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Eric Salter was a 42-year-old runner in the prime of his life when in May 2017, on his daughter's 11th birthday, he suffered a life-threatening aortic dissection while sitting at the desk in his home office.
During an aortic dissection, the inner layer of the aorta — the major blood vessel that takes oxygenated blood to the body — tears, causing the inner and middle layers to become separated. For Eric, the dissection resulted in emergency surgery at a medical center near his Florida home. The surgeon repaired Eric's damaged aorta and replaced his bicuspid aortic valve with a mechanical valve. After 13 days in the hospital, Eric went home.
At that point, Eric was told his aorta was fixed, and that was the end of the story. In reality, it was just the beginning of a medical voyage that continues to this day. Eric's journey led him to the office of Sabrina Phillips, M.D., a cardiologist at Mayo Clinic in Florida and eventually to the operating room of Alberto Pochettino, M.D., a cardiovascular surgeon at Mayo Clinic in Rochester. Eric's Mayo Clinic team has guided him through years of monitoring his dissected aorta and provided surgical treatment that corrected the initial repair. Moreover, Eric's team has established a plan of action to deal with future issues as they arise.
"On May 10, 2017, I was told I had an aortic dissection and would have to be flown by helicopter to another hospital," Eric says. "I had just eight minutes to say goodbye to my wife and record a message to my two daughters. I prayed the entire time in the helicopter: 'Lord Jesus, please just give me one more day. I don't want to die on my daughter's birthday.' I only asked for one more day, and I'm blessed with a lot more than that. I'm not completely back to normal, but I can do just about anything I want to do and have a lot to be thankful for. It usually doesn't turn out that way for patients like me."
For people who experience aortic dissection, simply surviving the event is a triumph. Nearly 18% of those who sustain aortic dissection die before arriving at the hospital, and 21% die within 24 hours if they don't have surgery.
So when patients undergo successful surgery to repair the initial dissection, it is not uncommon for the surgeons to declare victory, Dr. Pochettino says. "Aortic dissection is a life-threatening issue up front. Just to get the patients to survive is a success, even though often the aorta is not a normal aorta."
What Eric did not understand following his first surgery was that, although the operation tackled the immediate problem by fixing the dissected portions of his aorta closest to the heart, it didn't address the fact that his aorta was dissected beyond the area of repair. And his doctors at the time of surgery didn't clarify that the condition required regular follow-up imaging.
"I was being told the problem is fixed, and to go enjoy my life and not worry about it."Eric Salter
"I did have a follow-up plan, but the follow-up I was given didn't seem to line up with the follow-up plans of other dissection patients that I had met," says Eric, who joined a support group for aortic dissection survivors. "What they were doing seemed completely different from what I was being advised. I remember telling my wife, Madelen, that I don't really belong in that group. I was being told the problem is fixed, and to go enjoy my life and not worry about it."
Learning that other survivors were on alternate treatment paths compelled Eric to seek a second opinion at Mayo Clinic in the Department of Cardiovascular Medicine. "When we first met, Eric was taken back when I asked him when was his last CT scan since the surgery," Dr. Phillips says. "He hadn't had one."
When urgent repairs are done, typically only the part of the aorta that comes out of the heart to the aortic arch is repaired. The lower part of the aorta leading toward the abdomen, the descending aorta, is left alone. Eric needed to be checked to see if his descending aorta had torn or changed.
The CT scan ordered by Dr. Phillips found that Eric's dissection was by no means fixed. "After the scan, I met with Dr. Phillips," Eric says. "That's when I first found out I had a remaining dissection."
Dr. Phillips put Eric on a three-month schedule of follow-up CT scans to monitor his aorta. For more than a year, the scans came back unchanged. But in October 2018, a scan revealed a pseudo aneurysm, which is a pocket of vascular tissue that forms in some, but not all, of the layers of the aortic wall. Six months later, in April, another CT scan revealed a new pseudo aneurysm, and it had grown significantly. At that point, Eric was fast-tracked for surgery.
