1. Multidisciplinary Thoracic Aortic Rounds Foothills Medical Centre
2016 CCS/CSCS/CSVS Joint Position Statement on Open and Endovascular Thoracic Aortic Surgery
Jehangir Appoo
Multidisciplinary Thoracic Aortic Rounds
Foothills Medical Centre
January 29th, 2016

2. Multidisciplinary Thoracic Aortic Rounds
History
Feedback
Content
Format

3. Why 18mins ?
long enough to be serious and short enough to hold people’s attention

4. Why 18mins ?
long enough to be serious and short enough to hold people’s attention
Speakers have to think about what they want to say. What is the key point they want to communicate?
a clarifying effect
brings discipline

5. Why 18mins ?
long enough to be serious and short enough to hold people’s attention
Speakers have to really think about what they want to say. What is the key point they want to communicate?
a clarifying effect
brings discipline
“Cognitive Backlog”
act of listening can be as equally draining as thinking hard about a subject
“the more information we are asked to take in, the heavier and heavier it gets. Eventually, we drop it all, failing to remember anything we've been told.”

6. CCS/CSCS/CSVS Joint Position Statement on Interventions for Thoracic Aortic Disease
CCC Oct.2015 – Toronto
Canadian Journal of Cardiology, In Press

7. 2014
Topics: Size thresholds, Genetics, Medical Therapy, Diagnostic Imaging
Surgery and Endovascular Interventions not covered

8. Process Proposal for Position Statement accepted
Nationally Representative Primary Panel
Cardiac & Vascular Surgery
Focus on novel and emerging technical aspects of thoracic aortic disease interventions
Structured and focused literature review
Not “expert” consensus opinion
Primary literature
Existing systematic reviews when present
Creation of summary tables

9. Process GRADE criteria Quality of Evidence: Low, medium, or high
Cohort studies, RCTs…
Recommendations: graded as strong or weak
Quality of evidence
Balance btw desired and undesired effects
Values and Preferences

10. Process Voting by Primary Panel
Review by International Secondary Panel
Review by CCS Guidelines Committee
Review by CCS, CSCS, and CSVS Executive
*avoided use of “centres of expertise” term in Recommendation

11. Primary Panel Jehangir Appoo (Co-chair) University of Calgary
John Bozinovski University of British Columbia
Michael Chu Western University
Ismail El-Hamamsy University of Montreal
Tom L. Forbes University of Toronto
Michael Moon University of Alberta
Maral Ouzounian University of Toronto
Mark Peterson University of Toronto
Jacques Tittley McMaster University
Munir Boodhwani (Co-chair) University of Ottawa

12. Secondary Panel
Joseph E. Bavaria University of Pennsylvania Francois Dagenais Laval University Mark Farber University of North Carolina Chad Hughes Duke University Thoralf Sundt Harvard University

13. Sections Aortic valve preservation and repair
Aortic valve replacement in the young
Perfusion techniques for aortic arch surgery
Total and Hybrid Arch repair
Extended repair for type A dissection
Total endovascular arch repair
Descending thoracic aortic aneurysms
Acute type B dissections
Chronic type B dissections
Document contains total of 20 Recommendations

14. Highlights Today Aortic valve preservation and repair
Aortic valve replacement in the young
Perfusion techniques for aortic arch surgery
Contemporary total and hybrid arch repair
Extended repair for type A dissection
Total endovascular arch repair
Descending thoracic aortic aneurysms
Acute type B dissections
Chronic type B dissections
8 recommendations
Share some data behind recommendations

15. Aortic Valve Preservation

16. Functioning Aortic Valves in Root Aneurysms

17. 17

18. Free Margin Plication

19. Reimplanation and BAV repair

21. Total Follow-up Time: 11,274 pt-years
Meta-Analysis
Takkenberg Ann Thorac Surg 2015
N = 2,891 Patients
Total Follow-up Time: 11,274 pt-years

22. Early Mortality
Pooled Estimate: 1.53% (0.90 – 2.3)

23. Endocardits
Pooled Estimate: 0.23%/pt-yr (0.08 – 0.44)

24. Thrombo-embolism
Pooled Estimate: 0.33%/pt-yr (0.2 – 0.4)

25. Late AV Reoperation
Pooled Estimate: 1.2%/pt-yr (0.6 – 2.0)

26. PROACT Trial – Mechanical Valve
Outcome
Low INR
Regular INR
P-value
Neurologic Events
2.07%/pt-yr
1.46 %/pt-yr
0.38
All TE
2.67%/pt-yr
1.59 %/pt-yr
0.16
TE + Thrombosis
2.96%/pt-yr
1.85 %/pt-yr
0.17
Total Mortality
1.48%/pt-yr
1.46%/pt-yr
0.97
Total Bleeding
6.62%/pt-yr
<0.001

