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Page 1: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Prevention, Management and Follow up

ACUTE AORTIC DISSECTIONPrevention, Management and Follow up

Page 2: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Can we really PREVENT Acute Aortic Dissection?

Most Likely !

Page 3: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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

Page 4: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Mechanical Properties/Remodeling (3)

Gene Mutations (1)

MMPs ( 2)

WHAT WE KNOW

Page 5: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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”

Page 6: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Syndromic

Genetic variants withHigh risk mutations

Familial

Sporadic

Low risk variants

Genetic Variants with low risk

“Wear and tear”

GENETIC RISK FOR TAAD (Thoracic Aneurysm Acute Dissection)

Page 7: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

SYNDROMES and Thoracic Aortic Disease

MARFAN SYNDROMEYoung age at onsetAutosomal Dominant inheritanceAortic root aneurysms

Marfan Syndrome FBN1Loeys Dietz Syndrome TGFBR1

TGFBR2Aortic Osteoarthritis Syndrome SMAD3Aortic disease with MFS Features TGFB2

Page 8: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

MARFAN SYNDROME (FBN 1 mutation)

Skeletal manifestations

Occular Manifestations

Pectus deformitiesReduced U/L segment (<0.85)Wrist & thumb signScoliosis

MANAGEMENT

Surgical Aortic Root repair at 5.0-5,5 cm diameter

Ectopia lentis

ROUTINE IMAGING OF THE AORTA!!!

Page 9: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Loeys -Dietz Syndrome ( TGFBR1 and TGFBR2 mutations)

CraniosynostosisBifid Uvula/cleft palateHypertelorismTranslucent skin

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

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

Page 10: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Aortic Osteoarthritis syndrome ( SMAD 3 mutation)

Early onset of osteoarthritis and aortic aneurysmsAneurysms in intracranial arteries ,AA A ,Iliac artery aneurysmsExtensive imaging of different vascular bedsEarly surgery for aortic dimensions > 4.5 cms

Page 11: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

What We Know (2)

MMPsA group of zinc dependent enzymes whose role is to degrade the extracellular matrixThey 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.

Page 12: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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

Page 13: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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

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

Page 14: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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

Page 15: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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

Aortic Size and Likelihood of Dissection

Page 16: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

.

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

Page 17: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

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

Page 18: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

Surgery for Acute Type A Dissection

The basic principlesresect the primary tear

correct any valvular deficienciescorrect any malperfusionsre establish anatomy of the region

(ascending aorta ,arch, sinuses)

Page 19: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

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

Total Number : 73 patients Age range : 19-82 yearsSex : 66 males / 7 femalesSyndromic 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 & MortalityMortality (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

Page 20: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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

Page 21: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

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 )

Page 22: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

THIS? (hemi arch)

OR

THAT ( Total arch )(FET)

Less morbidity &mortalityEasier to masterFate of Arch and DA in question

More difficult ,demanding procedureHigher morbidity & mortalityLess problems with distal aorta

What choices do we have in the acute setting?

Page 23: Prevention, Management and Follow upstatic.livemedia.gr/hcs2/...25_oikonomopoulos.pdf · George Economopoulos, MD FACS. Personal experience at Hippokration Hospital (10/2007-10/2014

George Economopoulos, MD FACS.

THANK YOU!?????

T H AN K Y O U !