George Economopoulos, MD FACS.
Prevention, Management and Follow up
ACUTE AORTIC DISSECTIONPrevention, 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 withHigh 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 SYNDROMEYoung age at onsetAutosomal Dominant inheritanceAortic root aneurysms
Marfan Syndrome FBN1Loeys Dietz Syndrome TGFBR1
TGFBR2Aortic Osteoarthritis Syndrome SMAD3Aortic disease with MFS Features TGFB2
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!!!
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
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
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.
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 principlesresect the primary tear
correct any valvular deficienciescorrect any malperfusionsre 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 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
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 &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?
George Economopoulos, MD FACS.
THANK YOU!?????
T H AN K Y O U !