When surgery was recommended, many thoughts went through Eric's mind. "One of my first thoughts was, 'Should I get a second opinion?' Dr. Phillips listened and said I could get a second opinion. But the person I needed to see was at Mayo Rochester, and I needed to move quickly," Eric says. "It was comforting to know Dr. Pochettino had been following my progress since my first visit to the Mayo Clinic in Jacksonville, even though he was on the other side of the country."
Just days after being recommended for surgery, Eric and Madelen said goodbye to their two daughters and boarded a Minnesota-bound plane. At Mayo Clinic in Rochester, the Salters met Dr. Pochettino, who detailed Eric's condition and the proposed surgical repair.
"He sat with us and explained to us what it really meant, not only to have this aortic dissection, but what it means to have different types of dissection," Madelen says. "Those were some of the conversations we were having with Dr. Pochettino that we were never able to have with anyone else. Eric is able to take better care of himself being educated."
After that conversation, Eric decided to move forward with the surgery. On April 23, the day after meeting Dr. Pochettino, Eric's damaged tissues were repaired during an extensive 12-hour operation.
During Eric's surgery, Dr. Pochettino discovered that one of the reasons Eric's aorta was compromised was that the material used to strengthen the vascular connections during the initial surgery had failed. "The material sometimes used to stop the bleeding is glue," Dr. Pochettino says. "The problem with glue is it interacts with tissue and sometime causes necrosis, or tissue death. So the glue is effective at stopping the bleeding up front. But in the long term, it causes the tissue to become weaker, and a pseudo aneurysm may develop."
During Eric's surgery, all of the previous reconstruction connected to the weakened tissue was removed. It then was replaced with a new aortic root, which is the portion closest to the heart involving the aortic valve and coronary artery opening, ascending aorta and aortic arch.
Eric did extremely well throughout the surgery, says Dr. Pochettino. "At the end of such a long operation, his heart started working normally. The new valve is working normally. The brain looked completely normal. We were able to complete the operation with a good result."
Eric's initial few days in the hospital after surgery were difficult, but his Mayo Clinic team was receptive and responsive to his needs. After several days in the cardiac ICU, Eric moved to a rehabilitation unit, where he continued to heal for another week before being discharged from the hospital.
Three months after surgery, Eric visited Dr. Phillips for a follow-up appointment and CT scan, and he'll have another scan in December. Regular follow-up appointments and CT scans will continue to be essential for Eric's cardiac health. "The key to understanding this is that you have this life-threatening event, and you have this repair, but you are not cured," Dr. Phillips says.
Because Eric is only 45, it is likely that his dissection, which currently affects his descending aorta, will grow as a result of the pressure of the blood continually flowing through the weakened tissues. "We do know that expansion occurs quite frequently in younger patients and can necessitate another more serious surgery to take care of it if it does occur," Dr. Philips says.
"Plain and simple, my decision to get a second opinion at the Mayo Clinic in Jacksonville saved my life."Eric Salter
Living with the possibility that Eric will require more surgery is a heavy weight to bear, Eric and Madelen say. "Sometimes Eric has a hard day and sometimes I have a hard day," Madelen says. "But we know we at least have a place where Eric has been, and we have two sets of confidences in his care there."
From his perspective, Eric says his journey has filled him with gratitude and a drive to push for answers to questions even when they seem unknowable.
"I've only been home for five months since the surgery, and almost every time I meet people going through medical challenges, I end up saying, 'You may want to go to Mayo just to get a second opinion, even if you feel like you're doing OK, and you don't feel like you need one,'" Eric says. "Plain and simple, my decision to get a second opinion at the Mayo Clinic in Jacksonville saved my life. The postoperative care and follow-up plan I've received from Mayo Clinic has extended my life and allowed me to spend many more days with my family. "