00:00:00
so uh thank you for the floor I had to
00:00:03
smile when you talked about non-porous
00:00:05
graphs when I was a resident that
00:00:08
doesn't seem like so many years ago we
00:00:10
did not have gelatin and bovine
00:00:13
impregnated graphs and and we've spent
00:00:15
all night long trying to stop the
00:00:17
bleeding just through those Dacron
00:00:18
grafts it was really awful
00:00:20
so disclosures I'm on a clinical events
00:00:23
committee for a med pace and I may not
00:00:25
be the right one to be doing this debate
00:00:27
because mark moon and you'll see market
00:00:28
in some of the other sessions here today
00:00:30
has argued that this is a never-ending
00:00:32
debate the extent of resection and
00:00:36
endless an endless debate but I'll give
00:00:38
it a bit the best shot that I can so
00:00:40
first of all what's wrong with the
00:00:42
standard operation the standard
00:00:44
operation that's been described graft
00:00:46
replacement of the ascending aorta and a
00:00:48
hammie arch replacement under profound
00:00:50
hypothermia with circulatory arrest is
00:00:52
easily taught it gives quote unquote
00:00:55
satisfactory early results and it
00:00:58
achieves the primary objective which is
00:01:00
to get the patient out of the operating
00:01:01
room alive agreed but is this good
00:01:05
enough late survival is I think pretty
00:01:09
disappointing so again if you look at
00:01:11
data from wash you mark moons group the
00:01:14
50% survival at ten years for patients
00:01:18
with who have who have made it to the
00:01:21
hospital with a type-a dissection and
00:01:24
remember that the these are people who
00:01:26
are present with their dissection in the
00:01:27
in their 50s and 60s these are not 80
00:01:30
year olds these are relatively young
00:01:32
individuals and if you look at a
00:01:34
population study from Sweden laid
00:01:37
survival those who survive and do not
00:01:40
undergo a reoperation only 63% of
00:01:44
patients make it make it for a long term
00:01:47
survival the causes of light late
00:01:49
mortality among these patients in this
00:01:52
Swedish population study the number one
00:01:55
cause for late mortality are aortic
00:01:58
complications so the question is did you
00:02:00
get the job done in the operating room
00:02:02
at the index hospitalization or index
00:02:05
operation where's the problem the
00:02:08
problems in the descending thoracic
00:02:09
aorta that's why you're going to hear
00:02:11
from Christoph about the work
00:02:13
that he's led through the irad registry
00:02:15
about applying stent grafts to deal with
00:02:18
the descending thoracic aorta and he's
00:02:19
exactly right that's that's the killer
00:02:22
in the long term as the descending
00:02:23
thoracic aorta descending thoracic
00:02:26
aortic rupture and then of course death
00:02:28
during reoperation for descending
00:02:30
thoracic aortic complications those are
00:02:33
not minor operations operations for
00:02:35
descending thoracic dilatation and this
00:02:40
hasn't changed for years so these are
00:02:43
the data that Michael DeBakey published
00:02:46
in 1982 again as close as you can get to
00:02:49
a natural history study the most common
00:02:51
cause of late death for patients after
00:02:53
type-a dissection rupture of the distal
00:02:56
aortas now the proximal aorta is a
00:02:58
problem to more recent data these from
00:03:00
from from stanford demonstrating that if
00:03:04
you do a just a valve resuspension
00:03:06
rather than a more radical approach to
00:03:09
the aortic root you definitely increase
00:03:10
the likelihood of reoperation on the
00:03:12
aortic root and these are the kinds of
00:03:15
patients that we see this is a patient I
00:03:16
took care of a few years ago and you can
00:03:18
easily see that root aneurysm the Dacron
00:03:21
graft looks ridiculously small here
00:03:23
doesn't it just a tiny little piece of
00:03:25
Dacron an enormous root and a dilated
00:03:28
arch beyond it there is a solution to
00:03:33
this there's an easy solution to this or
00:03:35
a straightforward solution to this
00:03:37
composite root replacement whether it's
00:03:39
a biological root or or a mechanical
00:03:42
valve conduit and more recently valves
00:03:45
bearing root operations to deal with the
00:03:47
root deal with all of the intra
