2012 What is New in Aortic Surgery: Monitoring and Preventing Spinal Cord Injuries - Teamwork

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1 2012 What is New in Aortic Surgery: Monitoring and Preventing Spinal Cord Injuries - Teamwork George Silvay, MD, PhD Professor of Anesthesiology The Mount Sinai Medical Center New York, NY

2 I would like to dedicate my presentation to: Hans G. Borst, M.D. He arranged for me Alexander Humbold Scholarship (1965). Munchen, Germany. Borst H.G., Lemke M.L. Ruckenmarkschadigung nach Operation an der thorakalen Aorta descendens. Arztl. Forschung 1969;23:299 Robert S. Litwak, M.D He invited me for 2 years fellowship in cardio-thoracic surgery ( ). Mount Sinai Hospital, New York, NY, USA. Litwak RS, Lev R, Baron M, Silvay G, Gadboys HL: The surgical treatment of aortic aneurysm. Geriatrics 1967;21:105

3 August 21, 1968 Soviet Union and Warsau Pact invasion of Czechoslovakia My dream end : After surgical training in CSR, fellowship in Germany and USA.

4 The Mount Sinai School of Medicine, New York

5 New York April th Ann. Meeting EACTA May 2012 It was something new??? 5 th International Congress: Aortic Surgery and Anesthesia HOW TO DO IT Milano, Italy December 13-15, 2012.

6 September 2012 update, discussion: 1) Early diagnosis medical & surgical treatment 2) TEE in every patient! In OR during operation! 3) Detailed preoperative evaluation and strategy for OR (DAS) 4) Antibiotic prophylaxis!!! 5) Optimize prevention of CNS and spinal cord injury (DHCA, distal controlled perfusion, CSF drainage, steroids or other) 6) Utilize hemodynamic and MEP monitoring in OR and CICU 7) Participate in designing organ-preservation strategy 8) Maximize perfusion parameters intraoperatively 9) In CICU prevent hypoxemia and anemia prevent the late spinal cord ischemia continue the same monitoring as in OR.

7 The Value of Echo Monitoring in OR: 1) Visualization of aorta, heart chambers-anatomy, air, thrombus and emboli 2) Location and size of the aneurysm 3) Recognition and location of atherosclerotic changes in aorta 4) Demonstration of an aortic flap with true and false lumen 5) Differential flow in the true and false lumens 6) Verification of cannula positioning

8 September 2012 update, discussion: 1) Early diagnosis medical & surgical treatment 2) TEE in every patient! 3) Detailed preoperative evaluation and strategy for OR (DAS) 4) Antibiotic prophylaxis!!! 5) Optimize prevention of CNS and spinal cord injury (DHCA, distal controlled perfusion, CSF drainage, steroids or other) 6) Utilize hemodynamic and MEP monitoring in OR and CICU 7) Participate in designing organ-preservation strategy 8) Maximize perfusion parameters intraoperatively 9) In CICU prevent hypoxemia and anemia prevent the late spinal cord ischemia continue the same monitoring as in OR.

9 Antibacterial Preoperative Prophylaxis 1. Lengthy operative procedure 2. Use of hypothermia 3. Use of prosthetic graft material

10 September 2012 update, discussion: 1) Early diagnosis medical & surgical treatment 2) TEE in every patient! 3) Detailed preoperative evaluation and strategy for OR (DAS) 4) Antibiotic prophylaxis!!! 5) Optimize prevention of CNS and spinal cord injury (DHCA, distal controlled perfusion, CSF drainage, steroids or other) 6) Utilize hemodynamic and MEP monitoring in OR and CICU 7) Participate in designing organ-preservation strategy 8) Maximize perfusion parameters intraoperatively 9) In CICU prevent hypoxemia and anemia prevent the late spinal cord ischemia continue the same monitoring as in OR.

11 Size of the aorta?

12 Etz et al. J Thorac Cardiovasc Surg 2011; 141:1020-8

13 Etz et al. J Thorac Cardiovasc Surg 2011; 141:1020-8

14 A Comparison of Regional Variations in Deep Hypothermic Circulatory Arrest for Adult Aortic Surgery Augoustides JG, Silvay G. HSR Proceedings In press

15 Silvay G, et al Aortic Symposium 2012 (April 26-27) POD #252

16 Improved Surgical and Perfusion Technique MEP s CSF Drainage Hypothermia Minimized the ischemic time Hemodynamic Manipulation Avoid Hypotension and Anemia Prevent Paraplegia Control Distal Perfusion (Measuring Direct Spinal Artery Pressures)

17 Neuroprotective Strategies CPB with hypothermia (32 C) or DHCA Distal perfusion CSF drainage Steroids or other agents MAP over 80 mm Hg Neurophysiologic monitoring

18 Monitoring and Prevention of Spinal Cord Injuries - Teamwork

19 Replacement of Thoracoabdominal Aorta Using HCA N=243 (TAAA repair under CPB and HCA) CPB 160±44 min DHCA 31±12 min Stroke rate 3.7% Spinal cord injury 5.3% Renal failure 3.6% 30-day mortality 7.8% Spinal cord injuries are more frequent in emergency cases 5-year survival was 55%. Kouchoukos NT. Aortic Symposium 2012 (49)

20 Lima et al. J Thorac Cardiovasc Surg 2012;143:945-52

21 Lima et al. J Thorac Cardiovasc Surg 2012;143:945-52

22 Lima et al. J Thorac Cardiovasc Surg 2012;143:945-52

23 Lima et al. J Thorac Cardiovasc Surg 2012;143:945-52

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25 Greiner A, at al. J Vasc Surg 2012;55:

26 Greiner A, et al: J Vasc Surg 2012;55:

27 Greiner A, et al: J Vasc Surg 2012;55:

28 Management of Thoracoabdominal Aortic Aneurysms Author Patients (n) 30-day mortality (%) Paraplegia/ Praparesis (%) Dialysis (%) Coselli Svensson Rigberg no data no data Sandmann Griepp Crawford Schepens no data no data Conrad Chiesa R, et al: HSR Proceeding 2009;1:47-55 (Modified)

29 Build a Hybrid OR, Build a Team AATS Meeting showcase future of CT Surgery April 28 May 2, 2012 San Francisco, CA Modern cardiac surgery will require a hybrid OR and hybrid OR skills, said Dr. Byrne.

30 TEAMWORK and HARMONY in the OR and CTICU Provide Optimal Results, Decreasing MORBIDITY, MORTALITY, EXPENSES and SUPRISSES in the OR

31 Teamwork Is Important but Who Is in Charge in your OR?

32 GRACIAS ありがとう ΕΥΧΑΡΙΣΤΩ MAHALO 谢谢 СПАСИБО תודה ا م ت نان CÁM ƠN ANH ASANTE MULTUMIRI FALEMNDERIT KIA ORA TEŞEKKÜR TAK Thank You ขอบค ณ DANK U MERCI TERIMA KASIH KÖSZÖNÖM D AKUJEM GRAZIE DANKE サンキュー DEKUJEME HO OMAIKA I OBRIGADO TRADUKU