2016 CCS/CSCS/CSVS Joint Position Statement on Open and Endovascular Thoracic Aortic Surgery

1. 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 Presented @ 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 TittleyMcMaster 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 Document contains total of 20 Recommendations • 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

14. Highlights Today 8 recommendations Share some data behind recommendations • 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

15. Aortic Valve Preservation

17. Free Margin Plication

18. Reimplanation and BAV repair

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

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

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

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

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

25. PROACT Trial – Mechanical Valve

26. A Word of Caution JTCVS 2014 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%

27. #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.

28. 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.

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

30. 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

31. 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. 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.

34. 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

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

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

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

38. 46y.o male Will visceral, renal, & peripheral malperfusion be resolve?

39. 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

40. Standard hemiarch

41. Extended Arch

42. 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

43. 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

44. 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: 1975-1980 • Those not in the ascending aorta are not addressed by hemiarch procedures

45. 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 ThoracSurg2001; 71:1244-1250 • In 95 survivors of ATAD repair • Kazuiet al. Ann ThoracSurg2002; 74: S1844-1847 • In 113 survivors of ATAD repair • Zeireret al. Ann ThoracSurg2007; 84: 479-487 • Odds ratio 4.0 (168 survivors of ATAD repair)

46. Extending the Distal Repair survival months PATENCY OF THE FALSE LUMEN Does it increase risk of death • YES • Halstead et al. J ThoracCardiovascSurg 2007; 133:127-135 • 179 patients with type A dissections (DeBakey I) • Patency of the false lumen was a predictor of death after discharge • Sagaguchiet al. ICVTS 2007; 6: 204-208 • 52 patients

47. Extending the Distal Repair PATENCY OF THE FALSE LUMEN Does it increase risk of death • NO • Kimura et al. J ThoracCardiovascSurg 2008; 136:1160-1166 • 193 patients with type A (DeBakey I) dissections • 124 patent false lumen; 69 thrombosed

48. Extending the Distal Repair PATENCY OF THE FALSE LUMEN Does it increase risk of reoperation • YES • Sagaguchiet al. ICVTS 2007; 6: 204-208 • NO • Kimura et al. J ThoracCardiovascSurg 2008; 136:1160-1166

49. Extending the Distal RepairMalperfusion GERAADA REGISTRY, JACC 2015; 65(24) Patients with malperfusion have an increased mortality Mortality increases depending on number of organ systems involved None 12.6% One 21.3% Two 30.9% Three 43.4% .

50. Review of Publications for Extended Distal Repair for Acute Type A Dissection