Diseases of The Aorta 2016 Understanding & Approach TAA, TAD, AAA, AAR

Transcription

1 Diseases of The Aorta 2016 Understanding & Approach TAA, TAD, AAA, AAR ACC-New York, Dec. 12, 2015 No Disclosures

2 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA,AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Th.Ao.An. TAD: Th.Ao.Dis. AAA: Abd.Ao.An AAR: Abd,Ao.Rupt.

3 1). Classification of Thoracic Aortic Dissection (6 people per per year) VS Ramanath et. al. Mayo Clin Proc. 2009;84:465. CA Nienaber et. al. Circulation 2003;108:628.

4 2) A 14-day Mortality In 645 Pts From IRAD Stratified By Medical And Surgical Treatment In TAD Type A & B TA Mort 1% q.2h 4 Days TB. S TA. S TB. M IRAD (TT Tsai et. al.) Eur J Vasc Endov Surg 2009;37:149-Av 9h to Surgery PG Hagan et. al. JAMA 2000;283:897

5 3) Imaging Modalities In The Diagnosis Of AAS A Evangelista et. al. Nat. Rev. Cardiol. 2013;10:477 End Doing Both

6 4D Phase Contrast MRI From A Patient With Aortic Dissection RE Clough et. al. Nat. Rev. Cardiol. 2015;12:103

7 4)Pathophysiological Features of Marfan s & Bicuspid Aortopathy S Verma et. al. N Engl J Med 2014;370:1920

8 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA,AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Th.Ao.An. TAD: Th.Ao.Dis. AAA: Abd.Ao.An AAR: Abd,Ao.Rupt.

9 1).TAA, 2).TAD, 3). AAA, 4). AAR 2. TAA 1. Marfan s 3. AAA, Prevalence 1.25% 1 in 10,000 5% Genetic Genetic Genetic Risk Factors Predisposition Predisposition Predisposition a. Bicuspid Valve Age, Male b. Hypertension Hypertension c. Atherosclerosis Smoking Cystic medial Cystic medial Inflammatory Histology Necrosis Necrosis Infiltrate, VSMC Apoptosis Rupt./ Disect SL Liao, V Fuster et al. Nat. Rev. Card. 2012

10 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA, AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Thor. Aort. Aneur. TAD: Thor. Aort. Dissect. AAA: Abd. Aort. Aneur.

11 STRUCTURE NORMAL AORTA FUNCTION ELASTIN Fibrillin TGF-b MMPs SMC DISTENSION ACTIVITY > Mucoid COLLAGEN RESISTANCE VASA VASORUM NUTRITION Junquiera LC, Carneiro J: Basic Histology Text and Atlas, 11th ed. McGraw-Hill Access Medicine

12 1). Mutant Fibrillin 1 in the Regulation of Aorta Homeostasis? I El-Hamamsy et. al. Nat Rev Cardiol. 2009;6:771.

13 STRUCTURE 1) AORTIC ANEURYSM - MFS DYSFUNCTION < Fibrillin > TGF > MMPs < ELASTIN < DISTENSION >SMC < SMC > ACTIVITY >Collagen > Mucoid < COLLAGEN < RESISTANCE < VASA VASORUM Junquiera LC, Carneiro J: Basic Histology Text and Atlas, 11th ed. McGraw-Hill Access Medicine < NUTRITION

14 1,2a) TAA/TAD MARFAN S / BIC. 2bc) HYPERT. / ATHER FBN1 Mutation Rupture Fibrillin Collagen TIMP TGF-β MMP Aneurysm Formation Stiffness dp/dt Aortic diameter BP Elastin Collagen CMD Proteases Degenerative Diseases VSMC SL Liao, V Fuster et al. Nat. Rev. Cardiol. 2012

