Acute Aortic Dissection: Decision and Outcome
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1 Acute Aortic Dissection: Decision and Outcome Marc R. Moon, M.D. John M. Shoenberg Chair in CV Disease Chief, Cardiac Surgery Director, Center for Diseases of the Thoracic Aorta Washington University School of Medicine St. Louis, MO USA AATS/STS Adult Cardiac Surgery Symposium 95 th Annual Meeting, Seattle, Sunday April 26, 2015 Disclosures: NONE
2 Acute Aortic Dissection DECISION and OUTCOME Clinical presentation How do we image them? How do we treat them? Cerebral protection Long-term expectations
3 Acute Aortic Dissection CARDINAL FEATURES Most common catastrophe involving the aorta Relatively rare cause of chest pain prevalence of CAD times > AAD 3 ADD for each 1,000 pts presenting to ER with CP/BP Morbidity and mortality remain high
4 Clinical Presentation IRAD DATABASE Clinical manifestations are protean Diagnosis is Challenging! Missed on initial exam in 38% Severe worst ever pain in 85% Sharp in 65% > tearing/ripping Localized to chest in 73% Type B more often in back/abdo, but substantial overlap Abdominal pain only (no CP/BP) in 5% Most often type B, mortality (28% vs. 10%) mesenteric ischemia rare (4%) poor prognosis (63% vs. 24%) JAMA 2000;283:897 JTCVS 2013;145:385
5 Acute Aortic Dissection SIDE BRANCH INVOLVEMENT True lumen False lumen True lumen False lumen Intimal tear Renal 23-75% Peripheral 25-60% Mesenteric 10-20% Coronary 5-11% Cerebral 3-13% Spinal 2-9%
6 Acute Aortic Dissection DECISION and OUTCOME Clinical presentation How do we image them? How do we treat them? Cerebral protection Long-term expectations
7 Aortic Dissection CT Scan Imaging
8 Aortic Dissection CT Scan Imaging
9 Aortic Dissection Magnetic Resonance Imaging DeBakey II DeBakey III Stanford A Stanford B
10 Aortic Dissection Transesophogeal Imaging
11 Choice of Imaging Study IRAD DATABASE 628 patients First diagnostic modality: CT scan: 63% TEE: 32% Aortography: 4% MRI: 1% 70% had multiple studies Sensitivity: TYPE A TYPE B CT scan: 93% 93% TEE: 90% 80% Aortography: 87% 89% MRI: 100% 100% Moore et al. Am J Cardiol 2002;89:1235
12 Acute Aortic Dissection DECISION and OUTCOME Clinical presentation How do we image them? How do we treat them? Cerebral protection Long-term expectations
13 Acute Aortic Dissection NATURAL HISTORY Lethal if undiagnosed early & not treated appropriately 30% mortality by 24 hrs, 50% by 48 hrs, 90% by 3 months Hirst et al. 505 patients with acute Ao dissection (1958) 100 Percent Survival HRS 24 HRS 48 HRS 1 WK 2 WKS 1 MO 3 MOS 1 YR Medicine 1958;37:219
14 Acute Aortic Dissection INDICATIONS FOR SURGICAL TX Type A Dissection All patients deemed survivable (>80, CVA, CPR in OR) Intramural Hematoma? (35% risk of rupture) Type B Dissection -blockers initially, then vasodilators (afterload > NTG) Decreasing BP from HTN levels can reverse malperfusion Surgical Tx: rupture impending rupture (not pleural effusion), malperfusion (endovascular), persistent pain
15 Acute Aortic Dissection SURGICAL TREATMENT Goals of Surgical Therapy Obviate the usual causes of death (local phenomenon in 60-90% of cases) Reconstitute distal flow in the true lumen Correct compromise of contiguous Ao branches (coronary, innominate, carotid) Restore aortic valve competence Resect primary intimal tear (if exposed) Eliminate flow in false lumen? (seldom accomplished)
16 Acute Aortic Dissection SURGICAL INTERVENTION
