Verbrede mediastinum: Treatment

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1 Verbrede mediastinum: Treatment Klinische les - Cardiale Heelkunde Gabriele Bislenghi ASO Heelkunde UZ Leuven Moderator: prof. B. Meuris

2 Overview Aortic dissection Boerhaave

3 Aortic Dissection Aortic dissection

4 MEDICAL TREATMENT reduce shear stress on the aortic wall and reduce cardiac contractility by controlling BP and HR Target systolic BP and HR 60bpm - Antihypertensiva ---> Bblokk iv associated with improved survival regardless of surgical therapy - Significant AR must be excluded by TTE before initiation of Bblokk since they may inhibit compensatory tachicardia - Dihydropyridine calcium channel antagonists (verapamil, diltiazem) are good alternatives Possible settings: - aortic rupture - tamponade - acute AR and acute heart failure - circulatory arrest - stroke - visceral ischemia

5 Surgery is the only effective treatment. Operative mortality is 20%, but 50% mortality within 48h, 91% at 6 months if not surgery Presence of stroke or acute paraplegia does not controindicate operation as patient may experience significant recovery after operative repair Even in patients >70y superiority of surgery over medical treatment

6 Principles of surgery: excision of intimal tear (entry point) Obliteration FL reconstitution of aorta with interposition graft +/- coronary reimplantations restoration of aortic valve competence The purpose of operation: eliminate the aortic segments at risk for rupture. This requires obliteration of all false channels with reconstitution of blood flow exclusively into the true lumen. Unfortunately this objective is rarely achieved except for DeBakey type II dissection (involving only the ascending aorta)

7 General consideration: sternotomy CPB under moderate or deep hypothermia site of arterial cannulation? Femoral vs axillary? Axillary cannulation: Advantages Antegrade perfusion No manipulation of the ascending aorta Recommended over femoral cannulation as prophylaxis against malperfusion, lower extremity ischemia, retrograde dissection and retrograde embolization of debris Disadvantages Time consuming Impossible to CNS perfusion if dissected Brachial plexus injury Vascular complication

8 European Society of Cardiology task force on acute type A Dissection 2014

9 Proximal aortic anastomosis: Anatomy of the aortic root: implications for valve-sparing surgery Efstratios I. Charitos, Hans-Hinrich Sievers

10 Proximal aortic anastomosis Surgical options for repair supracommissural ascending aorta replacement (ascending aortic replacement) composite conduit root replacement aortic valve-sparing root replacement

11 Whenever possible aortic root replacement is avoided (root not dilated, the entry not located in the root, AV intact, absence of phenotypic and historical markers for a connective tissue disorders ) supra-commissural AA replacement can be performed via simple tube-graft replacement of the ascending aorta and an open anastomosis with reconstruction of the downstream aorta

12 Young patients Connective tissue disease (Marfan, Ehlers-Danlos) Dilatation of the sinotubular junction Dilatation of the aortic annulus Given the future risk of aortic root dilatation and complexity of repeat aortic root surgery aortic root replacement with prosthetic replacement of the ascending aorta including the sinus portion

13 Valve sparing surgery vs AV replacement? Absolute contraindications for Valve-Sparing Root Replacement: - advanced degenerative calcification of the aortic valve - overstretched and thin cusps with stress fenestrations and perforations - acute infective endocarditis

14 Bentall vs VSRR? Author N B/VSSR Mean f/u survival Event free survival Bernhard A., Reichenspurner et al / y 87% B 89%VSSR 14Y-48% B 14Y-44% VSSR Freedom from Reoperation Bekkers JA, Boggers Ad et al / Y 53.4% without significant difference 100% B 85% VSSR significant diff. Subramanian S, Mohr FW et al /78 7.2Y Overall 8y-55% without significant diff Overall 8y-95% without significant diff.