15 1). Marfan s Type of Syndromes + MARFAN SYNDROME DIAGNOSTIC CRITERIA FOR Ghent Nosology FBN1/TGFBR2 MUTATIONS Consider other diseases MRA, Biochemical diagnosis, Genetic LOEYS-DIETZ TYPE I Aortic An. arterial Tort., hypertelorism, cleft pal, bifid uvula TGFBR1 and TGFBR2 MUTATIONS Visceral rupture, bruising, LOEYS-DIETZ TYPE II Normal synthesis Thin translucent skin, Type III procollag. Characteristic facial appearance EHLERS-DANLOS TYPE IV Abn. synthesis of type III procollag. COLA31 MUTATIONS FAAD First-degree relat. with aortic aneur. or Dissect.or aneury. in other localizat. TAAD1, TAAD2 and FAA MUTATIONS V Canadas, I Vilacosta, I Bruna, V Fuster. Nat Card Rev 2012

16 2a) Bicuspid Aortic Valve - Morphology Features That Influence the Pattern of Aortopathy S Verma et. al. N Engl J Med 2014;370:1920 Types 1,2,3

17 Bicuspid Aortic Cusp Fusion Alters Aortic 3D flow Patterns, Wall Shear Stress & Aortopathy R Mahadevia et. al. Circulation. 2014;129:673

18 Group -2abc) Pathways In TAA Fibrillin?,TGF-b E Gillis et. al. Circ Res. 2013;113:327

19 1Group -2abc) Monogenic Disorders of Aortic Dissection by Site and Gene CA Nienaber et. al. Lancet 2015; 385: 800

20 3) MRI Imaging Aortic Aneurysm Mouse Model and Nanoparticle PET-CT J Swedenborg et. al. Arterioscler Thromb Vasc Biol. 2011;31:73 T Duellman et al. Circ Cardiov. Genet 2012; 5:529 (Marshfield, WI) MMP 9 M Nahrendorf, Rweissleder et. al. ATVB. 2011;31:750 A Klink, V Fuster, ZA Fayad et. al. J Am Coll Cardiol 2011;58:2522

21 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA,AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Th.Ao.An. TAD: Th.Ao.Dis. AAA: Abd.Ao.An AAR: Abd,Ao.Rupt.

22 Hemodynamic Factors - Dilatation To Dissection BP 2 3 dp / dt max 1.Arterial Diameter 1 - EK Prokop, RF Palmer, MW Wheat. Circ Res 1970; 27:121 TURKEY DISSECTION

23 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA,AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Th.Ao.An. TAD: Th.Ao.Dis. AAA: Abd.Ao.An AAR: Abd,Ao.Rupt.

24 1) TAD Hemodynamic Approach Baseline 2) Vasodilator (i.e., Nitroprusside) (3) Beta blockade Time TAD - J Sanz, A Einstein, V Fuster. In Acute Aortic Disease. Ed. J Elefteriades

25 2) MFS - IMPACT OF β BLOCKERS ON AORTIC ROOT DIAMETER 45 Aortic Diameter (mm) Treatment Group: slope = 1.04±0.05 Control Group: slope = 1.15± Age (y.o.) M Ladouceur et al., AJC 2007; 99:406 (Paris)

26 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA,AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Th.Ao.An. TAD: Th.Ao.Dis. AAA: Abd.Ao.An AAR: Abd,Ao.Rupt.

27 1a) TAA in Marfan s (and Other?) - ARBs Look Promising COMPARE: evaluated the effect of losartan on aortic dilatation rate in adults with Marfan syndrome (MFS). Patients with MFS have an increased risk of life-threatening aortic complications, mostly preceded by aortic dilatation. A total of 233 patients (47% female) underwent randomization to losartan mg/d (n=116) or no additional treatment (n=117). Followup was 3.1 ± 0.4 years. End Points Losartan Control 1. Aortic-root enlargement (mm) No aortic-root growth (%) Previous root replacem.: significant lower aortic arch expaansion MARFAN SARTAN: 300 patients, 1ary EP-root diameter, 2ary EP-clinical M Groenink et al., EHJ 2013; Aug 21 - Netherlands p

28 1b) Atenolol vs Losartan in Children and Young Adults with Marfan s Syndrome We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan s syndrome. The primary outcome was the rate of aortic-root enlargement, over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the aortic root; the rate of change in aortic regurgitation; the time to aortic dissection, aortic-root surgery, or death; somatic growth; and the incidence of adverse events. A total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6 years. We found no significant difference in the rate of aortic-root dilatation between the two treatment groups over a 3-year period. RV Lacro et al., NEJM 2014; 371:2061 American Study