27. A Word of Caution
Prospective, multi-center, international registry –ao root replacement in Marfans
Ao Valve Sparing vs. Replacement
316 pts – 76% AVS
Early Mortality 0.6%
Early (1-year) AI recurrence 7%
JTCVS 2014

28. #1 We recommend aortic root and ascending aortic aneurysms in patients with normally functioning or mildly regurgitant trileaflet aortic valves be treated with valve sparing operations whenever feasible
Strong recommendation Medium quality evidence
Values and Preferences: A composite valve and root replacement may be preferred in emergency settings, in elderly patients, those with multiple co-morbidities, poor left ventricular function, or with poor quality cusp tissue. A reimplantation approach to valve sparing root replacement may be preferred in those with connective tissue diseases and bicuspid aortic valves.

29. Recommendation
#2 We suggest aortic root and ascending aortic aneurysms in patients with moderate or greater insufficiency with or without bicuspid aortic valves be considered for valve sparing root replacement with or without cusp repair.
Weak recommendation Medium quality evidence
Values and Preferences: A number of important considerations should guide this decision including surgeon experience, patient age and preference, quality of cusp tissue, and the ability to perform these procedures with similar mortality and morbidity as composite valve and root replacement procedures.

30. Considerations for Aortic Valve Replacement inYoung Patients with Aortic Dilatation

31. Considerations for Aortic Valve Replacement in Young Patients with Aortic Dilatation
Aortic valve replacement is required if a successful and durable valve-sparing/repair operation can not be performed
The ideal valve substitute remains elusive
There is a paucity of data especially in patients with associated aortic dilatation

32. Considerations for Aortic Valve Replacement in Young Patients with Aortic Dilatation
Growing body of literature focusing on this specific patient subset in the last 5-10 years
Options
Mechanical
Tissue
Ross
Homograft

33. Operative mortality (%) 5-Year Survival (%) 10-Year Survival (%)
Study
Study Type
Study Period N
Mean Follow-up
(years)
Mean Age
BAV (%)
AS (%) /
AI (%)
Mixed AS-AI (%)
Operative mortality (%)
5-Year Survival (%)
10-Year Survival (%)
15-Year Survival (%)
5-Year Freedom from reoperation (%)
10-Year Freedom from reoperation (%)
15-Year Freedom from reoperation (%)
El-Hamamsy et al. (2010)2
RCT
216 pts (108 Ross)
10.2 (2173 pt-yrs) 38
49%
28% 45% 27%
0.9%
97%
95%**
96%
95%
94%
Sievers et al. (2015)3
Multicenter Ross Registry (prospective)
1779
8.3 (14,288 pt-yrs)
44.7
64.8%
24%
22% 52%
1.1% NA
90%**
94.9%
91.1%
82.7%
David et al. (2014)4
Single center
212
13.8* 34
71.7%
50% 36% 13%
0.4%
98.6%
97.5%
93.6%**
AG 98%
HG 100%
AG 97%
HG 98%
AG 93%
HG 96%
Mastrobuoni et al. (2015)5
306
10.6* 42
58.5%
68% 31% 0%
2.3%
88%**
75%
(AS 83%)
(AI 65%)
Skillington et al. (2013)6
310
9.4
39.3
92%
46% 32% 22%
0.3%
98%
97%**
93%
Da Costa et al. (2014)7
414
8.2
30.8
50%
29% 39% 31%
2.7%
89.3%**
81%
Kalfa et al. (2015)8
221
11.4*
41.5
76.5%
19%
90.5%
88%
Andreas et al. (2014)9
246
10* 29
29% 40% 31%
1.6%
91%**

34. (Strong recommendation, Medium Quality Evidence)
Considerations for Aortic Valve Replacement in Young Patients with Aortic Dilatation
#3 We recommend that the Ross procedure be considered as an alternative for prosthetic valve replacement in young adults with bicuspid or tricuspid aortic valve stenosis and aortic dilatation.
(Strong recommendation, Medium Quality Evidence)
Values and Preferences: The Ross procedure is most appropriate in patients with high levels of physical activity, those contemplating pregnancy and patients with small aortic annuli at risk of patient-prosthesis mismatch. Patients with aortic regurgitation and a dilated annulus may be at higher risk of a late operation. This recommendation elicited varied opinions from the expert panel, but was ultimately approved by the majority of panel members following extensive review of the available literature.

