Multidisciplinary Thoracic Aortic Rounds Foothills Medical Centre
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 Multidisciplinary Thoracic Aortic Rounds
History Feedback Content Format Why 18mins ? long enough to be serious and short enough to hold peoples attention Why 18mins ? long enough to be serious and short enough to hold peoples 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 Why 18mins ? long enough to be serious and short enough to hold peoples 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 oflisteningcan 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. CCS/CSCS/CSVSJoint Position Statement onInterventions for Thoracic Aortic Disease
CCC Oct.2015 Toronto Canadian Journal of Cardiology, In Press 2014 Topics: Size thresholds, Genetics, Medical Therapy, Diagnostic Imaging Surgery and Endovascular Interventions not covered 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 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 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 Primary Panel Jehangir Appoo (Co-chair) University of Calgary
John BozinovskiUniversity of British Columbia Michael ChuWestern University Ismail El-HamamsyUniversity of Montreal Tom L. Forbes University of Toronto Michael MoonUniversity of Alberta Maral OuzounianUniversity of Toronto Mark PetersonUniversity of Toronto Jacques Tittley McMaster University Munir Boodhwani (Co-chair)University of Ottawa 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 Sections 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 Document contains total of 20 Recommendations Highlights Today 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 8 recommendations Share some data behind recommendations Aortic Valve Preservation Functioning Aortic Valves in Root Aneurysms 17 Free Margin Plication Reimplanation and BAV repair Total Follow-up Time: 11,274 pt-years
Meta-Analysis Takkenberg Ann Thorac Surg 2015 N = 2,891 Patients Total Follow-up Time: 11,274 pt-years Early Mortality Pooled Estimate: 1.53% (0.90 2.3) Endocardits Pooled Estimate: 0.23%/pt-yr (0.08 0.44) Thrombo-embolism Pooled Estimate: 0.33%/pt-yr (0.2 0.4) Late AV Reoperation Pooled Estimate: 1.2%/pt-yr (0.6 2.0) PROACT Trial Mechanical Valve
Outcome Low INR Regular INR P-value Neurologic Events 2.07%/pt-yr 1.46 %/pt-yr 0.38 All TE 2.67%/pt-yr 1.59 %/pt-yr 0.16 TE + Thrombosis 2.96%/pt-yr 1.85 %/pt-yr 0.17 Total Mortality 1.48%/pt-yr 1.46%/pt-yr 0.97 Total Bleeding 6.62%/pt-yr 4cm False Lumen > 22mm Large proximal entry tear >1.0cm #7 We recommend that patients with uncomplicated acute type B aortic dissections be managed with hypertension and pain control and radiologic surveillance. (Strong Recommendation, Medium quality evidence) Values and Preferences: If patients remains uncomplicated early follow up imaging at hrs and 1-4 weeks is recommended to detect early signs of aneurysm expansion and radiologic malperfusion. #8 We suggest that endovascular repair be considered for patients with uncomplicated type B aortic dissections to improve aorta-specific endpoints (Weak recommendation, Low quality evidence) Values and Preferences: The Instead XL trial which randomized patients in the delayed phase (2-52 weeks) showed decreased aorta specific 5-year mortality and improved aortic remodelling. The ADSORB trial which randomized patients in the acute phase (< 2 weeks) showed improvement in aortic remodelling at one year. Summary: Evolution in open and endovascular aortic surgery Improved patient outcomes Rapid change thus, little high quality evidence to make strong recommendations New Recommendations: Valve Repair.with caution in regurgitant valves Extended arch at time of Type A.distal tears, aneurysm strong recommendation Asymptomatic Type B Dissections.consider early TEVAR weak recommendation Highlights Today 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