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Preoperative evaluation for aortic surgery            . Inter-hospital Conference 2 (2/2554) Aortic surgery: Update & Decision making วันเสาร์ที่  17  กันยายน 2554 ห้องประชุมสมาคมศิษย์เก่าแพทย์ศิริราช โรงพยาบาลศิริราช. นพ.วันชัย   วงศ์กรรัตน์. Acute aortic syndrome.

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preoperative evaluation for aortic surgery

Preoperative evaluation for aortic surgery           

Inter-hospital Conference 2(2/2554)

Aortic surgery:

Update & Decision making

วันเสาร์ที่  17  กันยายน 2554ห้องประชุมสมาคมศิษย์เก่าแพทย์ศิริราช โรงพยาบาลศิริราช

นพ.วันชัย   วงศ์กรรัตน์

acute aortic syndrome
Acute aortic syndrome
  • Aortic dissection
  • Intramural Hematoma
  • Penetrating Atherosclerotic Ulcer
  • Pseudoaneurysms of the Thoracic Aorta
  • Traumatic Rupture of the Thoracic Aorta
acute surgical management pathway
Acute surgical management pathway

Ascending Aortic dissection by imaging

Step 1

Determine

suitable for

surgery

no

Is pt a suitable candidate for Sx?

Medical Tx

yes

no

Step 2

Determine

stability for

preop testing

Is pt stable enough to allow pre-op testing?

yes

yes

no

Assess need

for preop CAG

Age > 40 yr

no

Step 3

Determine

likelihood of

coexistent CAD

Known CAD?

Significant risk factors for CAD?

yes

no

Significant CAD by angiography?

yes

Plan for CABG if appropriate at time of AoD repair

slide5

Urgent operative management

Step 4

Intraoperative

evaluation of

aortic valve

Intra operative assessment

of aortic valve by TEE

Aortic regurgitation?

or

Dissection of aortic sinuses?

no

yes

Step 5

Surgical

intervention

Graft replacement

of ascending aorta

+/- aortic arch

and

repair/ replacement

of aortic valve or

aortic root

Graft replacement

of ascending aorta

+/- aortic arch

acute aortic syndrome7
Acute aortic syndrome
  • Perfusion Deficits and End-Organ Ischemia
  • Acute aortic regurgitation
  • Myocardial Ischemia or Infarction
  • Heart Failure and Shock
  • Pericardial Effusion and Tamponade
  • Syncope
  • Neurologic Complications
  • Pulmonary Complications
  • Gastrointestinal Complications
acute aortic syndrome9
Acute aortic syndrome
  • BP and HR
  • 71% type B, 36% type A  hypertension
  • 20%  hypotension ( cardiac tamponade, aortic hemorrhage, severe AR, MI)
  • Measure BP in both arms and legs
evaluation and management of acute thoracic aortic disease
Evaluation and Management of AcuteThoracic Aortic Disease
  • Recommendations for Estimation of Pretest Risk ofThoracic Aortic Dissection

Class I

  • specific questions about medical history, family history, and pain features as well as a focused examination to identify findings that are associated with aortic dissection,
slide11
High risk conditions and historical features
  • Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos

syndrome, Turner syndrome, or other connective tissue disease.

  • Patients with mutations in genes known to predispose to thoracic

aortic aneurysms and dissection, such as FBN1, TGFBR1, TGFBR2,

ACTA2, and MYH11.

  • Family history of aortic dissection or thoracic aortic aneurysm.
  • Known aortic valve disease.
  • Recent aortic manipulation (surgical or catheter-based).
  • Known thoracic aortic aneurysm.
  • High risk chest, back , abdomianl pain features
  • Pain that is abrupt or instantaneous in onset.
  • Pain that is severe in intensity.
  • Pain that has a ripping, tearing, stabbing, or sharp quality.
  • High risk examination features
  • Pulse deficit.
  • SBP limb differential > 20 mm Hg.
  • Focal neurologic deficit.
  • Murmur of AR (new).
evaluation and management of acute thoracic aortic disease12
Evaluation and Management of AcuteThoracic Aortic Disease

Laboratory testing

  • D-dimer- venous thromboembolism, sepsis, DIC, malignancies, recent trauma or surgery, and acute MI
  • Pre-surgical screening
  • CBC, serum chemistry, coagulation profiles, blood type and screen
evaluation and management of acute thoracic aortic disease13
Evaluation and Management of AcuteThoracic Aortic Disease

Recommendations for Screening Tests

Class I

  • ECG – all patients
  • CXR( intermediate and low risk)
  • Urgent and definitive imaging of the aorta using TEE, CT, MRI is recommended to identify or exclude thoracic aortic dissection in pts at high risk for the disease by initial screening.

