READ Vol. XXII, Nr.
Mortality rates over time. Of these, acute aortic dissection is the most frequent and catastrophic manifestation1.
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Traditional classification systems, such as the Stanford and DeBakey, facilitate the decision-making process4; more recently though, a classification based on the pathophysiological features of the aortic lesion rather than its location has been proposed; currently it is recommended that AAD be classified according to both lesion type and location.
Still, while the primary goal of surgery is to obliterate the intimal tear in the ascending aorta, thereby preventing flow and encouraging thrombosis of the false lume1, neither of these classification systems dictates the site of the originating entry tear2.
It is not known whether the apparent increase in incidence represents improved rates of diagnosis or the dramatic consequence of an aging population2. While immediate decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation and intervention for malperfusion complications are mandatory, the diverse presentations of ATAAD can delay the diagnosis, adversely affecting outcomes2,6,7.
Acute type A aortic dissection. A single center experience acute dissection have their initial diagnosis made in a nonspecialised hospital. The primary presentation of AAD to the emergency room ER is most commonly an elderly male, with hypertension and sudden onset chest pain8, as it was in our study.
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- Nr. 4, - Romanian Journal of Cardiology
- Test de Efort | Aorta | Surgery
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Without clinical suspicion, patients are not immediately channeled into an appropriate imaging pathway2. Acute aortic syndromes have no reliable point-of-care biomarkers2,8. D-dimer measurements might be for now the most useful tool: a negative assay is highly predictive that a patient does not have dissection, whereas a high level makes the differential diagnosis of ATAAD or pulmonary embolism far more likely and once suspected, definitive imaging comprising CT, transthoracic echocardiography TTEtransesophageal leonisa slimming bray body shaper recenzii and MRI, is required for confirmation2.
TTE is a rapid and readily available investigation in the emergency department and it should be performed without delay in patients with suspected AAS. A single center experience of the cases. In this situation, the role of preoperative coronary angiography is still controversial. The low rate of concomitant coronary artery disease, the risk of catheter-induced lesions and management delay are substantial arguments against it.
Angiography may be indicated during or after surgery in the era of the hybrid procedures in patients with visceral malperfusion and dilatation of the descending aorta for appropriate treatment guidance9.
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Surgical indications and predictors of operative mortality As mentioned above, time-honored dictum is that type A aortic dissection requires urgent surgery. There are, however, controversial situations where the patients treatment may stop with medical management: patients with completed stroke, comorbid conditions e.
Type II aortic dissection appears to associate a better prognosis than Type I, in terms of perioperative, long-term, and aneurysm-free patient survival, related to the propensity for distal malperfusion phenomena and persistence of a distal false lumen. Arterial hypertension, although considered one of the most important predisposing factors of acute aortic dissection, does not seem to influence the prognosis of these patients Preoperative coma, as well as the state of shock secondary to either leonisa slimming bray body shaper recenzii tamponade or coronary dissection and ische Romanian Journal of Cardiology Vol.
According to Pacini et al.
Another major determinant of outcome in type-A dissection is advanced age. While ATAAD incidence increases with age, recent studies have highlighted the excessive risks associated in patients over 70 years old5. As with all cardiovascular surgery emergencies, advanced age proved an independent predictor of worse operative mortality and morbidity and reduced longer-term survival of ATAAD.
However, in western societies one-fifth of the population are 65 years of age and this fraction is increasing2. In a study, Piccardo reported an overall mortality rate in the group of surgically treated octogenarians with ATAAD of His conclusion was that octogenarians with uncomplicated ATAAD may benefit from emergency surgical repair Our study included Still, the management of acute type A aortic dissection in these age groups remains controversial All these and other factors have been incorporated into predictive risk models on the basis of IRAD and individual center data, which might aid the decision making process.
However, although each complication might engender additional risk, this does not preclude a superior outcome with surgery and rigid treatment exclusion criteria are inappropriate2. Romanian Journal of Cardiology Vol.
Techniques used to achieve these aims have not been subject to randomized studies so they remain issues of debate2. Arterial cannulation site The optimal site of arterial cannulation also remains controversial.
While femoral artery has been the primary leonisa slimming bray body shaper recenzii for arterial cannulation in surgery for ATAAD for a long time2,15, it has lost popularity during recent years given the worse outcomes it appears to associate compared to other strategies in contemporary studies9.