17 Acute Type A Dissection What is a Safe and Durable Surgical Strategy? Pts were dying despite their best efforts! Dramatic reduction in mortality after adoption of reproducible repair technique no cross clamp, resection of primary tear, antegrade reperfusion Suggested improved early and late outcomes David et al. ATS 1999; 67:1999
18 Acute Type A Dissection SURGICAL RESULTS Wash U. Incidence of AVR and Hemiarch Replacement by Era: 60% AVR 60% Hemiarch 40% 20% p < p = % 20% 0% % Zierer et al. ATS 2007;83:2122
19 Acute Type A Dissection SURGICAL RESULTS Wash U. 25-year period: 1984 to 2009, 26 surgeons 201 patients: 158 men (63%), 94 women (37%) Mean age: 60 ± 16 years, range 18 to 88 years Operative mortality 16% ± 3% 100% 80% p = 0.37 Survival 60% 40% 20% 0% X-clamp HCA HCA&RCP Years ATS 2007;83:2122 J Clin HTN 2013; 15:63
20 Acute Type A Dissection What is a Safe and Durable Surgical Strategy? At Wash U, 196 acute type A ( ) Group 1 (Classic David): No X-clamp, DHCA, antegrade reperfusion 49 pts Group 2-6: All other strategies 147 pts Lawton et al. JTCVS 2015 (in press)
21 Acute Type A Dissection What is a Safe and Durable Surgical Strategy? Classic David (No X-clamp, DHCA, antegrade reperfusion) vs Other Strategies: No difference in operative mortality or morbidity No difference in FL patency Long-term survival impaired with non-david strategy Lawton et al. JTCVS 2015 (in press)
22 Acute Aortic Dissection DECISION and OUTCOME Clinical presentation How do we image them? How do we treat them? Cerebral protection Long-term expectations
23 Surgery for Type A Dissection CEREBRAL PROTECTION Crawford s classic dictum: With HCA: >40 minutes Stroke >65 minutes Death Retrograde Cerebral Perfusion Maintains brain cooling Retrograde flushing of debris Only 10-15% of nutrient flow Antegrade Cerebral Perfusion nutrient flow safe circulatory arrest time? Allows warmer perfusion?
24 Aortic Arch Replacement Unilateral vs. Bilateral ACP HCA with ACP (28 C): Frankfurt & Bad Neustadt (AATS 2012, 2013) 1,002 pts: mortality with HCA > 30 min Unilateral vs. Bilateral ACP 1097 pts, elective arch, propensity matched No difference in mortality or TND, but CVA with bilateral (6% vs. 2%, p=.06) Zierer et al. JTCVS 2012, 2014
25 Surgery for Type A Dissection CEREBRAL PROTECTION CA Time 0-30 min: Any approach seems adequate CA Time min: RCP / ACP CA Time > 45 min: ACP? ACP can be unilateral, but only with cerebral oximetry
26 Acute Aortic Dissection DECISION and OUTCOME Clinical presentation How do we image them? How do we treat them? Cerebral protection Long-term expectations
27 Freedom from Reoperation Acute Type A Dissection LATE REOPERATION Wash U. 100% 80% 90 ± 3% 74 ± 5% 65 ± 7% 60% 40% 20% op survivors 0% Years Unrelated to initial surgical technique (prox/distal extent, perfusion strategy) Non-resected primary tear (p = 0.05) Marfan syndrome (p < 0.001) Elevated systolic BP at late F/U (p = 0.008) Absence of -blocker (p = 0.02) Zierer et al. ATS 2007, 84:479
28 Freedom from Reoperation Impact of Late β-blocker Use LATE REOPERATION Wash U. Impact of late -blocker use (250 pts) J Clin HTN 2012 (in press): 100% 80% 75 ± 5% 60% 40% 20% yes no p = ± 7% 0% Years ATS 2007;83:2122 J Clin HTN 2013; 15:63
29 Freedom from Reoperation Impact of Late BP Control LATE REOPERATION Wash U. Impact of late systolic BP control (250 pts) J Clin HTN 2012 (in press): 100% 80% 83 ± 5% 60% 40% 20% 0% <120 mmhg mmhg >140 mmhg p = ± 6% 34 ± 7% Years ATS 2007;83:2122 J Clin HTN 2013; 15:63