Class III

  • A negative chest x-ray should not delay definitive aortic imaging in patients determined to be high risk for aortic dissection by initial screening.
evaluation and management of acute thoracic aortic disease14
Evaluation and Management of AcuteThoracic Aortic Disease

Recommendations for Diagnostic Imaging study

Class I

  • Selection of a specific imaging modality to identify or exclude aortic dissection should be based on patient variables and institutional capabilities, including immediate availability
  • If a high clinical suspicion exists for acute aortic dissection but initial aortic imaging is negative, a second imaging study should be obtained.
evaluation and management of acute thoracic aortic disease15
Evaluation and Management of AcuteThoracic Aortic Disease

Recommendations for initial management

Class I

  • Control HR and BP

a. iv beta blockade  titrated target HR of ≤ 60 bpm or less.

b. In pts with r contraindications to beta blockade,

nondihydropyridine calcium channel blocking agents should be

used as an alternative for

rate control.

c. If SBP ≥ 120 mm Hg after adequate HR control has been obtained, then ACEI and/or other vasodilators should be administered intravenously to further reduce BP that maintains adequate end-organ perfusion.

d. Beta blockers should be used cautiously in the setting of acute AR because they will block the compensatory tachycardia.

Class III

  • Vasodilator therapy should not be initiated prior to rate control so as to avoid associated reflex tachycardia that may increase aortic wall stress, leading to propagation or expansion of a AoD
evaluation and management of acute thoracic aortic disease16
Evaluation and Management of AcuteThoracic Aortic Disease

Recommendations for definite management

Class I

  • Urgent sx consultation should be obtained for all patients diagnosed with thoracic AoD regardless of the anatomic location (ascending versus descending) as soon as the diagnosis is made or highly suspected.
  • Acute thoracic AoD the ascending aorta should be urgently evaluated for emergent surgical repair because of the high risk of associated life-threatening complications such as rupture
  • Acute thoracic AoD involving the descending aorta should be managed medically unless life-threatening complications develop (eg, malperfusion syndrome, progression of dissection, enlarging aneurysm, inability to control blood pressure or symptoms)
aod evaluation pathway
AoD evaluation pathway

Step 1

Identify patient at

Risk For

acute AoD

  • Consider Acute AoD in all pt presenting with
        • Chest, back, abdominal pain
        • Syncope
        • Symptom consistent with perfusion deficit

+

  • High risk
  • conditions
  • Marfan syndrome
  • CNT disease
  • Fm hx of AoD.
  • Known AV disease.
  • Recent aortic
  • manipulation
  • Known thoracic
  • aortic aneurysm
  • High risk pain
  • features
  • chest, back , abdomianl
  • abrupt in onset.
  • severe in intensity
  • ripping, tearing
  • stabbing
  • sharp quality
  • High risk exam
  • features
  • Pulse deficit.
  • SBP limb
  • diferential > 20 mm Hg.
  • Focal neurologic deficit.
  • Murmur of AR (new)

Step 2

Bedside risk

assessment

+

+

Determine pre-test risk by combination of risk condition, history, exam

slide18

Step 3

Risk based

diagnostic

evaluation

yes

Low risk

No high risk features

intermediate risk

Any single high

risk features

High risk

≥2 high risk features

Proceed with diagnostic

Evaluation as

clinically indicated

by presentation

Immediate Sx consult

and imaging

yes

ECG: STEMI

Primary ACS :

reperfusion Tx

no

yes

Alternative diagnosis

identified

yes

no

CXR : clear

alternate Dx

Initiate appropriate tx

yes

no

no

yes

yes

Initiate

appropiate Tx

Alternate Dx

confirm

by other

further testing

Clinical suggest

alternate Dx

no

no

Unexplained

hypotension or

widened mediastinum

yes

Expedited Ao imaging

no

Expedited Ao imaging

TEE, MRI, CT

Consider Ao

imaging

slide19

Step 4

Acute AoD

Identified of

excluded

If high clinical suspicious

AoD exists,

consider secondary

imaging study

Aortic dissection

present

no

yes

Proceed to

treatment pathway

slide20

Initial management

  • Once the diagnosis of AoD or one of its anatomic variants (IMH or PAU) is obtained, initial management is directed at limiting propagation of the false lumen by controlling aortic shear stress while simultaneously determining which patients will benefit from surgical or endovascular repair
initial management
Initial management
  • Blood Pressure and Rate Cont

targets HR <60 bpm

SBP 100-120 mmHg

  • Pain control
  • Hypotension : volume replacement, immediate operation
  • For patients with hemopericardium and cardiac tamponade who cannot survive until surgery, pericardiocentesis can be performed by withdrawing just enough fluid to restore perfusion
  • Determine definite tx
acute aod management pathway
Acute AoD management pathway.

