Edward P. Chen MD. Director Thoracic Aortic Surgery Division of Cardiothoracic Surgery Emory University School of Medicine Atlanta, Georgia

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David Procedure in Acute Type A Dissection Edward P. Chen MD Director Thoracic Aortic Surgery Division of Cardiothoracic Surgery Emory University School of Medicine Atlanta, Georgia The Houston Aortic Symposium, February 23, 2017

Root Replacement in Type A Dissection Performed in the setting of: Extensive Tissue Destruction Preexistent aortic root aneurysm Known connective tissue disorder

Root Replacement in Type A Dissection Significantly more complex procedure than ascending/hemiarch replacement alone Longer myocardial ischemic and cardiopulmonary bypass times Often needed in the setting of end-organ malperfusion/cardiogenic shock Frequent coronary ostial involvement requiring: Repair Conduit extension (Cabrol) Coronary bypass

Compared with performing CVG More complex procedure Surgical dissection of the root from surrounding structures more extensive In acute dissection: Disruption of normal tissue planes Edema/hematoma Extended cross-clamp and CPB times Additional time needed with significant AR after CPB

Root Replacement in Acute Type A Dissection IRAD Study 1995 patients 699 Root replacements 1296 Root repair Root replacement patients: Younger (56.9 vs 62.3) Larger root size (4.7 cm vs 4 cm) Marfan (8.7% vs 2.5%) Bicuspids (9.4% vs 2.5%) AI (64% vs 50.3%) Hypotension/shock/tamponade (33% vs 26.5%)

Root Replacement in Acute Type A Dissection Compared with Root Repair: No increase in hospital mortality (propensity score-adjusted OR 1.14, p=0.674) Similar 3 year survival: RR 92.5% vs CR 91.6%; log-rank p=0.623 Freedom from aortic root reintervention: RR 99.2% vs CR 99.3%; log-rank p=0.77)

Early Experience of Valve-Sparing in Acute Dissection First Author Year No. pts Op Mortality Mean F/U Freedom Freedom (Journal) (months) from >2+ AI from AVR RG Leyh 2000 (ATS) 20 10% 26 100% 100% RG Leyh 2002 (Circ) 30 17% 22.6 Unknown 95%-David 63%-Yacoub AW Erasmi 2003 (ATS) 36 19.4% 11.3-David 29.6-Yacoub 100% 100%-David *82%-Yacoub K Kallenbach 2002 (EJCTS) 22 14% 18.4 100% 100% F Farhat 2007 (EJCTS) 15 6.7% 11 100% 100% TP Graeter 2000 (ATS) 22 9.1% 24 93.2% 100% K Kallenbach 2004 (EJCTS) 44 11.4% 19 100% 97% K Kallenbach 2004 (Circ) 48 10.4% 19 100% *65%@5 yrs S Leontyev 2012 (EJCTS) 28/179 pts 7.1% Unknown 93.6% overall 95.9% overall F Kerendi 2010 (ATS) 16/37 pts 6.3% 8.8 overall 100% 100% B Leshnower 2012 (JTCVS) 29/150 pts 6.8% 19 overall 93% 100% S Miyahara 2015 (ATS) 21/183 pts 4.8% Unknown 85.8% (>1+ ) 92.9%

Largest single series to date, 1995-2010 374 pts with Type A Dissection No. pts Op Mortality Ave F/U (months) Bentall 130 27% Yacoub 51 16% 44 David 27 15% 27 Ann Thorac Surg 2012;94:1230-4.

Survival Freedom from Reop Ann Thorac Surg 2012;94:1230-4.

VSRR in Type A 2005-2013 350 patients with Acute Type A 98 patients with root replacement 43 patients (14%) VSRR Mean age 46 years

VSRR in Type A Follow-up: 85% complete Mean follow-up: 40 months (0.2-103 months)

Salient Points of Valve-Sparing in Type A Dissection Cusps should have minimal degeneration and sclerosis? role for extensive cusp repair AI is due to acute prolapse so the nature of the regurgitant jet less of a concern with normal cusps Coronary buttons can be friable Not indicated in the setting of shock, organ malperfusion or surgeon inexperience In high volume centers and experienced hands, not In high volume centers and experienced hands, not associated with worse outcome

Factors Influencing VSRR vs. CVG in Type A Dissection VSRR Younger patients Absence of cusp degeneration Aortic regurgitation/bicuspid valves do not represent absolute contraindications CVG Patients over 65 years old Malperfusion syndromes Neurologic complications Coronary artery disease Cardiomyopathy

Baseline TEE Images

Valve sparing root replacement in Type A Dissection Initial surgical maneuvers Excision of abnormal sinus tissue (leaving 4-5 mm rim of aortic tissue) Creation of coronary buttons

Upward traction on commissural posts Creation vacuum in LV to induce valve coaptation (LV vent and cell saver)- suction test Examine valve cusps for competency: Degeneration Coaptation zone Presence of prolapse Cusp restriction Fenestrations Free margin length

Graft Sizing/Tailoring: David-Feindel Formula 2 [(Average 2 [(Average Cusp Height) ⅔]+6 Height) ⅔]+6 Anchoring graft to base of heart Tacking commissural posts: key step Post heights and angles not necessarily equal Reimplant valve inside graft Assess for valve competency Valve/cusp repair if needed Coronary reimplantation

TEE Images after Repair

In acute Type A dissection, performance of an aortic root replacement has not been shown to be associated with an increase in operative risk Despite unique technical challenges related to the disease process, valve-sparing procedures can be safely and effectively performed with acceptable operative risk in patients presenting with acute Type A aortic dissection and aortic root pathology. In experienced hands, the indications for valvesparing aortic root surgery should be expanded to include Type A dissection.

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