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
Faculty Disclosure Dr Issam Abouliatim
I have no financial relationships to disclose
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
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
Not dilated aortic root
Repairable aorticroot
NO
YESNO
Bentall (composite) or David (AVS)
YES
Pathologic aorticvalve
Aortic valve replacement
normal aortic valve
Resuspenssion (SCR)
Not dilated aortic root +
normal aortic valve
Supracommissural resuspension (SCR)
pull up the aortic commisures
attach them to aortic adventitia
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 !!!
Dilated aorticroot
Pathologicaortic valve
Normal aortic valveaortic valve
Bentall procedure (comp)
valve
David or Yacoubprocedure (AVS)
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
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
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
Reimplantation: David procedure
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%)
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
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
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
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
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
Thank you !
Aortic tearThrombosis of fals lumen
of the ascending aorta
Coronary
ostia
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