1. Surgery for Aortic Dissection Adrian E. Manapat, M.D.

2. Mortality of Aortic Dissection Acute aortic dissection Lindsay, Hurst (1967) :33% within 24 hrs 50%within 48 hrs 80% within 7 days 95% within 1 month for Type B25% at 1 month Acute/Chronic/A/B Anagnostopoulos (1972) 70% at 1 week 90% at 3 months

3. Management of acute aortic dissection Type A dissectionSurgical repair (Modes of exit: Cardiac tamponade MI MI Heart failure from AI Heart failure from AI Stroke) Stroke) Type B dissectionMedical > Surgical Risk of cardiac tamponade 2%

5. Stanford Duke Collaborative Study

6. Management of Type B dissection Indications for surgery 1. Life threatening complications of dissection a) Aortic rupture/leak b) Infarction/ischemia of major end organ (kidneys, abdominal viscera, extremities) 2) Progression of dissection during medical treatment Indications for medical management 1) Elderly 2) Coexisting serious medical problem - cardiac, pulmonary, renal, peripheral or cerebrovascular 3) Thrombosed false lumen 4) Primary tear in distal aorta or abdominal aorta Craig Miller, 1992

7. Principles of repair  Complete obliteration of the tear of the ascending aorta  Obliteration of the false lumen  Prevention of rupture of the jeopardized segment  Correction of aortic regurgitation if present

8. What is so difficult about repair of aortic dissection?  Weakened friable aorta does not tolerate clamping - requires “no touch technique”  Need for deep hypothermic circulatory arrest Prolonged complex operation Almost all of them bleed Potential for multiple organ damage Possible catastrophic complications  Emergency nature

9. Deep hypothermic circulatory arrest (DHCA)  Every 10 o decrease in T causes a 50% decrease in metabolic rate - protects the organs from the effects of circulatory arrest  Safe period CA is usually 45 minutes  Disadvantages:prolonged surgery bleeding potential for end organ damage

10. Cerebral protection during circulatory arrest Cerebral perfusion  Antegrade perfusion via carotid arteries  Retrograde perfusion via superior vena cava Adjunctive measures:  Head packed in ice  Mannitol, steroids  Sodium pentothal  Trendelenberg position

11. Surgical options  Supracoronary AA replacement  Bentall procedure (composite ascending aorta & aortic valve replacement w/ re-implantation of coronary ostia)  Supracoronary AA replacemnt w/ aortic valve repair or replacement  Any of the above combined with CABG

12. Ascending aortic dissection

13. False and true lumen

14. Dealing with the aortic valve Resuspension of the commissures to repair the aortic valve Insertion of a valved conduit

15. Proximal graft anastomosis completed

16. Aortic graft in place

17. Ascending aortic replacement with CABG

18. Results of Surgical repair Operative (30-day) mortality 1960’s30-60% 1990’s to the present 5-30% Cleveland Clinic experience (208) predictors of mortality: Earlier operative year Hypotension Non-use of DHCA Composite valve graft CABG Late survival (Crawford, 1990) 1 year78%Acute type A 5 yrs 56% 5 years63% 10 yrs 46% 10 years 55% 20 yrs 30%

19. Long term follow up  Lifelong antihypertensive, B blocker  Anticoagulation for prosthetic valve  Surveillance : new dissections aneurysm formation prosthetic valve function