Prevention, Management and Follow · PDF file George Economopoulos, MD FACS. Personal...

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Transcript of Prevention, Management and Follow · PDF file George Economopoulos, MD FACS. Personal...

  • George Economopoulos, MD FACS.

    Prevention, Management and Follow up

    ACUTE AORTIC DISSECTION Prevention, Management and Follow up

  • George Economopoulos, MD FACS.

    Can we really PREVENT Acute Aortic Dissection?

    Most Likely !

  • George Economopoulos, MD FACS.

    WHAT WE KNOW

    -Thoracic Aneurysms Aortic Disections (TAADs)Do not Occur by accident

    -They represent a spectrum of processes that begin oftentimes at conception (genetic) and progress throughout the life time of an individual to result in the acute condition

    -Many factors in this process are measurable and to some degree modifiable

  • George Economopoulos, MD FACS.

    Mechanical Properties/Remodeling (3)

    Gene Mutations (1)

    MMPs ( 2)

    WHAT WE KNOW

  • George Economopoulos, MD FACS.

    What we know (1)

    1.There is rapid accumulative evidence that genetic variants predispose some individuals to aortic diseases ( aneurysms, dissections)

    2. Gene based Tx beginning to show promise for reducing catastrophic complications of aortic disease(ie: dissections) by preventive medical or surgical interventions the so called : “Personalized Medicine”

  • George Economopoulos, MD FACS.

    Syndromic

    Genetic variants with High risk mutations

    Familial

    Sporadic

    Low risk variants

    Genetic Variants with low risk

    “Wear and tear”

    GENETIC RISK FOR TAAD (Thoracic Aneurysm Acute Dissection)

  • George Economopoulos, MD FACS.

    SYNDROMES and Thoracic Aortic Disease

    MARFAN SYNDROME Young age at onset Autosomal Dominant inheritance Aortic root aneurysms

    Marfan Syndrome FBN1 Loeys Dietz Syndrome TGFBR1

    TGFBR2 Aortic Osteoarthritis Syndrome SMAD3 Aortic disease with MFS Features TGFB2

  • George Economopoulos, MD FACS.

    MARFAN SYNDROME (FBN 1 mutation)

    Skeletal manifestations

    Occular Manifestations

    Pectus deformities Reduced U/L segment (

  • George Economopoulos, MD FACS.

    Loeys -Dietz Syndrome ( TGFBR1 and TGFBR2 mutations)

    Craniosynostosis Bifid Uvula/cleft palate Hypertelorism Translucent skin

    Type A aortic dissections with minimal dilatation Tortuous arteries Aneurysms and dissections of other arteries

    Surgery on the Aorta at 4- 4.2 cm diameter in adults

  • George Economopoulos, MD FACS.

    Aortic Osteoarthritis syndrome ( SMAD 3 mutation)

    Early onset of osteoarthritis and aortic aneurysms Aneurysms in intracranial arteries ,AA A ,Iliac artery aneurysms Extensive imaging of different vascular beds Early surgery for aortic dimensions > 4.5 cms

  • George Economopoulos, MD FACS.

    What We Know (2)

    MMPs A group of zinc dependent enzymes whose role is to degrade the extracellular matrix They are active in a wide array of disease states from periodontal disease to CHF

    MMPs activity in TAADs is evident from animal studies and MMPs inhibition (targeted gene inhibition, drugs) resulted in decrease in aneurysmal expansion in animal experiments and in humans

    Do circulating levels of MMPs(MMP 9) correlate with aortic wall levels?

    Agents that limit production of MMPs include: ACE inhibitors, sulfa antibiotics ,tetracyclines,statins, NO inhibitors, rapamycin

    macrolides, and others.

  • George Economopoulos, MD FACS.

    What we Know (3)

    The aorta is not a passive tube but an organ with muscular wall (media) able to adapt to high variation of intraluminal pressures

    There are measurable indices of the mechanical properties of the aorta easily obtainable by TTE

    The laws of physics apply to the aorta as in any other tubular structure

  • Mecanical Properties of Aortic wall in Aneurysmal Aortas (Yale Univ ersity)

    From “Acute aortic Dissection” : J Elefteriades (Editor) Informa Health care 2007

  • J Elefteriades in “Acute Aortic Dissection “ Editor , Informa Health Care 2007

  • From “ Acute Aortic Dissection “ Informa Health Care , J Elfteriades 2007.

    Aortic Size and Likelihood of Dissection

  • .

    From : John Elefteriades (Editor) : In “Acute aortic Dissection “, Informa Health Care 2007.

  • George Economopoulos, MD FACS.

    From : John Elefteriades (Editor) : In “Acute aortic Dissection “, Informa Health Care 2007.

  • George Economopoulos, MD FACS.

    Surgery for Acute Type A Dissection

    The basic principles resect the primary tear

    correct any valvular deficiencies correct any malperfusions re establish anatomy of the region

    (ascending aorta ,arch, sinuses)

  • George Economopoulos, MD FACS.

    Personal experience at Hippokration Hospital (10/2007-10/2014

    Total Number : 73 patients Age range : 19-82 years Sex : 66 males / 7 females Syndromic Patients : 14

    PROCEDURES PERFORMED - Root replacements : 25

    . 21 Composite grafts

    . 4 Re-implantations (David 1) - Aortic Hemi –arch replacements : 69 - Total Aortic Arch replacements : 4

    Other Procedures - CABGs : 4 (all vein grafts) - MV repair :1 - Femoral-femoral bypass : 2

    Morbidity & Mortality Mortality (30 days) : 6/72 ( 8,3%) Morbidity

    - Bleeding 30% - CVA : 2/72 (2,7%)

    - Sepsis 3/72 ( 4.1%) - GI malperfusion : 3 /72 (4,1%) - Long Vent Tx : (>48Hrs) : 3/72 (4.1%)

    Unique Complications - Detachment of native Aortic Valve - Intussusception of intima in the DA - Obstruction of LVOT

  • George Economopoulos, MD FACS.

    Follow up and Problems

    George Economopoulos, MD , FACS

    BP Control ( b blockers, ACE inhib, statins )

    CT A of thoracic Aorta bi annually first and annually afterwards

    Family screening

  • George Economopoulos, MD FACS.

    Most Common Worrisome Finding in Follow Up (post acute Type A repair)

    -Patent (non thrombosed ) False Lumen (FL) Patent FL in 60 /69 Hemiarch

    replacements (86%) - partially thrombosed in 35 - without thrombus in 25 ( 11 with

    dilatation )

  • George Economopoulos, MD FACS.

    THIS? (hemi arch)

    OR

    THAT ( Total arch )(FET)

    Less morbidity &mortality Easier to master Fate of Arch and DA in question

    More difficult ,demanding procedure Higher morbidity & mortality Less problems with distal aorta

    What choices do we have in the acute setting?

  • George Economopoulos, MD FACS.

    THANK YOU!?????

    T H AN K Y O U !