CURIOSARE FRA LE RACCOMANDAZIONI delle LINEE GUIDA ESC

SULLA PATOLOGIA AORTICA

Michele Portoghese

Cardiochirurgia

Ospedale SS Annunziata . Sassari

• ACUTE THORACIC AORTIC SYNDROMES

• AORTIC ANEURYSMS

• GENETIC DISEASE

• ACUTE ATHEROSCLEROTIC LESIONS

• AORTITIS

• AORTIC TUMOURS

• ACUTE THORACIC AORTIC SYNDROMES

• AORTIC ANEURYSMS

• GENETIC DISEASE

• ACUTE TATHEROSCLEROTIC LESIONS

• AORTITIS

• AORTIC TUMOURS

ACUTE AORTIC SYNDROMESan emergency conditions

• AORTIC DISSECTION -

• INTRAMURAL HEMATOMA -

• PENETRANTING AORTIC -

ULCER

• AORTIC PSEUDOANEURYSM -

• AORTIC ROPTURE (contained) -

• TRAUMATIC AORTIC INJURY -

disruption of madial layer provoked by intramural bleeding

resulting in true and false lumen

haematoma in the media on absence of false lumen

ulceration of athreros. plaque

through internal alastic lamina

disruption of all aortic layers contained by peraortic

connective tissue only

disruption of all aortoc layers contained by

peraortic structures

intimal tear, intramural haematoma,

pseudoaneurysm or ropture

ACUTE AORTIC SYNDROMES

Acute aortic dissection - diagnosis

HIGH RISK

•anamnesis

•pain features

• examination

pre-test probability (score 0 to 3)

ACUTE AORTIC SYNDROMES

Acute aortic dissection - diagnosis

D – dimer test

ACUTE AORTIC SYNDROMES

Acute aortic dissection -diagnosis

ACUTE AORTIC SYNDROMES

Acute aortic dissection

ANSTABLE PTS

ACUTE AORTIC SYNDROMES

Acute aortic dissection

STABLE pts

ACUTE AORTIC SYNDROMES

Acute aortic dissection -treatment

type A

still controversy in case of:

•neurological deficits or coma

•mesenteric malperfusion

ACUTE AORTIC SYNDROMES

Acute aortic dissection - treatment

FENESTRATION

AND

ENDOVASCULAR INTERVENTION

ACUTE AORTIC SYNDROMES

Acute aortic dissection

type B

COMPLICATED pts

treatment of choice

TEVAR

ACUTE AORTIC SYNDROMES

Acute aortic dissection

type B

COMPLICATED pts

indicated

ENDOVASCULAR

complicated means:•recurent pain

•uncontrolled hypertension

•early aortic expansion

•malperfusion

•sign of ropture (hemotorax)

ACUTE AORTIC SYNDROMES

Acute aortic dissection

type B

UNCOMPLICATED :

medical therapy

ACUTE AORTIC SYNDROMES

Intramural Haematoma -treatment

in ederly pts or those with significant comorbiditieswait and watch strategy

if

aortic dilatation < 50 mm

IMH thickness < 11 mm

urgent surgery

ACUTE AORTIC SYNDROMES

Pernetranting ulcer

TEVAR increaslingly used

since these pts poor candidates for

conventional surgery:

•advanced age

•comorbidity

ACUTE AORTIC SYNDROMES

Traumatic aortic injury - treatment

ACUTE AORTIC SYNDROMES -surgical techniques

ACUTE AORTIC SYNDROMES – surgical technique

ACUTE AORTIC SYNDROMES –surgical technique

THORACIC AORTIC ANEURYSMS - treatment

THORACIC AORTIC ANEURYSMS - treatment

THORACIC AORTIC ANEURYSMS - treatment

THORACIC AORTIC ANEURYSMS - treatment

risk factors:

•family history of AD

•aortic size increase > 3mm/y

•severe aortic regurgitation

•severe mitral regurgitation

THORACIC AORTIC ANEURYSMS - treatment

risk factors:

•aortic size increase > 3mm/y

•coartation of the aorta

•systemic hypertension

THORACIC AORTIC ANEURYSMS

AORTIC ANEURYSMS

THORACIC AORTIC ANEURYSMS - arch

THORACIC AORTIC ANEURYSMS - descending

ABDOMINAL AORTIC ANEURYSMS

GENETIC DISEASE

TURNER (x monosomy) : incidence of AD 100 TIME MORE than in general woman pop.

MARFAN : most frequent heritable connettive tissue disorder – fibrillin 1 defient

EHLERS-DANLOS type IV : spontaneous ropture of blood vessel (wthout PREVIOUS dilatation)

LOEYS-DIETZ : arterial tortuosity and arterial aneurysm

ARTERIAL TORTUOSITY SYNDROME : elongation, stenosis and aneurysms (mutation SLC2A10)

SYNDROMIC

GENETIC DISEASE – medical therapy

MARFAN syndrome

In a fibrillin deficient mouse model of Marfan an inibition of TGF-BETA with

angiotensin II type 1 receptor blochers (LOSARTAN) show to reverse vascular complication

THE FIRST NEW THERAPEUTIC OPTION IN OVER 20 Y

• Several RCTs under way

• results of the first 2 trial show Losartan effective

• in Guidelines of grown-up conenital heart disease

GENETIC DISEASE

IDENTIFY FAMILIAR FORM

REFER TO A GENETIST

GENETIC DISEASE

BICUSPID AORTIC VALVE

TYPE

LCC-RCC

• ascending aorta dilatation

• aortic root dilatation

type

RCC - NCC

• ascending aorta dilatation only

GENETIC DISEASE

GENETIC DISEASE

GENETIC DISEASE

GENETIC DISEASE

EVIDENCE BASED MEDICINE v. EVIDENCE BASED SURGERY

Guidelines

RCT’ s

5000 – 40000 pts

RCT’ s

5000 – 40000 pts

expert opinionexpert opinion

expert opinionexpert opinion

observational strudy

80 – 400 pts

observational strudy

80 – 400 pts

HEART FAILURE

UNSTABLE ANGINA

STEMIVALVULAR HEART DISEASE

expert opinionexpert opinion

observational strudyobservational strudy

AORTIC DISEASE

up to date

extensive rewiew through November 2012

selected references through October 2013

II CC HEART VALVE TEAM when intervention is considered

cardiologist

surgeon

structural valve interventionist

cardiovascular imaging specialist

anesthesiologist

nurse

in selected

pts

IIaIIa CCconsultation with or referral to a

HEART VALVE CENTER of EXCELLENCE

• experienced healtcare provider from multiple discipline

• offer all available options for diagnosis and management

• demonstrate adherence to national guidelines

• partecipate in continued evalation and quality process

• publicly report their available mortality and seccess rates

1. ASYmptpmatic pts with severe VHD

2. pts who my benefit from valve REPAIR

3. PTS with multiple COMORBIDITIES

IIaIIa BB LOW DOSE DOBUTAMINE STRESS TESTING

LACK of CONTRACTILE RESERVE

VERY POOR PROGNOSIS WITH EITHER MEDICAL OR SURGICAL THERAPHY

…..a third group of pts

AORTIC STENOSIS - diagnosis