STS/EACTS LatAm CV Conference 2017
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1 STS/EACTS LatAm CV Conference 2017 Joseph E. Bavaria, MD Director, Thoracic Aortic Surgery Program Roberts-Measey Professor and Vice Chair of CV Surgery University of Pennsylvania Immediate-Past President of STS
2 Series/Author Date Mortality Stroke Comments Emory/Leshnower % 7% Highly selected DV cases only IRAD % % over 17 years GERAADA % All patients Canadian Aortic/McClure % All patients; 30% deaths from CVA UPenn Series % 11% All patients; 5% new CVA; 6% new TIA Need New Treatments!!!
3 Type A Dissection is a Catastrophic Presentation!!
4 Central Aortic Cannulation Distal Aortic Solutions The Root Valve Retention vs Composite graft Root Towards an Endo Aortic solution
5 Arch dissection Left Subclavian dissection Calcified femoral artery
6 Right Carotid Artery Doppler (TEE Probe): Acute Type A Dissection Confirm Diagnosis and on-line reports
7 Small DTA True Lumen
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10 Intraoperative view of the cannulated distal ascending aorta Rylski B; Bavaria, J et al. Eur J Cardiothorac Surg 2014;46:
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12 N=264 Consecutive Debakey Type I Dissections ( ) Their concept.. Diagnosis to Incision (DTI) Incision to Bypass (IBT) 203/264 Central Aortic Cannulation Reduced IBT from 61 to 37 min (compared to AX). P=.001 Mortality: 7 vs 13 vs 29 (Central/Ax/Femoral) CVA: 3 vs 4.4 vs 7.7
13 Penn Thoracic Aorta Program Data
14 Postoperative morbidity Central Cannulation (n = 205) In-hospital mortality 17 (8.3) Morbidity Bleeding 9 (4.4) Stroke 10 (4.9) TIA 11 (5.4) Renal failure (STS defn) 34 (16.6)
15 Central Aortic Cannulation Distal Aortic Solutions The Root Towards an Endo Aortic solution
16
17 40 y.o male 1 year post Type A repair (6.4 cm)
18 Do we have a problem with the distal aorta after repair of acute type A dissection?. YES Especially if we use a COMPOSITE index of Index Operation Failure: 1. Aortic Death; 2. Reoperation; 3. Aneurysm > 6.0 cm. 18
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20 Desai, Bavaria (First presented) STS 2015 JTCVS 2017 (in press); AATS 2017 Advantages Simpler Distal Anastomosis Can address most complex arch tears and eliminate flap in proximal head vessels Shorter ACP times Definitive TEVAR options Less risk of Recurrent larnygeal nerve injury TBE Mona LSA
21 Zone 2 TBE (12 mm Portal) in Residual Type A Dissection (Downstream Aorta) 10 days Side branch sheath positioned in LSA Note nice horizontal access 3 cm Dacron LZ previously constructed with Zone 2 Arch (10 days earlier) 21
22 Central Aortic Cannulation Distal Aortic Solutions The Root Valve Retention vs Composite graft Root Towards an Endo Aortic solution
23
24 Aortic Valve Resuspension
25 ROBUST: Aortic Root Reconstruction/Sinus of ValSalva Repair Bavaria, Pochettino, Gleason, et al; Ann Thor Surg 2003
26 Bavaria JE, et al; AATS 2001
27 Completed Root Repair and Aortic Valve Resuspension with Neo-Media Bavaria, Pochettino, Gleason, et al; Ann Thor Surg 2003 IMPORTANT: 72% of Aortic Roots/Valves were NORMAL prior to Dissection!
28 Type A (Debakey Type I) Dissection: Pre and Post Proximal Repair with E-Vita (type) Distal Graft: Note Root Repair and AI Severe AI Zero AI
29
30 Acute Type A Dissection: Freedom from Proximal Re- Operation using Neo-Media Resuspension and the Penn Aortic Root Decision algorithm 1.0 Freedom From Proximal Reoperation Patients at risk: Time (years) 91% (+/- years STS Jan 2014; Desai, Bavaria, et al, Ann. Thor. Surg 2014 Figure 5
31 Freedom from All Aortic Reintervention after VSRR in acute type A aortic dissection Mean = 40 months At 9-year follow-up, the rate of freedom from proximal aortic reintervention was 100%, and that of freedom from distal aortic reintervention was 80% Leshnower Chen. Ann Thorac Surg 2015;99:
32 Central Aortic Cannulation Distal Aortic Solutions The Root Valve Retention vs Composite graft Root Towards an Endo Aortic solution
33 Central cannulation: true lumen ascending aorta, SVC and RA DHCA with retrograde cerebral perfusion
34
35 Central Aortic Cannulation Distal Aortic Solutions The Root Valve Retention vs Composite graft Root Towards an Endo Aortic solution
36 Availability/Creation of a Newly Designed Thoracic Aortic Surgery Database: A Report from the STS Adult Cardiac Surgery Database Nimesh D. Desai MD. PhD., J. Bavaria, MD on Behalf of the STS Aortic Surgery Task Force (First reported at the Jan STS Annual Mtg)
37 Questions?
Joseph E. Bavaria, MD
EACTS Master Class on Aortic Valve Repair Joseph E. Bavaria, MD Director, Thoracic Aortic Surgery Program Roberts Measey Professor and Vice Chair of CV Surgery University of Pennsylvania Immediate-Past
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