Apparently, retrograde perfusion through the femoral artery may further exacerbate dissected intimal flaps and determine organ malperfusion, progressive arch vessel compromise, and neurologic injury and it has also been associated with a greater stroke risk in patients with concurrent distal aortic aneurysmal or atherosclerotic disease2, Previous studies have reported an incidence of malperfusion syndrome with femoral cannulation of 2.
However, the clinical incidence of these events is low. Therefore, in ATAAD, initial femoral artery cannulation remains reasonable, if provided malperfusion monitoring is applied and potential distal aortic pathology is excluded2.
Besides the decreased risk of stroke or malperfusion, the theoretical advantages of axillary artery cannulation in ascending aorta and arch surgery include the continuous provision of cerebral flow by means of culori pierdere în greutate hyderabad antegrade cerebral perfusion. It remains controversial whether the axillary artery should be cannulated directly, or using the sidegraft technique9.
In our Institute the primary arterial cannulation site was chosen according to preoperative imaging techniques and intraoperative findings, thus explaining the variable frequencies between the axillary and femoral arteries over the years. Central cannulation is another option, many surgeons preferring to cannulate the dissected aorta itself either with TTE or TEE guidance or under direct vision after transecting the tourniquet controlled distal ascending aorta, therefore allowing very fast cannulation in an emergency.
Left ventricular apex is another potential can- Ovidiu Stiru et al. A single center experience nulation site7. In a meta-analysis, axillary artery cannulation seemed to give better short-term mortality and neurological dysfunction rates than femoral artery cannulation Because no study was a randomized trial these results are more than uncertain2,16; as the pathoanatomy differs among patients with ATAAD, so does the optimal cannulation strategy9.
Preservation of the native aortic valve has obvious advantages.
In case of normal leaflet morphology, of flap interference with valve closure or central regurgitation due to prior dilation of the sinotubular junction, valve competence can usually be restored by re-affixing the commissures to the aortic wall.
In patients with pre-existing root pathology VSRR may be an option, with the added disadvantages of longer operating times and superior technical requirements. Of the 2 types of valve sparing root replacement, the reimplantation technique might leonisa slimming bray body shaper recenzii superior in ATAAD2.
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Kallenbach et al. In terms of survival and reoperation rates, the authors concluded that the reimplantation technique yields results comparable to those of the established procedures Some centers prefer a more aggressive strategy, replacing the aortic valve and adding the well-known risks of prosthetic valves. An aortic root repair ARR procedure could also increase risk in inexpert hands.
Thus, the role of aggressive ARR management of the aortic valve versus conservative valve re-suspension is incompletely defined2. In our series aortic valve involvement reached When a competent non-calcified bicuspid aortic valve BAV is detected, the decision to conserve will depend upon age, presence of annulo-aortic ectasia and degree of aortic root destruction.
If the valve Ovidiu Stiru et al. A single center experience is functionally abnormal, but without associated sinus disease, prophylactic simple aortic valve replacement is justified.
Alternatively, reparative bicuspid valve procedures are well-reported, but their application should be judicious2. According to Schfers et al.
The type of disease i. Also these patients have a distinctive dissection pattern with the entry tear frequently located in the aortic root and-despite their younger age-are at risk of substantial hospital mortality.
It has been reported that composite root replacement yields an excellent outcome in BAV patients suffering from aortic dissection, equal to an age- and gender-matched normal population The routine use of intra-operative TEE is now regarded as an essential adjunct2.
In ATAAD the primary intimal tear is usually present within the ascending aorta, sometimes accompanied by secondary, more distal tears. Sometimes, involvement of the ascending aorta can result from retrograde propagation of the dissection flap with the primary tear originating within the arch or descending aorta.
Occasionally, no intimal tear is identified2. Suboptimal connection of the distal part of the graft implanted in the ascending aorta to the TL or presence of secondary entry tears may account for the postoperative persistence of residual flow into the distal FL. The long-term outcomes of aortic dissections with patent false lumen show a high risk of complications, leonisa slimming bray body shaper recenzii death and need for surgery, particularly from the third year of evolution.
In addition to Marfan syndrome, maximum aortic diameter and the presence of a large, proximal entry tear imply Romanian Journal of Cardiology Vol. In the present study an isolated ascending aortic replacement was most often necessary, with an associated mortality rate of Aortic arch and descending aorta replacement were performed with a frequency of Probably in association with these complex procedures prolonged CPB time also significantly increased mortality rates: a CPB duration of minutes or longer related to a mortality rate of Himanshu and Deeb reported in a study on patients with open arch reconstruction a mortality rate of Novel hybrid techniques have.