Παρακολουθηση ασθενων μετα απο επεμβασεισ θωρακικησ αορτησ ΤΣΙΠΑΣ ΠΑΝΤΕΛΗΣ MD, MSc, FETCS ΧΕΙΡΟΥΡΓΟΣ ΚΑΡΔΙΑΣ - ΘΩΡΑΚΟΣ ΕΠΙΜΕΛΗΤΗΣ ΔΙΑΚΛΑΔΙΚΗΣ ΚΑΡΔΙΟΧΕΙΡΟΥΡΓΙΚΗΣ ΚΛΙΝΙΚΗΣ ΕΔ 401 ΓΣΝΑ

AORTIC DISEASES Aortic aneurysms Acute aortic syndromes (AAS) Aortic dissection (AD) Intramural haematoma (IMH) Penetrating atherosclerotic ulcer (PAU) Traumatic aortic injury (TAI) Pseudoaneurysm Aortic rupture Atherosclerotic + Inflammatory affections Genetic diseases (e.g. Marfan syndrome) Congenital abnormalities -coarctation of the aorta (CoA).

Endovascular Era

REGISTRIES 1. International registry of Aortic Dissection (IRAD) 2. German Registry for Acute Aortic Dissection Type A (GERAADA)

Complex thoracic aortic pathologies (Aneurysms/Dissections) Ascending thoracic aorta + Aortic arch Descending thoracic aorta

Complexity of surgical management Surgical approach Myocardial protection Management of the aortic valve Brain protection Respiratory compromise Risk of spinal cord injury Risk of organ failure (liver, kidneys)

Surgical/Endovascular Strategies Surgical management in two stages open (Conventional “elephant trunk” technique) or two stages open/endovascular technique Surgical management in one stage: 1. Sternotomy + Left thoracotomy 2. Transmediastinal replacement 3. Clamshell technique 4. The frozen “elephant trunk” technique Endovascular-based approaches: 1. Debranching procedures + EVS placement 2. Total EV repair with side-branch deployment

Follow up 1. The first follow-up examination usually takes place before discharging the patient. 2. Renewed imaging is recommended after 6 months and following that, annually. 3. Under stable conditions and close consultation with the responsible physician, the intervals between the follow-up appointments can be lengthened.

Follow-up Depending on the type of intervention, localisation and type of aortic disease, different follow up appointments are required.The first year of post-operative care serves to monitor the outcome of the operation and to allow for the review of complications that can arise from the surgery. Thereafter the follow-up serves to identify new aortic changes. After surgery of the aortic root and ascending aorta If surgery is limited to the aortic root + ascending aorta, annual echocardiography examinations of the heart will suffice. The first heart ultrasound takes place during hospital stay. After heart valve surgery or a replacement of the ascending aorta, the patient should be referred to an out-patient cardiologist. After surgery of the aortic arch and thoracoabdominal aorta A CT angiography is the test of choice for the aortic arch and thoracoabdominal aorta. If there is a contra-indication for a computed tomography (CT) or the administration of a contrast agent (dye), magnetic resonance imaging (MRI) can be used to carry out the follow-up examination. To reduce radiation exposure in young patients, an MRI examination is recommended as long as an exact anatomical assessment is not necessary.

When all affected parts are not replaced or the aortic disease is chronic If not all affected sections of the aorta are replaced or there is a chronic aortic disease, post-operative care is not only needed to monitor the operation results but to identify new aortic changes. Through continuous imaging and clinical examinations progression of the disease can be detected. In this way, the need for another operation can be discovered early. Complications can be avoided. CT angiography is the most common examination technique to assess the aorta during follow-up. MRI examination can be used under certain conditions. As well as aortic imaging, routine doctor visits should take place. In addition to the surgery, optimising cardiovascular risk factors and monitoring medication regime are essential.

Lifestyle After completing a rehabilitation plan, the patient should be able to return to daily life or work as usual. Because the healing process is different for every person, it is difficult to make binding statements. In addition, some professions and hobbies should be stopped if patients have to take blood thinners (e.g. warfarin). The breastbone should heal after about three months and patient can again take up exercise. Take care to exert yourself steadily. Endurance exercise (walking, bicycle riding, jogging, swimming) and moderate strength training are suitable.

Driving The patient should refrain from driving an automobile for the first six weeks because glancing over the shoulder and turning the steering wheel put pressure on the chest that can cause pain. As a passenger, the patient should take time getting in and out of an automobile to protect his/her chest. Using a seatbelt is still mandatory after an operation.

Medication Next to surgery, medication plays an important role. Risk factors like too high blood sugar or high blood pressure must face targeted treatment. After an aortic intervention, patients should take a platelet aggregation inhibitor, like ASS 100 (once daily) for the rest of his/ her life. An exception is when warfarin is necessary for blood thinning.

Travel and wellness Long trips can be taken three months after surgery at the earliest. Bring an adequate supply of medicine as well as a copy of the medical report. Also, use caution when carrying heavy luggage. Flying after being discharged from the hospital is possible. Stays at altitudes up to 2,000 meters are also safe. Sauna visits should first be enjoyed no earlier than three months after the operation.

Gen Thorac Cardiovasc Surg. 2017 Sep 13. doi: 10 Gen Thorac Cardiovasc Surg. 2017 Sep 13. doi: 10.1007/s11748-017-0830-9. Measuring what matters to the patient: health related quality of life after aortic valve and thoracic aortic surgery. de Heer F, Gökalp AL, Kluin J, Takkenberg JJM. Abstract With improved outcomes following cardiac surgery, health related quality of life (HRQoL) gains increasing importance for the better judgement of choosing the preferred treatment strategy in the individual patient. The physician perception of patient preferences can differ considerably from actual patient preferences, underlining the importance of gathering evidence of actual patient preferences before and quality of life after cardiac surgery. The objective of the current review is to provide an overview of current insights into the quality of life measurements after aortic valve and thoracic aortic surgery and to provide starting points for the application of HRQoL measurements toward the future. The amount and level of evidence on HRQoL outcomes after aortic valve and thoracic aortic surgery seems to be insufficient. Little has been investigated about the natural course of HRQoL after cardiac surgery, HRQoL outcomes between different surgical strategies, HRQoL outcomes between surgical patients and the general population, the different factors influencing HRQoL after cardiac surgery, and the effect of HRQoL on healthcare costs. More prospective studies should be performed, taking into account the knowledge gaps that need to be filled. Computerized adaptive testing methods through open source programs can be implemented to keep the burden to the patient as low as possible and catalyze the use of these tools. Our cardiovascular surgery community has the responsibility to deliberate how it can proceed to effectively fill in these knowledge gaps, and use this newfound knowledge to improve shared treatment decision making, patient outcomes, and ultimately optimize health care efficiency.

Conclusions Aortic diseases contribute to the wide spectrum of arterial diseases. Complex open/endovascular/hybrid procedures are often performed. Closed + individualized follow up is recommended. With improved outcomes following cardiac surgery, health related quality of life (HRQoL) gains increasing importance for the better judgement of choosing the preferred treatment strategy in the individual patient.

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