29 1c). Marfan Sartan: A Randomized, Double-Blind, Placebo-Controlled Trial A double-blind, randomized, multi-centre, placebo-controlled, add on trial comparing Losartan (50 mg when < 50 kg, 100 mg otherwise) vs. placebo in patients with MFS according to Ghent criteria, age > 10 years old, and receiving standard therapy. 303 patients, mean age 29.9 years old, were randomized. The two groups were similar at baseline, 86% receiving β-blocker therapy. The median follow-up was 3.5 years. Losartan was able to decrease blood pressure in patients with MFS but not to limit aortic dilatation during a 3-year period in patients > 10 years old. β-blocker therapy alone should therefore remain the standard first line therapy in these patients. O Milleron et al., Eur Heart J 2015; 36:2160 French Study

30 Marfan Sartan: A Randomized, Double-blind, Placebo-controlled Trial - Aortic Root Dilatation O Milleron et. al. Eur Heart J. 2015;36:2160 French Study

31 Understanding - TAA, TAD, AAA, AAR Definition, Mortality, Imaging, ECM (4) Types, Demographics (TAA,TAD,AAA,AAR) (5) Etiology, Pathogenesis (TAA,TAD,AAA,AAR) Dysfunctional Structure (5) Hemodynamics (3) Approach to Hemodynamics (2) Approach to Dysfunctional Structure (1) Interventional (TAA,TAD,AAA,AAR) (4) TAA: Th.Ao.An. TAD: Th.Ao.Dis. AAA: Abd.Ao.An AAR: Abd,Ao.Rupt.

32 1a) TAA - Indications For Surgery 40 mm with indication for elective AVR (BAV etc) 45 mm in MFS 50 mm in BAV (?) 55 mm for an ascending aortic aneurysm, 60 mm for a descending aortic aneurysm; 70 mm in high-risk comorbidities; Growth rate 10 mm per year in <55 mm diameter Recurrent symptoms, Evidence of proximal dissect. L Cozijnsen et al., Circ 2011; 123:924 Ince, CA Nienaber. Nature CV Med 2007; 4:418

33 1b) Temporal Trends In The Overall Number Of Aortic Root Procedures And By Type Of Operation M Gaudino et. al. J Thorac Cardiovasc Surg 2015;150:1120

34 Predictors of Early and Medium-Term Outcome of 200 Consecutive Aortic Valve and Root Repairs Between 2003 and 2013, 200 consecutive patients (149 men, 51 women; mean age, 52.1 years) with significant aortic regurgitation and aortic root enlargement underwent aortic valve repair and associated root reconstruction. Root management consisted of either root remodeling or reimplantation with Dacron prostheses. Early mortality was 2%, and early repair failure was 3%. Survival at a mean follow-up of 48.6 ± 34.3 months was 94%, with a freedom from reoperation of 91%. Repair failure and reoperation were associated with bicuspid valve and complex leaflet repair. MJ Jasinski et al., J Thorac Cardiovasc Surg 2015; 149:123 (Poland)

35 1c). Risk of Aortic Surgery After Definite Bicuspid Aortic Valve Diagnosis (n=416) HI Michelena et. al. JAMA 2011;306:1104.

36 1d) Children With Marfan s Or Loeys-dietz s (N=35) Freedom From Reoperation And Actual Survival Event-Free Survival (%) Survival Reoperation Months After Operation ACEI postop, valve-sparing root replacement, and mitral valve repair have low reoperative risk MD Everett, AT Yetman et al., JTCS 2009; 137:1327 (Salt Lake City, Denver)

37 2a). Contained Acute Aortic Syndrome RE Clough et. al. Nat. Rev. Cardiol. 2015;12:103 RR Baliga et. al. J Am Coll Cardiol Img 2014;7: % -CT / MR Diameter 16 mm, Rupture within 10 days

38 Early & Late Outcomes of Acute Type A Aortic Dissection With Intramural Hematoma Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection: 64 patients or 15% had type A IMH and 354 patients 85% with typical dissection. With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours), but no mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection (10.9% vs 14.7%). Although expectant repair within 3 days may be applied, the purposeful delay imparted little advantage. AL Estrera et al., J Thorac Cardiovasc Surg 2015; 149:137 (Houston)

39 Acute Type A Intramural Hematoma Analysis of Current Management Strategy Best cutoff to Predict Events: 16 mm (Hematoma) - Often Type A AL Estrera et al., J Thorac Cardiovasc Surg 2015; 149:137 (Houston) No mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection (10.9% vs 14.7%).

