Surgery for Aortic Surgery for Aortic DissectionDissection

Adrian E. Manapat, M.D.Adrian E. Manapat, M.D.

Mortality of Aortic DissectionMortality of Aortic Dissection

Acute aortic dissectionAcute aortic dissectionLindsay, Hurst (1967) :Lindsay, Hurst (1967) : 33% within 24 hrs33% within 24 hrs

50%50% within 48 hrswithin 48 hrs80% within 7 days80% within 7 days95% within 1 month95% within 1 month

for Type Bfor Type B 25% at 1 month25% at 1 month

Acute/Chronic/A/BAcute/Chronic/A/BAnagnostopoulos (1972) 70% at 1 weekAnagnostopoulos (1972) 70% at 1 week

90% at 3 months90% at 3 months

Management of acute aortic Management of acute aortic dissectiondissection

Type A dissectionType A dissection Surgical repairSurgical repair(Modes of exit: Cardiac tamponade(Modes of exit: Cardiac tamponade

MIMI Heart failure from AIHeart failure from AI

Stroke)Stroke)

Type B dissectionType B dissection Medical > SurgicalMedical > SurgicalRisk of cardiac tamponade 2%Risk of cardiac tamponade 2%

Stanford Duke Collaborative Stanford Duke Collaborative StudyStudy

0

10

20

30

40

50

60

70

80

Lifethreatening

complications

Other medicalproblems

Low risk, openchoice

MedicalSurgical

Management of Type B Management of Type B dissectiondissection

Indications for surgeryIndications for surgery1. Life threatening complications of dissection1. Life threatening complications of dissection

a) Aortic rupture/leaka) Aortic rupture/leakb) Infarction/ischemia of major end organ (kidneys, b) Infarction/ischemia of major end organ (kidneys,

abdominal viscera, extremities)abdominal viscera, extremities)2) Progression of dissection during medical treatment2) Progression of dissection during medical treatment

Indications for medical managementIndications for medical management1) Elderly1) Elderly

2) Coexisting serious medical problem - cardiac, pulmonary, renal , 2) Coexisting serious medical problem - cardiac, pulmonary, renal , peripheral or cerebrovascularperipheral or cerebrovascular

3) Thrombosed false lumen3) Thrombosed false lumen4) Primary tear in distal aorta or abdominal aorta4) Primary tear in distal aorta or abdominal aorta

Craig Miller, 1992Craig Miller, 1992

Principles of repairPrinciples of repair

Complete obliteration of the tear of the Complete obliteration of the tear of the ascending aortaascending aorta

Obliteration of the false lumenObliteration of the false lumen Prevention of rupture of the jeopardized Prevention of rupture of the jeopardized

segmentsegment Correction of aortic regurgitation if presentCorrection of aortic regurgitation if present

What is so difficult about repair of What is so difficult about repair of aortic dissection?aortic dissection?

Weakened friable aorta does not tolerate Weakened friable aorta does not tolerate clamping - requires “no touch technique”clamping - requires “no touch technique” Need for deep hypothermic circulatory arrestNeed for deep hypothermic circulatory arrest

Prolonged complex operationProlonged complex operationAlmost all of them bleedAlmost all of them bleedPotential for multiple organ damagePotential for multiple organ damagePossible catastrophic complicationsPossible catastrophic complications

Emergency natureEmergency nature

Deep hypothermic circulatory Deep hypothermic circulatory arrest (DHCA)arrest (DHCA)

Every 10 Every 10 o o decrease in T causes a 50% decrease in T causes a 50% decrease in metabolic rate - protects the organs decrease in metabolic rate - protects the organs from the effects of circulatory arrestfrom the effects of circulatory arrest

Safe period CA is usually 45 minutesSafe period CA is usually 45 minutes Disadvantages:Disadvantages: prolonged surgeryprolonged surgery

bleedingbleeding

potential for end organ potential for end organ damagedamage

Cerebral protection during Cerebral protection during circulatory arrestcirculatory arrest

Cerebral perfusionCerebral perfusion Antegrade perfusion via carotid arteriesAntegrade perfusion via carotid arteries Retrograde perfusion via superior vena cavaRetrograde perfusion via superior vena cava

Adjunctive measures:Adjunctive measures: Head packed in iceHead packed in ice Mannitol, steroidsMannitol, steroids Sodium pentothalSodium pentothal Trendelenberg positionTrendelenberg position

Surgical optionsSurgical options

Supracoronary AA replacementSupracoronary AA replacement Bentall procedure (composite ascending aorta Bentall procedure (composite ascending aorta

& aortic valve replacement w/ re-implantation & aortic valve replacement w/ re-implantation of coronary ostia)of coronary ostia)

Supracoronary AA replacemnt w/ aortic valve Supracoronary AA replacemnt w/ aortic valve repair or replacementrepair or replacement

Any of the above combined with CABGAny of the above combined with CABG

Ascending aortic dissectionAscending aortic dissection

False and true lumenFalse and true lumen

Dealing with the aortic valveDealing with the aortic valve

Resuspension of the Resuspension of the commissures to repair commissures to repair the aortic valvethe aortic valve

Insertion of a valved Insertion of a valved conduitconduit

Proximal graft anastomosis Proximal graft anastomosis completedcompleted

Aortic graft in placeAortic graft in place

Ascending aortic replacement Ascending aortic replacement with CABGwith CABG

Results of Surgical repairResults of Surgical repairOperative (30-day) mortalityOperative (30-day) mortality 1960’s1960’s 30-60%30-60%

1990’s to the present 5-30%1990’s to the present 5-30%

Cleveland Clinic experience (208) predictors of mortality:Cleveland Clinic experience (208) predictors of mortality: Earlier operative yearEarlier operative year

HypotensionHypotensionNon-use of DHCANon-use of DHCA

Composite valve graftComposite valve graftCABGCABG

Late survival (Crawford, 1990)Late survival (Crawford, 1990)

1 year1 year 78%78% Acute type A 5 yrs 56%Acute type A 5 yrs 56%

5 years5 years 63%63% 10 yrs 46% 10 yrs 46%10 years 55%10 years 55% 20 yrs 30% 20 yrs 30%

Long term follow upLong term follow up

Lifelong antihypertensive, B blockerLifelong antihypertensive, B blocker Anticoagulation for prosthetic valveAnticoagulation for prosthetic valve Surveillance : Surveillance : new dissectionsnew dissections

aneurysm formationaneurysm formation

prosthetic valve prosthetic valve functionfunction