myrmel  Patrick O’Gara  Himanshu Patel  Mark Peterson  Linda Pitler  Brett Reece  Hasan Siddiqi  Sonja Sierpath  Peter Taylor  Santi Trimarchi  Elise Woznicki  Syed Yusuf

Charing Cross Attendees

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IRAD IVC Meeting:

 Wednesday, April 25th, 4:00-6:00 p.m.  The Hilton New York  Investigator dinner to follow (sponsored by

GORE)

Attendees Confirmed: 8

AATS Aortic Symposium 2012: April 26-27, New York City

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Oral Presentation:

 Patients with Type A Acute Aortic Dissection

Presenting with Major Brain Injury: Should we Operate on Them?

Presentation on Demand:

 Outcomes Following Repair for Acute Type A

Dissection are Independent of Cannulation Strategy: Femoral vs. Right Axillary Artery

AATS Aortic Symposium 2012 (continued)

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Two abstracts submitted:

 The Use of Chest X-Ray as a Diagnostic Tool in Acute

Aortic Dissection

 Racial Differences in Acute Aortic Dissection

ESC 2012: August 25-29, Munich

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Funding

{

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W.L. Gore & Associates, Inc. Varbedian Aortic Research Fund Hewlett Foundation Mardigian Foundation UM Faculty Group Practice Terumo

Current IRAD Funding Sources

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2011 in Review

{

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16 abstracts accepted for presentation 8 manuscripts published in peer-reviewed

journals

3 investigator meetings, with one dedicated

solely to the Interventional Cohort

16 topics suggested for the AHA 2012 submission 32 projects in preparation

IRAD by the Numbers

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In 2011 (compared to 2010):

 135.2% increase in IVC data  26.1% increase in overall patient enrollment  10.9% increase in follow-up forms completed  50.0% increase in yearly manuscript publication  16.7% increase in annual abstract acceptance

 So far in 2012, there has been a 28.6% increase in

accepted abstracts when compared to 2011

IRAD by the Numbers

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3 international investigators visited the

coordinating center:

 Toru Suzuki – Medications in Aortic Dissection;

Medications in Marfan Syndrome Patients

 Truls Myrmel and Magnus Larsen – False Lumen

Thrombosis and Left Renal Artery Involvement

4 investigators plan to visit MCORRP:

 Linda Pape – Trends in IRAD  Magnus Larsen – Left Renal Artery Involvement,

Aortic Rupture on Follow-Up

 Jip Tolenaar – Aortic Arch Dissection

IRAD by the Numbers

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Future Directions

{

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Standardize training for data abstraction Improve follow-up percentages Enroll 1000 patients into the IVC registry;

publish subgroup-focused papers and incorporate new surgical data into other IRAD projects.

Registry Aims for 2012

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Expand IRAD to new sites using the pay-to-play

model, focusing on geographical diversity and high-enrolling surgical and endovascular centers

f excellence

Begin work on IRAD imaging protocols Disseminate information gleaned from the

patient education survey