The Case for Early Intervention inAscending Aortic Aneurysm

The Case for Early Intervention inAscending Aortic AneurysmAscending Aortic AneurysmAscending Aortic Aneurysm

John A. Elefteriades, MDWilliam W.L. Glenn Professor of Surgery

Director, Aortic Institute at Yale-New HavenDirector, Aortic Institute at Yale-New Haven

Yale University School of Medicine

New Haven, Connecticut, USA

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Ziganshin BA, Elefteriades JA. Semin Thoracic Surg. 2015;27:135-143

1. PREDICTION: Cannot predict onset of dissection with1. PREDICTION: Cannot predict onset of dissection withcomplete accuracy.

2. IMPACT: Aortic dissection that has been allowed to2. IMPACT: Aortic dissection that has been allowed tooccur has high early mortality and impaired latesurvival.

3. SAFETY: Aortic surgery is very safe in the present era.

4. LEFT-SHIFT: Intervention point may move left.4. LEFT-SHIFT: Intervention point may move left.

5. EMOTIONAL BURDEN: Living with threat of aorticdissection imposes great psychological burden.dissection imposes great psychological burden.

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• 57 y.o. male• 57 y.o. maleEx-football player• Ex-football player

• Porsche master mechanic andservice manager

• Operated on his father for 5.0 cm• Operated on his father forascending aneurysm—still alive@ 85 y.o.

• Ascending Aorta – 5.0 cm

5.0 cm

• Saw him on Thursday

• Arranged cath on Monday, op to• Arranged cath on Monday, op tobe done Wednesday

• Died of Type A aortic dissectionat sign-in desk at Cath Lab on

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at sign-in desk at Cath Lab onMonday am

What about the Frequency DistributionParadox for Aortic Dissection?Paradox for Aortic Dissection?

Numerator KnownNumerator

Denominator

Known

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Pape LA, Tsai TT, Isselbacher EM, et al. Aortic diameter >or = 5.5 cm is not a good predictor of type A aortic dissection: observations from theIRAD. Circulation. 2007 Sep 4;116:1120-7.

4Paruchuri V, Salhab KF, Kuzmik G, et al. Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection.Cardiology 2015;131:265-272.

What about the Frequency Paradox forAortic Dissection?Aortic Dissection?

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er

Size

Nu

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er

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SizeNu

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Size

5 cm4.5 cm4 cm

Size

5Paruchuri V, Salhab KF, Kuzmik G, et al. Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection.Cardiology 2015;131:265-272.

Relative risk of aortic dissection based on size

6Paruchuri V, Salhab KF, Kuzmik G, et al. Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection.Cardiology 2015;131:265-272.

• Operative mortality for acute type A aortic• Operative mortality for acute type A aorticdissection at experienced centers rangesfrom 7% to 36%from 7% to 36%

[Black JH, Manning WJ, Management of acute aortic dissection. UpToDate, 2017]

• Most recent data from IRAD (n=2,552):– In-hospital mortality for acute Type A aortic– In-hospital mortality for acute Type A aortic

dissection – 19.7%[Pape LA, Awais M, Woznicki EM, et al. Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: 17-Year Trends From the International Registry of Acute Aortic Dissection. J Am Coll Cardiol 2015;66:350-358]

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• Post-mortem CT scans in Japan show a• Post-mortem CT scans in Japan show astunning 8.07% of out of hospital arrests aredue to acute Type A dissection.due to acute Type A dissection.

8Moriwaki Y, Tahara Y, Kosuge T, Suzuki N. Etiology of out-of-hospital cardiac arrest diagnosed via detailed examinations including perimortemcomputed tomography. J Emerg Trauma Shock 2013;6:87-94.

9Davies RR, Gallo A, Coady MA, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg2006;81:169-177.

10Davies RR, Gallo A, Coady MA, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg2006;81:169-177.

Location of SurgeryOperative Postoperative

Location of SurgeryOperativeMortality

PostoperativeStroke

Composite Aortic Root Replacement 1.9% 1.4%

Root Sparing Ascending Aortic Replacement 0% 1.0%

Aortic Arch Replacement with DHCA 1.4% 1.2%

Mok SC, Ma WG, Mansour A, Charilaou P, Chou AS, Peterss S, Tranquilli M, Ziganshin BA, Elefteriades JA. Twenty-five year outcomes followingcomposite graft aortic root replacement. J Card Surg 2017;32:99-109.

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Peterss S, Charilaou P, Dumfarth J, Ziganshin BA, Elefteriades JA. Aortic valve disease with ascending aortic aneurysm: Impact of concomitant root-sparing (supracoronary) aortic replacement in nonsyndromic patients. J Thorac Cardiovasc Surg 2016;152:791-798 e791.

Ziganshin BA, Rajbanshi BG, Tranquilli M, Fang H, Rizzo JA, Elefteriades JA. Straight deep hypothermic circulatory arrest for cerebral protection duringaortic arch surgery: Safe and effective. J Thorac Cardiovasc Surg 2014;148:888-898; discussion 898-900.

• Size prior to dissection—NEW DATA• Size prior to dissection—NEW DATA

• Centerline method• Centerline method

• “Bad actors” upon Whole Exome Sequencing

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So, dissections areoccurring at smallersize than we thought.size than we thought.

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“Centerline” results in measurements 5 to 7 mm smaller“Centerline” results in measurements 5 to 7 mm smaller

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Rengier. Centerline analysis of aortic CT. AJR 2009;192:w255-263.

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CurrentIntervention

???? Intervention

Criterion???

Aortic Size

5.0 cm 5.5 cm 6.0 cm4.5 cm4.0 cm

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Aortic Size

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