Type A aortic dissection,

Proximal repair :

valve resuspension, remodelling or

reimplantation ?

i_abouliatim@hotmail.com

Issam Abouliatim, MD

Department of Thoracic, Cardiac and Vascular surgery. Rennes, France

CACVS, 27- 29 january 2011

Faculty Disclosure Dr Issam Abouliatim

I have no financial relationships to disclose

Principles of surgery

Aorta:

Resection and replacement of the aortic tear site

Root: Root:

Replacement / Repair of aortic sinus segments with false

lumen obliteration to prevent:

Coronary malperfusion

Late aortic root complications

Valve:

Resuspension / Replacement of the aortic valve

Normal dimensions of the aortic rootTwo-Dimensional Echocardiographic Aortic Root Dimensions in Normal

Children and AdultsRoman MJ. Am J Roman MJ. Am J CardiolCardiol 1989;64:5071989;64:507--512512

Upper normal dimensions:

Aortic annulus(DAA) < 1.6 cm/m Aortic annulus(DAA) < 1.6 cm/m (31mm for male; 26mm for female)

Sinus (DSV) < 2.1 cm/m (40 mm for male and 36mm for female)

Sino-tubular junction < 1.8 cm/m

Not dilated aortic root

Repairable aorticroot

NO

YESNO

Bentall (composite) or David (AVS)

YES

Pathologic aorticvalve

Aortic valve replacement

normal aortic valve

Resuspenssion (SCR)

Not dilated aortic root +

normal aortic valve

Supracommissural resuspension (SCR)

pull up the aortic commisures

attach them to aortic adventitia

Not dilated aortic root +

normal aortic valve

SCR: Re-attachement of the dissected aortic

root layers with biological glues

Test the competence of aortic valve !!!

Dilated aorticroot

Pathologicaortic valve

Normal aortic valveaortic valve

Bentall procedure (comp)

valve

David or Yacoubprocedure (AVS)

Dilated aortic root +

Pathologic aortic valve:

Creation of coronary ostia buttons Resection of the aortic root and aortic valve Composite graft insertion in the aortic annulus Coronary reimplantation

BentallBentall Thorax. 1968; 23:338-9

composite replacementcomposite replacement

Dilated aortic root +

Normal aortic valve

Valsalva sinuses resection:Aortic root : Yacoub procedure

YacoubYacoub MM. . CirculationCirculation 19831983

Aortic valve sparing:

Remodeling

Non coronary sinus

resection

Coronary

reimplantationSupracoronary aortic

replacement

Dilated aortic root +

Normal aortic valve:

Graft insertion below the aortic annulus Running suture of the commisures in the graft Coronary reimplantation

TironeTirone David (David (David I JTCS 1992;103:617-22)AVS: Reimplantation

Reimplantation: David procedure

Supracommissural resuspension:Aortic root dilatation

Preop Early postop Follow up

(6132 months)

Effects of ascending aorta replacement on aortic root dilatation* Effects of ascending aorta replacement on aortic root dilatation* Ruggero De Paulisa,*, Enrico Cetranoa, Marco Moscarellia, Giuseppe Ando`a,b, Ruggero De Paulisa,*, Enrico Cetranoa, Marco Moscarellia, Giuseppe Ando`a,b, Fabio Bertoldoa, Fabio Bertoldoa,

Raffaele Scaffaa, Fabrizio Tomaia, Luigi Chiarielloa Raffaele Scaffaa, Fabrizio Tomaia, Luigi Chiarielloa

European Journal of CardioEuropean Journal of Cardio--thoracic Surgery 27 (2005) 86thoracic Surgery 27 (2005) 868989

Both the increase of aortic root diameter and the progressive

worsening of aortic valve insufficiency seem to justify a more aggressive treatment of the aortic root at the time of surgery

for acute aortic dissection.

Root diameter

(mm)

416 395 436

Aortic

regurgitation 2

25 (61%) 4 (10%) 23 (56%)

130 patients (80%) had a resuspenssion technic

Freedom from reoperation on the proximal aorta were

81%, 71% and 62% at 5, 10, 15 years.

Supracommissural resuspension: Reoperation

Risk factor analysis for proximal and distal reoperations Risk factor analysis for proximal and distal reoperations

after surgery for acute type A aortic dissection after surgery for acute type A aortic dissection Matthias Kirsch, Matthias Kirsch, Cline Soustelle , Cline Soustelle , RmiRmi HoulHoul, , Marie Line Marie Line HillionHillion, , Daniel Daniel LoisanceLoisance..

J Thorac Cardiovasc Surg 2002;123:318J Thorac Cardiovasc Surg 2002;123:318--2525

81%, 71% and 62% at 5, 10, 15 years.

Indication for reoperation: aortic valve insufficiency or

aortic root dilatation

Severe preoperative aortic insufficiency is a

significant risk factor for reoperation on the

proximal aorta

Patients with severe aortic insufficiency should benefit

from a more aggressive proximal repair at initial

operation

SCR Bentall AVS p

Patient 145 64 48

Resuspension / Bentall / Sparing

Evolving Strategies for Treatment of Acute Aortic Evolving Strategies for Treatment of Acute Aortic

Dissection Type ADissection Type AKlaus Klaus KallenbachKallenbach, Timm Oelze, Rolf Salcher, Christian , Timm Oelze, Rolf Salcher, Christian HaglHagl, Matthias , Matthias KarckKarck, Rainer , Rainer

G. G. LeyhLeyh and Axel and Axel HaverichHaverich

CirculationCirculation 2004;110;II2004;110;II--243243--IIII--249 249

Patient 145 64 48

Age 6011 5613 5413 0.002

Operating

time (min)

24268 301121 30575 0.001

30 day

mortality

26% 28% 10% 0.05

5 years

survival

895% 856% 804% 0.61

Resuspension / Bentall / SparingFreedom from Reoperation:

Bentall SCR AVS pBentall SCR AVS p

Reoperation 6% 22% - 0.005

Aortic valve 3% 12% - 0.035

log rank= 0.09

Patient recquiring reoparation after valve sparing aortic root

replacement for type A dissection

Patient Opeartion Marfan

syndrom

Aortic valve

insufficiency

Endocarditis Delay

(months)

AVS: Remodeling or Reimplantation ?

High Failure Rate After Valve-sparing Aortic Root Replacement

Using the "Remodeling Technique" in Acute Type A Aortic

Dissection

Rainer G. Leyh et al. Circulation 2002;106;I-229-I-233

syndrom insufficiency (months)

1 Remodeling yes severe No 24

2 Remodeling yes severe No 44

3 Remodeling No severe No 17

4 Remodeling No severe No 26

5 Reimplantation No None Yes 4

Conclusion

Type A aortic dissection is a night emergency

for experienced surgeons

In absence of aortic root enlargement, there is no

justified indication for its replacement or sparing.

In case of a massive aortic regurgitation, SCR

technique seems inappropriate.

For younger patients and marfan syndrome, AVS or

Composite technique seems adequate options.

Repair durability / operative mortality

Thank you !

Aortic tearThrombosis of fals lumen

of the ascending aorta

Coronary

ostia