00:03:49
pericardial a Horta Ed Chen particularly
00:03:54
at Emory has been interested in this and
00:03:56
has published excellent results for a
00:03:58
routinely using a valve sparing approach
00:04:01
for patients with an aortic dissection
00:04:02
and they're the ideal patients to do
00:04:04
about sparing operation in in so far as
00:04:08
the valve itself is usually normal the
00:04:12
leaflets themselves are typically normal
00:04:16
and what about distally this is that
00:04:18
same patient this is her descending
00:04:20
thoracic aorta the problem of dealing
00:04:22
with that knuckle of descending thoracic
00:04:24
aorta I told you that
00:04:26
Mark's been thinking about this for a
00:04:28
long-term market long time mark joined
00:04:31
us when I was on the faculty at Washu
00:04:33
back in 1999 he did this reported this
00:04:37
study about asking the question does the
00:04:39
extent of proximal and distal resection
00:04:42
influence outcome so you can see it has
00:04:45
been an endless debate at least for at
00:04:48
least it provides topics for a careers
00:04:52
worth of papers now back then not again
00:04:57
it doesn't seem so many years ago to me
00:04:58
it may seem like a long time ago to you
00:05:01
there was still some controversy about
00:05:03
the use of circulatory arrest and an
00:05:05
open distal anastomosis versus a a or to
00:05:08
cross-clamp and in fact if you try to to
00:05:11
look at objective data there there are
00:05:13
no prospectively randomized trials
00:05:15
comparing the use of a cross clamp to
00:05:17
the use of an open distal anastomosis so
00:05:21
that was one of the questions that we
00:05:22
asked and you can see that over time the
00:05:24
use of circulatory arrest at Wash U
00:05:26
increased and what's useful I think
00:05:30
about these data because it shows you
00:05:32
something about the long term results
00:05:33
for for aortic dissections repaired with
00:05:37
a cross clamp you can see that those who
00:05:40
have a Hemi arch replacement under
00:05:42
circulatory arrest do better in terms of
00:05:44
late reoperation the patency of the
00:05:49
false lumen matters as well so this is a
00:05:52
one of the many papers that demonstrates
00:05:55
the difference in a or decree modeling
00:05:57
with an occluded false lumen much better
00:05:59
serve out long term survival of the
00:06:01
patients if the entire false luminous is
00:06:03
is thrombosed and there's favorable
00:06:06
remodeling of the descending thoracic
00:06:07
aorta so that really ideally should be
00:06:10
part of our objective with the initial
00:06:12
operation set the patient up to optimize
00:06:15
the likelihood maximize the likelihood
00:06:18
that they will have thrombosis complete
00:06:20
thrombosis of the false lumen
00:06:22
interestingly fall from the I read
00:06:26
database partial thrombosis of the false
00:06:28
lumen may actually be just as bad as a
00:06:31
Payton false lumen which is this is an
00:06:33
interesting study that Thomas I
00:06:36
published Hemi arch versus total arch so
00:06:40
this is
00:06:40
the argument it's a pushed quite a bit
00:06:43
or promoted quite a bit by our Japanese
00:06:45
colleagues
00:06:46
it seems the Japanese aortic surgeons
00:06:49
are far ahead of so at least far ahead
00:06:51
of the the u.s. surgeons I'll give them
00:06:54
that
00:06:55
in terms of being innovative in their
00:06:58
approach to aortic disease and Okita has
00:07:01
certainly argued for the selective
00:07:04
approach of a total arch replacement and
00:07:07
these are the results that he has
00:07:09
demonstrated superior long-term results
00:07:13
and pretty equivalent early results with
00:07:16
total arch replacement so if you don't
00:07:18
pay a price at the index operation in
00:07:22
terms of perioperative mortality and you
00:07:24
get a long-term benefit doesn't it make
00:07:26
complete sense that we should do a total
00:07:28
arch replacement there are other options
00:07:33
as well if you if you're reluctant to
00:07:36
undertake a total arch replacement so
00:07:37
this was promoted by the pen group some
00:07:40
time ago Alberto cloaca tena published
00:07:43
this the idea of doing a Hemi arch
00:07:45
replacement and while the patient is
00:07:47
arrested under circulatory arrest just
00:07:49
deploy a stent graft in the upper
