Aggressive Resection/Reconstruction of the Aortic Arch in Type A Dissection: Con
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1 Aggressive Resection/Reconstruction of the Aortic Arch in Type A Dissection: Con Thomas G. Gleason, M.D. Ronald V. Pellegrini Professor and Chief Division of Cardiac Surgery University of Pittsburgh
2 Presenter Disclosures Thomas G. Gleason, MD Financial disclosures: Institutional research support from Medtronic, Abbott, Boston Scientific (no personal remuneration). Nominal personal remuneration for Medical Advisory Boards of Abbott and Cytosorbents (<$10K/yr). Unlabeled/unapproved uses disclosures: none.
3 Classically 3 (4?) phases of the reconstruction 1) Circulation management 2) Root reconstruction 3) Arch reconstruction? 4) Descending stabilization?
4 Acute type A dissection: new paradigm 1) Rapid transport and treatment 2) Sinus segment repair/root replacement 3) EEG monitoring to direct HCA 4) Hemiarch replacement using RCP 5) Antegrade graft perfusion 6) Routine use of TEE Mortality stats Presented at the 121st American Surgical Association Ann Surg 2001 Sep;234(3):
5 Penn experience with TAAD and hemiarch J Thorac Cardiovasc Surg 2014;148:
6 Acute Type A Aortic Dissection University of Pennsylvania (RCP favored) n=629/ 20 yrs Hospital Mortality 13.2% Postop Stroke 5.1% Hemiarch Replacement 95.1% Total Arch Replacement 4.3% Emory University (MHCA/ ACP favored) n=346/ 10 yrs Hospital Mortality 14.5% Deep HCA 20.3% Moderate HCA 9.8% PND 10.4% Hemiarch Replacement 90.7% Total Arch Replacement 9.3% Ann Thorac Surg 2014;97: Ann Thorac Surg 2013;96:
7 Acute Type A Aortic Dissection IRAD Registry n= 974 Hospital mortality 23.6% Postop Stroke N/A All Neurological Deficit 22.7% Total Arch Reconstruction 9.4% Japan Adult Cardiovascular Database n=4128 Hospital Mortality 8.6% Postop Stroke 10.7% ACP 11.2% RCP 9.7% Am J Med 2013 Aug;126(8):730 Circulation Nov 21;114(21): Circ J 2014;78:
8 IRAD data J Thorac Cardiovasc Surg Apr;153(4):S74-S79. 8
9 IRAD data: Hemi vs Total Eur J Cardiothorac Surg. 2017;52(6):
10 Acute Type 1 Aortic Dissection German Registry for Acute Aortic Dissection Type A: GERAADA, n=2137 Hemi Arch Reconstruction 46% Total Arch Reconstruction 16.2% Ascending Reconstruction Alone 37.7% Stroke Rate N/A Hemiplegia/ hemiparesis 9.4% Coma 8.6% 30 Day Mortality 17% Ann Surg Mar;259(3):
11 Mortality 18.7% hemiarch 25.7% total arch p=
12 Cologne Experience Ther Adv Cardiovasc Dis Oct 8:
13 Griepp data J Thorac Cardiovasc Surg 2007;133:
14 He points out that 80-90% of late re-interventions are elective with relatively low risk (4-12%). 14
15 Long-term survival not significantly affected by treatment distal arch Ann Thorac Surg 2002;74:S
16 Tear-oriented surgery J Thorac Cardiovasc Surg 2016;151:
17 Outcomes were the same Survival Reintervention J Thorac Cardiovasc Surg 2016;151:
18 Freedom from distal aortic events: Okita group J Thorac Cardiovasc Surg 2016;151:
19 False lumen patency impacting late outcome J Thorac Cardiovasc Surg 2015;149:S
20 Reoperation rate Only 11% required reoperations J Thorac Cardiovasc Surg 2010;139:
21 Bologna Hemi vs. Total Ann Thorac Surg 2015;100:
22 Hiroshima Hemiarch vs. FET Ann Thorac Surg 2009;87:
23 Early survival Meta-analysis Aortic Events Renal failure Stroke Eur J Cardiothorac Surg. 2015;49(5):
24 Freedom from distal reoperation J Thorac Cardiovasc Surg 2000;119:
25 Freedom from distal reoperation Ann Thorac Surg 2007;84:
26 Extent of reconstruction over 17 year experience Extent of replacement Ascending aorta only 65 36% Ascending aorta and hemiarch 97 54% Ascending aorta and total arch 11 6% Ascending, arch and proximal descending 6 3% 8.9% out of 179 cases over 17 years had more than hemiarch 16% risk of reoperation at 10 years J Thorac Cardiovasc Surg 2007;133:
27 Late reoperation risk low Index operation Late reoperation J Thorac Cardiovasc Surg 2012;144:
28 Freedom from distal reoperation Ann Thorac Surg 2007;84:
29 Reoperation correlates with hypertension J Thorac Cardiovasc Surg 2013;145:S85-90 Ann Thorac Surg 2007;84:
30 Number of TAAD repairs by site: STS data Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery data J Card Surg 2018;33:7-18.
