Issam Abouliatim, MD
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Transcript of Issam Abouliatim, MD
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Type A aortic dissection,
Proximal repair :
valve resuspension, remodelling or
reimplantation ?
Issam Abouliatim, MD
Department of Thoracic, Cardiac and Vascular surgery. Rennes, France
CACVS, 27- 29 january 2011
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Faculty Disclosure Dr Issam Abouliatim
I have no financial relationships to disclose
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Principles of surgery
Aorta:
Resection and replacement of the aortic tear site
Root: Root:
Replacement / Repair of aortic sinus segments with false
lumen obliteration to prevent:
Coronary malperfusion
Late aortic root complications
Valve:
Resuspension / Replacement of the aortic valve
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Normal dimensions of the aortic rootTwo-Dimensional Echocardiographic Aortic Root Dimensions in Normal
Children and AdultsRoman MJ. Am J Roman MJ. Am J CardiolCardiol 1989;64:5071989;64:507--512512
Upper normal dimensions:
Aortic annulus(DAA) < 1.6 cm/m Aortic annulus(DAA) < 1.6 cm/m (31mm for male; 26mm for female)
Sinus (DSV) < 2.1 cm/m (40 mm for male and 36mm for female)
Sino-tubular junction < 1.8 cm/m
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Not dilated aortic root
Repairable aorticroot
NO
YESNO
Bentall (composite) or David (AVS)
YES
Pathologic aorticvalve
Aortic valve replacement
normal aortic valve
Resuspenssion (SCR)
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Not dilated aortic root +
normal aortic valve
Supracommissural resuspension (SCR)
pull up the aortic commisures
attach them to aortic adventitia
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Not dilated aortic root +
normal aortic valve
SCR: Re-attachement of the dissected aortic
root layers with biological glues
Test the competence of aortic valve !!!
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Dilated aorticroot
Pathologicaortic valve
Normal aortic valveaortic valve
Bentall procedure (comp)
valve
David or Yacoubprocedure (AVS)
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Dilated aortic root +
Pathologic aortic valve:
Creation of coronary ostia buttons Resection of the aortic root and aortic valve Composite graft insertion in the aortic annulus Coronary reimplantation
BentallBentall Thorax. 1968; 23:338-9
composite replacementcomposite replacement
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Dilated aortic root +
Normal aortic valve
Valsalva sinuses resection:Aortic root : Yacoub procedure
YacoubYacoub MM. . CirculationCirculation 19831983
Aortic valve sparing:
Remodeling
Non coronary sinus
resection
Coronary
reimplantationSupracoronary aortic
replacement
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Dilated aortic root +
Normal aortic valve:
Graft insertion below the aortic annulus Running suture of the commisures in the graft Coronary reimplantation
TironeTirone David (David (David I JTCS 1992;103:617-22)AVS: Reimplantation
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Reimplantation: David procedure
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Supracommissural resuspension:Aortic root dilatation
Preop Early postop Follow up
(6132 months)
Effects of ascending aorta replacement on aortic root dilatation* Effects of ascending aorta replacement on aortic root dilatation* Ruggero De Paulisa,*, Enrico Cetranoa, Marco Moscarellia, Giuseppe Ando`a,b, Ruggero De Paulisa,*, Enrico Cetranoa, Marco Moscarellia, Giuseppe Ando`a,b, Fabio Bertoldoa, Fabio Bertoldoa,
Raffaele Scaffaa, Fabrizio Tomaia, Luigi Chiarielloa Raffaele Scaffaa, Fabrizio Tomaia, Luigi Chiarielloa
European Journal of CardioEuropean Journal of Cardio--thoracic Surgery 27 (2005) 86thoracic Surgery 27 (2005) 868989
Both the increase of aortic root diameter and the progressive
worsening of aortic valve insufficiency seem to justify a more aggressive treatment of the aortic root at the time of surgery
for acute aortic dissection.
Root diameter
(mm)
416 395 436
Aortic
regurgitation 2
25 (61%) 4 (10%) 23 (56%)
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130 patients (80%) had a resuspenssion technic
Freedom from reoperation on the proximal aorta were
81%, 71% and 62% at 5, 10, 15 years.
Supracommissural resuspension: Reoperation
Risk factor analysis for proximal and distal reoperations Risk factor analysis for proximal and distal reoperations
after surgery for acute type A aortic dissection after surgery for acute type A aortic dissection Matthias Kirsch, Matthias Kirsch, Cline Soustelle , Cline Soustelle , RmiRmi HoulHoul, , Marie Line Marie Line HillionHillion, , Daniel Daniel LoisanceLoisance..
J Thorac Cardiovasc Surg 2002;123:318J Thorac Cardiovasc Surg 2002;123:318--2525
81%, 71% and 62% at 5, 10, 15 years.
Indication for reoperation: aortic valve insufficiency or
aortic root dilatation
Severe preoperative aortic insufficiency is a
significant risk factor for reoperation on the
proximal aorta
Patients with severe aortic insufficiency should benefit
from a more aggressive proximal repair at initial
operation
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SCR Bentall AVS p
Patient 145 64 48
Resuspension / Bentall / Sparing
Evolving Strategies for Treatment of Acute Aortic Evolving Strategies for Treatment of Acute Aortic
Dissection Type ADissection Type AKlaus Klaus KallenbachKallenbach, Timm Oelze, Rolf Salcher, Christian , Timm Oelze, Rolf Salcher, Christian HaglHagl, Matthias , Matthias KarckKarck, Rainer , Rainer
G. G. LeyhLeyh and Axel and Axel HaverichHaverich
CirculationCirculation 2004;110;II2004;110;II--243243--IIII--249 249
Patient 145 64 48
Age 6011 5613 5413 0.002
Operating
time (min)
24268 301121 30575 0.001
30 day
mortality
26% 28% 10% 0.05
5 years
survival
895% 856% 804% 0.61
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Resuspension / Bentall / SparingFreedom from Reoperation:
Bentall SCR AVS pBentall SCR AVS p
Reoperation 6% 22% - 0.005
Aortic valve 3% 12% - 0.035
log rank= 0.09
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Patient recquiring reoparation after valve sparing aortic root
replacement for type A dissection
Patient Opeartion Marfan
syndrom
Aortic valve
insufficiency
Endocarditis Delay
(months)
AVS: Remodeling or Reimplantation ?
High Failure Rate After Valve-sparing Aortic Root Replacement
Using the "Remodeling Technique" in Acute Type A Aortic
Dissection
Rainer G. Leyh et al. Circulation 2002;106;I-229-I-233
syndrom insufficiency (months)
1 Remodeling yes severe No 24
2 Remodeling yes severe No 44
3 Remodeling No severe No 17
4 Remodeling No severe No 26
5 Reimplantation No None Yes 4
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Conclusion
Type A aortic dissection is a night emergency
for experienced surgeons
In absence of aortic root enlargement, there is no
justified indication for its replacement or sparing.
In case of a massive aortic regurgitation, SCR
technique seems inappropriate.
For younger patients and marfan syndrome, AVS or
Composite technique seems adequate options.
Repair durability / operative mortality
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Thank you !
Aortic tearThrombosis of fals lumen
of the ascending aorta
Coronary
ostia