00:07:51
descending thoracic aorta and it
00:07:55
demonstrated a favorable impact on false
00:08:00
lumen obliteration and of course the
00:08:02
total arch with frozen elephant trunk is
00:08:04
what we all talk about now whether it's
00:08:06
the right thing to do or not that's
00:08:08
certainly with a hot topic now is total
00:08:10
arch replacement with a frozen elephant
00:08:12
trunk again a Japanese series that shows
00:08:15
that a combined total arch replacement
00:08:17
and stent the frozen elephant trunk
00:08:18
demonstrates superior long-term survival
00:08:21
in aortic event-free survival why not
00:08:25
use the technologies that are now
00:08:26
available to us including endovascular
00:08:28
stent grafts to make the index operation
00:08:31
a more definitive one this is another
00:08:36
option debranching with the frozen
00:08:39
elephant trunk as it was described I
00:08:41
think that this is an appealing option
00:08:43
and in fact this is what I've migrated
00:08:46
to as a zone to arch what they call a
00:08:50
zone to arch replacement and selective
00:08:53
apple
00:08:53
occasion of a distal endovascular stent
00:08:56
graft so by doing the distal anastomosis
00:08:58
in zone 2 doing it between the carotid
00:09:02
and the subclavian that's right in your
00:09:05
face it really is right there it's not
00:09:08
significantly more challenging I think
00:09:10
than a Hemi arch replacement the
00:09:13
challenge with total arch replacement of
00:09:14
course is that corner behind the left
00:09:17
subclavian that's what we're all afraid
00:09:18
of that's where the Ord is the thinnest
00:09:21
and it's also the hardest to fix if it
00:09:23
bleeds right so Joba very has argued
00:09:26
forget about that
00:09:27
do the distal anastomosis between the
00:09:30
carotid and the subclavian place your
00:09:32
graph to the head vessels far enough
00:09:34
proximally but you have at least a two
00:09:37
centimeter Dacron landing zone and he
00:09:41
would argue I think if the patient
00:09:43
demonstrates mal perfusion after this
00:09:45
operation or if they demonstrate a
00:09:47
patency of the false lumen come back and
00:09:51
deploy a stent craft and land it in that
00:09:54
proximal two centimeters of graft I
00:09:56
think it makes a lot of sense and as a
00:09:57
selective approach to this so the
00:10:03
obvious question if total arch
00:10:04
replacement is so good
00:10:06
has it caught on again we can look at
00:10:08
the eye read data to ask has total arch
00:10:10
replacement caught on and I think you
00:10:12
can see in this table that it really has
00:10:14
not it's been pretty stable and the
00:10:18
reason for that I think is that there
00:10:20
are in the literature quite variable
00:10:22
results in terms of the comparative
00:10:25
mortality rate for Hemi arch replacement
00:10:27
and total arch replacement and there are
00:10:28
enough studies that you can find a paper
00:10:30
to support whatever position you choose
00:10:33
so you can see here quite variable
00:10:36
results in terms of the overall
00:10:38
mortality rate high in those two that
00:10:41
are that are marked with the red arrows
00:10:43
and in the second of those much higher
00:10:47
mortality rate associated with total
00:10:50
arts replacement than Hemi arch
00:10:51
replacement if you read those papers
00:10:53
you're not going to be inclined to do a
00:10:55
total arch replacement but of course
00:10:58
there are other studies other series
00:11:00
that have been published with very
00:11:02
comparable perioperative mortality rates
00:11:04
and it shouldn't be a surprise that the
00:11:07
are also the studies that show the
00:11:09
lowest overall mortality rates in aortic
00:11:13
dissection the likelihood is that
00:11:15
they're published by the by this by the
00:11:18
institutions or the surgeons that have
00:11:20
the greatest experience the largest
00:11:22
number of cases which brings us to
00:11:26
another question I'm going to pivot
00:11:28
there's a lot of talk in the u.s. about
00:11:31
pivoting the politicians all pivot I've
00:11:33
noticed that word comes up over and over
00:11:35
pivoting let's pivot to the question
00:11:38
where should a or take operations be
00:11:40
done are we are we tailoring the
00:11:44
operation to the surgeon or the surgeon
00:11:46
to the operation that needs to be done
