Preoperative evaluation for aortic surgery            Inter-hospital Conference 2 (2/2554)

Aortic surgery: Update & Decision making

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Acute aortic syndrome

1. Aortic dissection

2. Intramural Hematoma

3. Penetrating Atherosclerotic Ulcer

4. Pseudoaneurysms of the Thoracic Aorta

5. Traumatic Rupture of the Thoracic Aorta

Acute aortic syndrome

Acute surgical management pathwayStep 1

Determine suitable for

surgery

Step 2Determine stability for

preop testing

Ascending Aortic dissection by imaging

Is pt a suitable candidate for Sx? Medical Tx

Is pt stable enough to allow pre-op testing?

Age > 40 yrAssess need for preop CAG

Known CAD?Significant risk factors for CAD?

Significant CAD by angiography?

Plan for CABG if appropriate at time of AoD repair

Step 3Determine

likelihood of coexistent CAD

yes

yes

yes

yes

yes

no

no

no

no

no

Step 4Intraoperative evaluation of aortic valve

Urgent operative management

Intra operative assessment of aortic valve by TEEAortic regurgitation?

orDissection of aortic sinuses?

Step 5Surgical

interventionGraft replacement of ascending aorta

+/- aortic archand

repair/ replacement of aortic valve or

aortic root

Graft replacement of ascending aorta

+/- aortic arch

noyes

Acute aortic syndrome

Acute aortic syndrome

1. Perfusion Deficits and End-Organ Ischemia2. Acute aortic regurgitation3. Myocardial Ischemia or Infarction4. Heart Failure and Shock5. Pericardial Effusion and Tamponade6. Syncope7. Neurologic Complications8. Pulmonary Complications9. Gastrointestinal Complications

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 AcuteThoracic Aortic Disease

• Recommendations for Estimation of Pretest Risk ofThoracic Aortic Dissection

Class I

1. 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,

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 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 AcuteThoracic Aortic Disease

Recommendations for Screening TestsClass 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 AcuteThoracic Aortic Disease

Recommendations for Diagnostic Imaging study

Class I1. Selection of a specific imaging modality to identify or

exclude aortic dissection should be based on patient variables and institutional capabilities, including immediate availability

2. 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 AcuteThoracic Aortic Disease

Recommendations for initial managementClass I1. 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 AcuteThoracic Aortic Disease

Recommendations for definite managementClass I1. 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.

2. 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

3. 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

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 featureschest, back , abdomianl•abrupt in onset.•severe in intensity•ripping, tearing•stabbing•sharp quality

High risk examfeatures•Pulse deficit.•SBP limb diferential > 20 mm Hg.•Focal neurologic deficit.•Murmur of AR (new)

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

+

+

Step 1Identify patient at

Risk For acute AoD

Step 2 Bedside risk assessment

yes

intermediate riskAny single high

risk features

High risk≥2 high risk features

Proceed with diagnosticEvaluation as

clinically indicated by presentation

Alternative diagnosis identified

Initiate appropiate Tx

Unexplained hypotension or

widened mediastinum

Consider Ao imaging

Immediate Sx consultand imaging

ECG: STEMI

CXR : clear alternate Dx

Primary ACS : reperfusion Tx

Initiate appropriate tx

Clinical suggest alternate Dx

Alternate Dx confirm by other

further testing

Expedited Ao imaging

Expedited Ao imagingTEE, MRI, CT

Step 3Risk based diagnosticevaluation

Low riskNo high risk features

yes

yes

yes

yes

yes

no

no

no

no

no

no

no yes

yes

Step 4Acute AoD Identified of

excluded

Aortic dissection present

Proceed to treatment pathway

If high clinical suspiciousAoD exists,

consider secondary imaging study

yes

no

• 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.

Arrange for definite Tx•Appropriate Sx consultation

Step 1Immediate

post diagnosis management

obtain accurate BP prior to beginning TxMeasure in both arms

Step 2Innitial

managementaortic wall

stress

hypotension/shock stage

Anatomic based management

Intravenous rateand pressure

control

iv beta blocker / calcium channel

blocker (HR < 60 bpm)

Pain controliv opiate

SBP > 120 mmHg

Secondary pressureControl

Intravenous vasodilator(SBP < 120 mmHg)

Type A dissectionType 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 etiologyOf hypotension

contained rupture cardiac function

•Urgent Sx consult

Etioligy of hypotension amenable to

operative management

Yes

Yes

No

No

No

Step 3Definite

management

ongoing medical Tx Operative orIntervational management

Complication requiringOperative or Intervational management

Malperfusion syndromeProgression of dissection

Aneurysm expansionUncontrolled hypertension

Yes

Yes No

Close hemodynamic monitorMaintain

SBP < 120 mmHg

ongoing medical Tx

Close hemodynamic monitorMaintain

SBP < 120 mmHg

Complication requiringOperative or Intervational management

Malperfusion syndromeProgression of dissection

Aneurysm expansionUncontrolled hypertension

Yes

dissection involving the ascending aorta

Step 4 No No

Transition to oral medicine out patient disease surveillance imagine

Recommendation for Medical Treatment of PatientsWith Thoracic Aortic Diseases

Class I• 1. Stringent control of hypertension, lipid pro

file 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 PatientsWith Thoracic Aortic Diseases

Recommendations for Blood Pressure Control

Class I• 1. Antihypertensive therapy should be administered t

ohypertensive 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 PatientsWith Thoracic Aortic Diseases

Recommendations for Blood Pressure ControlClass 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 PatientsWith Thoracic Aortic Diseases

• Recommendation for DyslipidemiaClass 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 tob

acco 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 forPreoperative Evaluation

Class I• 1. In preparation for sx, imaging studies extent of disease an

d 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 forPreoperative Evaluation

Class 2 a• 1. Additional testing is reasonable pulmonary functio

n 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 forPreoperative Evaluation

Class 2 b• 1. For pts who are to undergo surgery o

r 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)