Step 1

Immediate

post diagnosis

management

  • Arrange for definite Tx
  • Appropriate Sx consultation
slide23

Step 2

Innitial

management

aortic wall

stress

obtain accurate BP prior to beginning Tx

Measure in both arms

No

Yes

hypotension/shock stage

Intravenous rate

and pressure

control

Anatomic based management

iv beta blocker /

calcium channel

blocker

(HR < 60 bpm)

Type A dissection

Type B dissection

  • Urgent Sx consult
  • Intravenous fluid
  • bolus titrate to
  • MAP 70 mmHg
  • Or
  • Euvolemia
  • Review imaging
  • tamponade
  • contained rupture
  • severe AR
  • Intravenous fluid
  • bolus titrate to
  • MAP 70 mmHg
  • Or
  • Euvolemia
  • Evaluate etiology
  • Of hypotension
  • contained rupture
  • cardiac function
  • Urgent Sx consult

Pain control

iv opiate

SBP > 120 mmHg

No

Secondary pressure

Control

Intravenous vasodilator

(SBP < 120 mmHg)

Etioligy of hypotension

amenable to

operative management

Yes

No

slide24

Step 3

Definite

management

Yes

dissection involving

the ascending aorta

No

ongoing medical Tx

Operative or

Intervational management

ongoing medical Tx

Close hemodynamic

monitor

Maintain

SBP < 120 mmHg

Close hemodynamic

monitor

Maintain

SBP < 120 mmHg

Complication requiring

Operative or Intervational

management

Complication requiring

Operative or Intervational

management

Yes

Yes

Malperfusion syndrome

Progression of dissection

Aneurysm expansion

Uncontrolled hypertension

Malperfusion syndrome

Progression of dissection

Aneurysm expansion

Uncontrolled hypertension

Step 4

No

No

Transition to oral medicine out patient disease surveillance imagine

recommendation for medical treatment of patients with thoracic aortic diseases
Recommendation for Medical Treatment of PatientsWith Thoracic Aortic Diseases

Class I

  • 1. Stringent control of hypertension, lipid profile optimization,smoking cessation, and other atherosclerosisrisk-reduction measures should be instituted forpatients with small aneurysms not requiring surgery,as well as for patients who are not onsideredto be surgical or stent graft candidates.
recommendation for medical treatment of patients with thoracic aortic diseases29
Recommendation for Medical Treatment of PatientsWith Thoracic Aortic Diseases

Recommendations for Blood Pressure Control

Class I

  • 1. Antihypertensive therapy should be administered tohypertensive patients with thoracic aortic diseases toachieve a goal of less than 140/90 mm Hg (patientswithout diabetes) or less than 130/80 mm Hg (patientswith diabetes or chronic renal disease) toreduce the risk of stroke, myocardial infarction,heart failure, and cardiovascular death.
  • 2. Beta adrenergic– blocking drugs should be administeredto all patients with Marfan syndrome andaortic aneurysm to reduce the rate of aortic dilatationunless contraindicated.
recommendation for medical treatment of patients with thoracic aortic diseases30
Recommendation for Medical Treatment of PatientsWith Thoracic Aortic Diseases

Recommendations for Blood Pressure Control

Class IIa

  • 1. For patients with thoracic aortic aneurysm, it isreasonable to reduce blood pressure with beta blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers89,413 to the lowest point patients can tolerate without adverse effects.
  • 2. An angiotensin receptor blocker (losartan) is reasonablefor patients with Marfan syndrome, to reducethe rate of aortic dilatation unless contraindicated
recommendation for medical treatment of patients with thoracic aortic diseases31
Recommendation for Medical Treatment of PatientsWith Thoracic Aortic Diseases
  • Recommendation for Dyslipidemia

Class IIa

  • 1. Treatment with a statin to achieve a target LDL cholesterol of less than 70 mg/dL is reasonable for patients with a coronary heart disease risk equivalent such as noncoronary atherosclerotic disease, atherosclerotic aortic aneurysm, and coexistent coronary heart disease at high risk for coronary ischemic events
  • Recommendation for Smoking Cessation
  • Class I
  • 1. Smoking cessation and avoidance of exposure toenvironmental tobacco smoke at work and home are recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement, buproprion, or varenicline) is useful, as is adopting a stepwise strategy imed at smoking cessation (the 5 A’s are Ask, Advise, Assess, Assist, and Arrange
recommendations for preoperative evaluation
Recommendations forPreoperative Evaluation

Class I

  • 1. In preparation for sx, imaging studies  extent of disease and planned procedure. (Level of Evidence: C)
  • 2. Pts with thoracic aortic dis. requiring a sx or catheter-based intervention who have symptoms or other findings of myocardial ischemia should Ix : significant CAD (Level of Evidence: C)
  • 3. Pts with unstable coronary syndromes and significant CAD should undergo revascularization prior to or at the time of thoracic aortic sx or endovascular intervention with percutaneous coronary intervention or concomitant CABG . (Level of Evidence: C)
recommendations for preoperative evaluation35
Recommendations forPreoperative Evaluation

Class 2 a

  • 1. Additional testing is reasonable pulmonary function tests, cardiac catheterization, aortography, 24-hour Holter monitoring, noninvasive carotid artery screening, brain imaging, echocardiography, and neurocognitive testing. (Level of Evidence: C)
  • 2. For patients who are to undergo surgery for ascending or arch aortic disease, and who have clinically stable, but significant (flow limiting), CAD it is reasonable to perform concomitant CABG (Level of Evidence: C)
recommendations for preoperative evaluation36
Recommendations forPreoperative Evaluation

Class 2 b

  • 1. For pts who are to undergo surgery or endovascular intervention for descending thoracic aortic disease, and who have clinically stable, but significant (flow limiting), CAD, the benefits of coronary revascularization are not well established. (Level of Evidence: B)