15 Bentall AVR Straightforward (standard technique) Shorter cross-clamp and bypass time compared to valve sparing operations

16 VSRR Potential rationale for Valve-Sparing Root Replacement Excellent aortic valve function with physiological hemodynamics Lifelong good functionality (avoidance of reoperations) Avoidance of prosthetic valve related complications.

17 VSRR AD type A Remodeling technique Yacoub

18 VSRR AD type A Remodeling technique Yacoub Principle focus - preserve native valve - recreating aortic sinuses improves blood flow from the aortic root into the coronary lumen - relief stress on aortic cusps Disadvantages - lack of stabilization of the aortic annulus late aortic insufficiency - aortic tissue left behind risk of aneurismatic dilation

19 VSRR AD type A Reimplantation technique David Principle focus - preserve native valve - avoid the disadvantages of Yacoub operation stabilizing the aortic annulus by sewing the native valve directly into a Dacron graft of a fixed circumference Disadvantages - no recreation aortic sinuses and improvement of blood flow from the aortic root into the coronary lumen - no relief stress on aortic cusps

20 Yacoub vs David Optimum event free survival Interactive CardioVascular and Thoracic Surgery 13 (2011) papers 1338 patients (Yacoub technique in 606 and David technique in 732) 13 centres Early mortality: 0% to 6.9% for the Yacoub technique and 0 6% for the David technique In the largest available series reported by David et al. in % in the Yacoub group and 1.7% in the David group The results for both techniques were almost comparable

21 Yacoub vs David Optimum event free survival Conclusions: - less freedom from AR in the Yacoub than the David - favour of the David technique rather than the Yacoub technique in: Marfan syndrome excessive annular dilatation -

22 Distal aortic anastomosis: how to deal with the arch?

23 Distal aortic anastomosis: how to deal with the arch? How much resect? The false lumen (DeBakey 1) in the arch and descending aorta remains untreated Aneurysma (thoraco-abdominal) formation 10% Rupture 10% Malperfusion 10-30% Redo-surgery?% Possible solution? elephant trunk Advantages: Replacement of the aortic arch Preparing future replacement of descending aorta providing a landing zone for a stent graft

24 AD type B Aortic dissection type B Uncomplicated (66%) or complicated (33%) Malperfusion with impending organ faillure Refractory hypertension despite full medical treatment Increased periaortic hematoma or haemorragic pleural effusion synonimous for aortic rupture

25 AD type B Aortic dissection type B Long term survival after TEVAR in complicated disease is superior compared to medical treatment alone. However TEVAR is still associated with high risk of reintervention and serial CT scans TEVAR is not recommended for uncomplicated type B AAD. Only patient with partial thrombosis of FL could be considered for the treatment since completed patent or thrombosed FL leads to a lower risk of rupture

26 Boerhaave Boerhaave and esophageal perforation Initial therapy Breed spectrum antibiotics - Piptazo 3-4/24h iv - Fluconazole 400 mg/24h if immunosuppression or long hospitalisation NPO, PPI Cristalloids (dependent on third space, peritonitis, pleuritic, sepsis) NGT under endoscopic vision

27 Boerhaave Boerhaave and esophageal perforation Therapy primary repair < 24h

28 Boerhaave Boerhaave and esophageal perforation Therapy Surgical alternatives

29 Boerhaave Boerhaave and esophageal perforation Therapy Endoscopy Coverstent Endoscopic clips Transoesoph debridement Stent failure: - cervical - gastro-esophagealejunctie - > 6 cm Collection drain -> source control!

30 Boerhaave Boerhaave and esophageal perforation Therapy Conservative management Patient selection: - Leak contained within the neck or mediastinum or between mediastinum and visceral pleura - Contrast able to flow back into esophagus from the cavity perforation - Not neoplastic tissue - Minimal symptoms - No sepsis Medical management: - Avoidance of oral intake at least 7 days - Parenteral nutrition support - Broad spectrum antibiotics iv - Drainage of fluid collection

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