30 Acute Type A Dissection Method to determine Ao expansion Method to determine aortic expansion over time: 412 total CT scans: 6 ± 5 scans/patient mean interval: 11 ± 16 mo mean total F/U: 7 ± 6 mo 343 CT intervals for analysis Zierer et al. ATS 2007, 84:479
31 Acute Type A Dissection Method to determine Ao expansion Descending Aorta Diaphragmatic Hiatus Abdominal Aorta Zierer et al. ATS 2007, 84:479
32 Acute Type A Dissection AORTIC EXPANSION OVER TIME Wash U. Aortic expansion: 18% (62/343) CT scan intervals, 49% pts Median growth rate (mm/year) Onset of growth unpredictable: most often > 1 year postoperatively mean: 59 ± 45 months (maximum: 167 months) p < Independent predictors of aortic growth: Greater aortic diameter (p < 0.001) 0 Elevated systolic BP at late F/U (p = 0.04) Desc. Diaphr. Abdo. Patent false lumen (p = 0.05) Unrelated to initial surgical technique (prox/distal extent) Zierer et al. ATS 2007, 84:479
33 Aortic Diameter Late F/U after Type A Repair AORTIC EXPANSION OVER TIME Wash U. Interval Between Imaging Studies < 6 mo (n=172) 6 12 mo (n=92) > 12 mo (n=79) Small (< 35 mm) Moderate (35-49 mm) Large ( 50 mm) 5 ± 2% 13 ± 5% 21 ± 7% 12 ± 5% 23 ± 9% 31 ± 8% 23 ± 12% 34 ± 9% 83 ± 15% Zierer et al. ATS 2007, 84:479
34 Impact of Patent False Lumen Jichi Medical University, Saitama, Japan Survival Distal Aortic Event 451 op survivors: 62% FL patent overall 4%: late rupture FL patent in 94% 8%: distal aortic reoperation FL patent in 92% 88% no reoperation, no rupture FL patent in 58% Multivariate analysis: FL patent: survival OR=1.70, distal aortic event OR=4.11 Kimura et al. JTCVS 2015; 149:S91
35 Impact of FL patency on survival IRAD Database TYPE B DISSECTION Tsai et al. NEJM 2007;357:349
36 Total Arch for Dissection Impact on False Lumen Patency 8 studies, 1602 patients ascd/hemiarch vs. total arch +/- S-G 5 total arch is safe, 3 mortality with total arch Freedom from reop is similar with hemiarch or total arch at 5-10 years complete FL thrombosis was seen more often with total arch Recommend extended resection when entry tear is in the arch Total arch may be justified in experienced hands Beijing Anzhen Hosp. JTCVS 2014;148:2466
37 Antegrade Thoracic Stent-Graft Impact on Development of TAAs 78 Type A, DeBakey I dissections at Penn ( ) 42 standard hemiarch, 26 additional descending stent-graft At 16 months, open TAA repair performed in 0% stented pts vs. 11% standard hemiarch group (p=0.08) Don t make the stent-graft too long! Pochettino et al. ATS 2009;88:482
38 Type A Dissection EXTENT OF DISTAL RESECTION Baylor / Texas Heart 157 pts ( ) 60% unilateral ACP, 41% bilateral ACP (22-24 C) conservative approach to arch replacement (7%) ACP, CPB, and cardiac ischemia mortality (p<.04 for all) HCA > 30 min associated with CVA (p=.03) Conclusion #1: In this intrinsically complex disease, survival is the most important outcome. Conclusion #2: A conservative approach to the distal end of the repair can address the primary objectives prevent rupture, re-establish TL flow, maintain competent AoV ATS 2015;99:80-7 JTCVS 2015; 148:2123
39 Acute Aortic Dissection DECISION and OUTCOME Surgical treatment does not cure the generalized disease Postoperatively, close medical follow-up mandates: Strict BP control Negative inotropic therapy ( -blockers even if normotensive) Serial (imaging) surveillance (indefinitely) Life-long surveillance with radiographic follow-up
40 Thank you for your attention.
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