35. Extended Repair Type A Dissection
Goals of Surgery
Acute Valvular Insufficiency
Ascending aortic rupture
Coronary Ischemia
But Dissection is a diffuse process involving other organ systems

36. Case Example: 46y.o male flown in from OSH
Hemodynamic shock
Abdomen tender
Intima intussuscepted through arch

37. Case Example: 46y.o male flown in from OSH
Compromised visceral flow
Renal infarct/malperfusion

38. Case Example: 46y.o male flown in from OSH
Both legs:
Cold
Mottled
Pulseless
Paralyzed

39. 46y.o male
Will visceral, renal, & peripheral malperfusion be resolve?

40. Extending the Distal Repair
THE PROBLEM
How much distal aorta should, or must, be repaired in an acute type A aortic dissection
Surgical principles
Resect dissected aorta
Resect primary intimal tear
Re-establish flow downstream, preferably in true lumen
Obliterate the false lumen
Basic techniques
Open distal anastomosis
Period of circulatory arrest
Hypothermia
cerebral perfusion during distal aortic repair
What we are less certain of is….

41. Standard hemiarch
What most people would consider current standard of care. Extended repair involves moving the distal repair beyond the IA or LCCA in the case of parital arch, or the LSCA in total arch.

42. Extended Arch

43. Extending the Distal Repair
Is it necessary?
Potential risks
Longer and more technically challenging operation
Potential benefits
Seal distal tears
Better likelihood of obliterating false lumen
Prevention of complications
Malperfusion
Aortic dilation
Re-intervention
Death

44. Extending the Distal Repair
What does the literature tell us?
Randomized controlled trials?
No RCT comparing extent of distal repair in acute type A dissection exist
Unlikely for one to be forthcoming
To establish whether it is necessary to extend the repair, ideally, we would look at RCTs comparing current standard hemiarch to extended repairs.

45. The Primary Intimal Tear
DOES A STANDARD HEMIARCH ADDRESS ALL PRIMARY INTIMAL TEARS
Not all
“Only 60 % of patients with acute type A dissections arose from solitary primary intimal tears in the ascending aorta”
Lansman et al. Ann Thorac Surg 1999; 67:
Those not in the ascending aorta are not addressed by hemiarch procedures

46. Extending the Distal Repair
RESECTION OF THE PRIMARY INTIMAL TEAR
Does it decrease the need for reoperation?
Failure to resect the intimal tear was independent determinant for late re-operation in these studies
Moon et al. Ann Thorac Surg 2001; 71:
In 95 survivors of ATAD repair
Kazui et al. Ann Thorac Surg 2002; 74: S
In 113 survivors of ATAD repair
Zeirer et al. Ann Thorac Surg 2007; 84:
Odds ratio 4.0 (168 survivors of ATAD repair)
So what if you don’t get the primary intimal tear?

47. Extending the Distal Repair
PATENCY OF THE FALSE LUMEN
Does it increase risk of death
YES
Halstead et al. J Thorac Cardiovasc Surg 2007; 133:
179 patients with type A dissections (DeBakey I)
Patency of the false lumen was a predictor of death after discharge
Sagaguchi et al. ICVTS 2007; 6:
52 patients
So what if you leave he false lumen patent? Is survival any worse?
survival
months

48. Extending the Distal Repair
PATENCY OF THE FALSE LUMEN
Does it increase risk of death NO
Kimura et al. J Thorac Cardiovasc Surg 2008; 136:
193 patients with type A (DeBakey I) dissections
124 patent false lumen; 69 thrombosed

49. Extending the Distal Repair
PATENCY OF THE FALSE LUMEN
Does it increase risk of reoperation
YES
Sagaguchi et al. ICVTS 2007; 6: NO
Kimura et al. J Thorac Cardiovasc Surg
2008; 136:
Similarly with the risk of reoperation evidence is equivocal

50. Extending the Distal Repair Malperfusion
Patients with malperfusion have an increased mortality
Mortality increases depending on number of organ systems involved
None %
One %
Two %
Three % .
We know that preoperative malperfusion is a risk for death.
GERAADA REGISTRY, JACC 2015; 65(24)