31 UPMC focus: neurologic outcomes Stroke rate-reduction and standardization to improve overall outcomes 1. Rapid transport to incision to CPB 2. Central cannulation 3. Neurocerebral protection including liberal use total arch/carotid replacement 4. Reduce use of blood products
32 Neurocerebral Protection/ Perfusion Protocol % use EEG/SSEP monitoring Steroids, lidocaine, MgSO 4, mannitol use DHCA initiation 4 min after electrocerebral silence (ECS) 2. Standardized cannulation: aortic arch tear status and carotid malperfusion 3. Central aortic cannulation is default 4. RSCA cannulation for bad intra-arch tears 5. RCP for Hemiarch reconstruction (DHCA <30 min) 6. ACP for Total Arch reconstruction (DHCA >30 min) 7. Common carotid replacement when dissected
33 1 or 2 Arch Tear Carotid Dissection Indications for Total Arch Circumferential Arch Dissection Aneurysmal Arch
34 Arch Reconstruction Total arch with ACP 36% Hemiarch with RCP 64% Complete Common Carotid Replacement in 33 patients using separate neck counter incisions
35 Uninterrupted Central ACP Technique Innominate, RCC or LCC grafting during cooling 2 arterial inflow No interruption of ACP Custom 3-branched brachiocephalic graft separately perfused
36 Outcomes with standardized protocol Hospital mortality 9.1% Postop stroke 3.4% Consecutive Acute Type A Dissection Repairs n=264 ( ) Ann Thorac Surg Mar;101(3): ; Discussion
37 Outcomes Hemi (64%) versus Total Arch (36%) Reconstructions* Hemiarch Total Arch Overall P value N= 167 N= 92 Postop CVA 6(4%) 3(3%) 9(3.5%) Hospital Mortality 11(7%) 13(14%) 24(9%) Day mortality 14(8%) 13(14%) 27(10%) yr mortality 23(15%) 21(27%) 44(19%) No Intraop use PRBC 52% 50% 51% FFP 63% 80% 69% Platelets 41% 45% 42% Intraop Factor VII 61(37%) 54(59%) 115(44%) *5 patients with limited Debakey II dissections required neither hemi nor total arch; all survived without stroke.
38 Value of Neurocerebral Monitoring 15% EEG/SSEP changes Changes prompt intraop adjustments and immediate postop CTA with immediate neurointervention when feasible EEG/SSEP independent predictor of postop CVA OR 8.7, 95% CI [ ] p=0.002 Negative Predictive Value 98.2%
39 Multivariate Predictors of Hospital Mortality OR [95% CI] Pre-op CVA 21.3 [6.2-73] p<0.001 Intra-op EEG Change 5.2 [ ] p=0.005 Frozen Trunk 14.5 [ ] p<0.001 Concomitant CABG 6.6 [ ] p=0.005
40 Multivariate Predictors of 1-yr Mortality 1 Year OR [95% CI] Age [ ] p=0.013 Pre-op CVA 12.3 [ ] p=0.000 RBC Transfusion 5 Units 5.9 [ ] p=0.001 Frozen Trunk 14.9 [ ] p=0.000 Concomitant CABG 2.8 [ ] p=0.023
41 Long-term Survival Kaplan-Meier survival estimate Months 95% CI Survival in Months
42 Conclusions 1. Expeditious restoration of perfusion and proximal stabilization saves lives. 2. Hemiarch replacement meets the primary goal most of the time. 3. Reoperation rate is low after hemiarch, and the reoperations can be done safely, with low risk in experienced hands. 4. Results with TAAD management have improved over time, particularly in-hospital results--hemiarch remains the most widely used strategy. 5. Late event rates can be reduced by more aggressive approach, but may be at the cost of higher in-hospital mortality and complications. 42
43 THANK YOU
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