40 Early And Late Outcomes Of Acute Type A Aortic Dissection With Intramural Hematoma AL Estrera et. al. J Thorac Cardiovasc Surg 2015;149:137

41 2b) Acute Type A Aortic Dissection: Comparing Bicuspid vs Tricuspid Valve Between 1995 and 2011, 460 consecutive patients had acute type A aortic dissection % with TAV and 8.4% with BAV. Patients with BAV have a distinctive dissection pattern with the entry tear frequently located in the aortic root and despite their younger age are subject to substantial hospital mortality. For BAV patients, composite root replacement yields an outcome equal to an age- and gender-matched normal population. CD Etz et al., Eur J Cardio-Thoracic Surg 2015; 48:142

42 2c). Neoaortic Arch From The Inside JM Zhu et. al. J Thorac Cardiovasc Surg. 2015;150: 101

43 Circulation. 2014;129:1610

44 2d) Irad Type B Dissection Survival Curve (N=300) 100 Survival rate (%) Hospital Mortality 29% 10% 10% Log rank P =.61 Surgical (11%) Endovascular (11%) Medical (18%) 0 Days Worst Prognosis: Hypotension, Pleural Effusion, Renal Failure Refractory Pain & Hypertension IRAD (Tsai TT et al.) Circulation 2006; 114:2226 IRAD (S Trimarchi et al.) Circulation 2010; 122:1283

45 Site of TEVAR Implementation RP Cambria. Advances at Mass General. 2015

46 Outcomes of Patients With Acute Type B Aortic Dissection RO Afifi et. al. Circulation 2015;132:748

47 3). Annual Risk of Rupture of AAA K Craig Kent. N Engl J Med 2014;371:2101

48 Screening for AAA: U.S. Preventive Services Task Force Recommendation Statement The USPSTF recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked. (B recommendation) The USPSTF recommends that clinicians selectively offer screening for AAA in men aged 65 to 75 years who have never smoked (C recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women aged 65 to 75 years who have ever smoked. (1 statement) The USPSTF recommends against routine screening for AAA in women who have never smoked. (D recommendation) ML LeFevre et al., Ann Intern Med 2014; 161:281

49 4) Growth Rate for Small AAA Meta-Analysis Small AAAs of 3.0 cm 5.4 cm in diameter are monitored by ultrasound surveillance. The intervals between surveillance scans should be chosen to detect an expanding aneurysm prior to rupture. Studies were identified for inclusion through a systematic literature search through December Study authors were contacted, which yielded 18 data sets providing repeated ultrasound measurements of AAA diameter over time in 15,471 patients. Predictions of the risk of exceeding 5.5-cm diameter and of rupture within given time intervals were estimated. Growth rates increased on average by 0.59 mm per year. In contrast to the commonly adopted surveillance intervals in current AAA screening programs, surveillance intervals of several years may be clinically acceptable for the majority of patients with small AAA. The RESCAN. JAMA 2013; 309:806 JL Duncan BMJ 2012; 344:e2958 > 25 mm LT Risk JM Guirguis-Blake et al., Ann Intern Med 2014; 160:321 Validated Prospectively

50 Long-Term Outcomes of Abdominal Aortic Aneurysm in the Medicare Population ML Schermerhorn et. al. NEJM 2015;373:328

51 Annual Proportion of Elective Endovascular & Open Repairs for AAA in the US K Craig Kent. N Engl J Med 2014;371:2101

52 Diseases of The Aorta 2016 Understanding & Approach TAA, TAD, AAA, AAR ACC-New York, Dec. 12, 2015 No Disclosures

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58 Interdisciplinary Expert Consensus Document on Management of TAD Type B - Complications Medical Rx 1548, Surgical Rx 1706, TEVAR 3457 R Fattori et. al. J Am Coll Cardiol 2013;61:1661