51. Review of Publications for Extended Distal Repair for Acute Type A Dissection
Author (Reference)
Year
Type of repair N
30-day / in- hospital mortality (%)
Permanent Stroke (%)
Permane nt SCI (%)
Yun et al.10
1991
Total Arch 7 29
N/A
Kazui et al.11
2000 70 16
2.9
1.4
Takahara et al.12
2002 37
8.1
Ohtsubo et al.13 24
33.3
12.5
Watanuki et al.14
2007 54
3.7
5.6
Kim et al.15
2011 44
13.4
15.9
2.3
Mizuno et al.16
FET & Total arch 9
11.1
22.2
Tsagakis et al.17
2010 68 13 10 1
Ma et al.18
2013
FET & Total Arch
398
7.8
2.5
Katayama et al.19
2015
120 6 3 2
Roselli et al.20
FET & Hemiarch 17
Pan et al.21 27
Chen et al.22
2014
FET & Hemi Arch
122
4.93
Preventza et al.23 25 12
Vallabhajosyul a et al.24 62 14 8
Diethrich et al.25
2005
Arch Debranching
Marullo et al.26 15
4.2
Kent et al.27
2012
Chang et al.28 21
4.8

52. Summary – Extended Distal Repair
Organ malperfusion portends to poorer outcomes
The primary intimal tear is not amenable to resection in many acute type A dissections
Resection of the primary intimal tear is likely to decrease reoperation rates
Obliteration of the false lumen may increase survival & decrease risk of reoperation
Extended surgery can be done with similar morbidity and mortality risk

53. RECOMMENDATIONS
#4 We recommend an extended distal arch repair technique be considered for patients who present with acute Type A dissection and one of the following
Primary intimal entry tear in the arch or descending aorta
Significant aneurysmal disease of the arch
(Strong recommendation, Low Quality Evidence)

54. RECOMMENDATIONS
#5 We suggest that it is reasonable to consider an extended distal arch repair technique for patients who present with acute Type A dissection and one of the following:
Distal malperfusion
Concomitant descending thoracic aortic aneurysm
Young patients
Patients with connective tissue disorders
(Weak recommendation, Low Quality Evidence)

56. Since 2008, known that in complicated acute Type B Dissection, Endovascular Rx is first line of therapy.
Management of Acute Uncomplicated Type B is not as clear

57. Admission acute Type B 6 months 2 years post Type B
“Uncomplicated” Type B - ? misnomer
Admission mortality < 10%
5 year mortality substantially higher in some publications
51 y.o male
Admission acute Type B
6 months
2 years post Type B

58. Uncomplicated Type B
Medical Management Alone vs. TEVAR & Medical management
Instead XL
Circ Cardiovasc Int 2013
RCT -140 pts OMT vs. OMT + TEVAR
Improved aortic remodelling & aorta specific survival in TEVAR group at 5 years
ADSORB
European J Vasc Endovasc Surg 2014
RCT 61 pts OMT vs. OMT + TEVAR
Improved aortic remodeling at 1 year
IRAD
Ann Cardiothorac Surg
2014
Retrospective review of registry patients
Improved aorta related survival at 5years

59. Predictors of Growth:
Initial aortic diameter > 4cm
False Lumen > 22mm
Large proximal entry tear >1.0cm

60. #7 We recommend that patients with uncomplicated acute type B aortic dissections be managed with hypertension and pain control and radiologic surveillance.
(Strong Recommendation, Medium quality evidence)
Values and Preferences: If patients remains “uncomplicated” early follow up imaging at hrs and 1-4 weeks is recommended to detect early signs of aneurysm expansion and radiologic malperfusion.

61. #8 We suggest that endovascular repair be considered for patients with uncomplicated type B aortic dissections to improve aorta-specific endpoints (Weak recommendation, Low quality evidence) Values and Preferences: The Instead XL trial which randomized patients in the delayed phase (2-52 weeks) showed decreased aorta specific 5-year mortality and improved aortic remodelling. The ADSORB trial which randomized patients in the acute phase (< 2 weeks) showed improvement in aortic remodelling at one year.

62. Summary:
Evolution in open and endovascular aortic surgery
Improved patient outcomes
Rapid change – thus, little high quality evidence to make strong recommendations
New Recommendations:
Valve Repair….with caution in regurgitant valves…
Extended arch at time of Type A….distal tears, aneurysm – strong recommendation
Asymptomatic Type B Dissections….consider early TEVAR – weak recommendation

63. Highlights Today Aortic valve preservation and repair
Aortic valve replacement in the young
Perfusion techniques for aortic arch surgery
Total and hybrid arch repair
Extended repair for type A dissection
Total endovascular arch repair
Descending thoracic aortic aneurysms
Acute type B dissections
Chronic type B dissections