00:11:48
for the patient well it turns out
00:11:51
there's quite robust data to demonstrate
00:11:54
an association between the surgeons
00:11:57
experience and the outcomes in the
00:12:00
setting of aortic dissection this is a
00:12:02
study that Joe Chick we did using the
00:12:05
National inpatient database looking at
00:12:08
the influence of surgeon and
00:12:10
institutional volume on operative
00:12:11
mortality in the setting of the section
00:12:13
note first that few hospitals at least
00:12:16
in the United States see more than a few
00:12:18
dissections every year the vast majority
00:12:22
of hospitals are way over there on the
00:12:24
Left seeing only a handful of the
00:12:26
sections and you can see if you look at
00:12:31
at a mortality rate versus surgeon
00:12:34
experience I could show you graphs that
00:12:37
show the surgeon experience similarly as
00:12:39
you can imagine most dissections are
00:12:42
taken care of or repaired in the United
00:12:44
States at least by surgeons that do a 2
00:12:47
or fewer dissections a year they're
00:12:49
working in those small volume
00:12:51
institutions oh the difference in
00:12:54
mortality rate between the highest and
00:12:56
the lowest volume surgeons is quite
00:12:59
significant 17 percent versus 27.5% now
00:13:05
certainly one could argue that transfer
00:13:08
of the patient to the acute patient the
00:13:11
senior emergency department to another
00:13:13
hospital with a greater experience in
00:13:17
dissection risks death of the patient
00:13:20
during
00:13:20
four agree that's not the question
00:13:23
though the question is will more lives
00:13:26
be saved
00:13:27
overall with that strategy yes you put
00:13:32
this particular patient at risk but if
00:13:34
you look at the group as a whole you can
00:13:36
see if there were a 10% mortality rate
00:13:39
just associated with with the transfer
00:13:42
process you'd breakeven and it is
00:13:48
possible it's also been demonstrated
00:13:50
this is data from Chad Hughes showing
00:13:53
that an integrated institutional
00:13:55
approach a focused institutional
00:13:58
approach within a given institution
00:14:00
having only a few surgeons operate on
00:14:03
the patients with two sections has an
00:14:05
impact on mortality here's what they
00:14:08
observed in the early years ninety nine
00:14:10
to 2005 everyone who was on call did the
00:14:14
aortic dissections whoever was on did
00:14:16
the dissection in 2005 they instituted a
00:14:21
specific dissection team focused the
00:14:23
experience and a handful of surgeons and
00:14:25
you can see how it changed the observed
00:14:29
mortality and if you look at the
00:14:31
expected mortality it's a bit lower but
00:14:33
it doesn't explain the dramatic drop in
00:14:37
the observed mortality so experience
00:14:39
matters in diseases like a Orting
00:14:42
dissection can it be regionalised well
00:14:45
it can be regionalised in Minnesota in
00:14:49
Minneapolis Kevin Harris who's a
00:14:51
cardiologist a friend of mine from
00:14:53
Washington University days he and his
00:14:56
colleagues developed a regional approach
00:14:59
to aortic dissection akin to the
00:15:01
approach that people have with stem ease
00:15:03
so there's a there's a regional app on
00:15:11
the phone they could you can download
00:15:14
the app and if there's a patient in the
00:15:15
emergency room you contact the central
00:15:19
coordinating Center and they facilitate
00:15:22
transfer of patients with aortic
00:15:24
dissection to Centers of Excellence and
00:15:26
this maps out their protocol and so on
00:15:31
and as you can
00:15:34
see this approach of regionalised care
00:15:38
even though it involved some transfer of
00:15:41
patients from one hospital to another
00:15:42
overall actually reduced the quote door
00:15:47
to o our time the equivalent of door to
00:15:50
balloon time the door to o our time for
00:15:53
patients with acute dissection so I
00:15:57
would argue that we should do the best
00:16:00
possible operation at the index
00:16:02
operation that the operation should be
00:16:05
tailored to the needs of the patient not
00:16:06
to the capacity of the surgeon that we
00:16:08
should develop regionalized networks
00:16:10
that provide for that kind of care thank
00:16:13
you very much
00:16:14
[Applause]
