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 root
Two-Dimensional Echocardiographic Aortic Root Dimensions in Normal
Children and Adults
Roman MJ. Am J Roman MJ. Am J Cardiol Cardiol 1989;64:507 1989;64:507--512 512
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 aortic
root
NO
YES
NO
Bentall (composite)
or David (AVS)
YES
Pathologic aortic
valve
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 aortic
root
Pathologic
aortic valve
Normal aortic
valve aortic valve
Bentall procedure
(comp)
valve
David or Yacoub
procedure (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
Bentall Bentall Thorax. 1968; 23:338-9
composite replacement composite replacement
Dilated aortic root +
Normal aortic valve
Valsalva sinuses resection:
Aortic root : Yacoub procedure
Yacoub Yacoub MM. . Circulation Circulation 1983 1983
Aortic valve sparing:
Remodeling
Non coronary sinus
resection
Coronary
reimplantation
Supracoronary aortic
replacement
Dilated aortic root +
Normal aortic valve:
Graft insertion below the aortic annulus
Running suture of the commisures in the graft
Coronary reimplantation
Tirone Tirone David ( David (David I JTCS 1992;103:617-22)
AVS: Reimplantation
Reimplantation: David procedure
Supracommissural resuspension:
Aortic root dilatation
Preop Early postop Followup
(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 Cardio European Journal of Cardio--thoracic Surgery 27 (2005) 86 thoracic Surgery 27 (2005) 8689 89
Both the increase of aortic root diameter and the progressive
worsening of aortic valve insufciency 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 , Rmi Rmi Houl Houl, , Marie Line Marie Line Hillion Hillion, , Daniel Daniel Loisance Loisance..
J Thorac Cardiovasc Surg 2002;123:318 J Thorac Cardiovasc Surg 2002;123:318- -25 25
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 A Dissection Type A
Klaus Klaus Kallenbach Kallenbach, Timm Oelze, Rolf Salcher, Christian , Timm Oelze, Rolf Salcher, Christian Hagl Hagl, Matthias , Matthias Karck Karck, Rainer , Rainer
G. G. Leyh Leyh and Axel and Axel Haverich Haverich
Circulation Circulation 2004;110;II 2004;110;II- -243 243- -II II- -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 / Sparing
Freedom from Reoperation:
Bentall SCR AVS p Bentall 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 tear
Thrombosis of fals lumen
of the ascending aorta
Coronary
ostia