1 / 37

Preoperative evaluation for aortic surgery           

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.

makaio
Télécharger la présentation

Preoperative evaluation for aortic surgery           

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. Acute aortic syndrome • Aortic dissection • Intramural Hematoma • Penetrating Atherosclerotic Ulcer • Pseudoaneurysms of the Thoracic Aorta • Traumatic Rupture of the Thoracic Aorta

  3. Acute aortic syndrome

  4. 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

  5. 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

  6. Acute aortic syndrome

  7. 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

  8. 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

  9. 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,

  10. 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).

  11. 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

  12. 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.

  13. 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.

  14. 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

  15. 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)

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. Acute AoD management pathway. Step 1 Immediate post diagnosis management • Arrange for definite Tx • Appropriate Sx consultation

  22. 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

  23. 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

  24. 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.

  25. 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.

  26. 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

  27. 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

  28. 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)

  29. 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)

  30. 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)

More Related