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