cath conf 06-17-2010

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cath conf 06-17-2010

  1. 2. <ul><li>DR IMRAN JAVED, </li></ul><ul><li>MBBS, FCPS. </li></ul><ul><li>INTERNATIONAL FELLOW </li></ul>Manufacturing and placing a bespoke support for the Marfan aortic root
  2. 3. INTRODUCTION <ul><li>Dissection of the ascending aorta is a characteristic manifestation of Marfan syndrome. </li></ul><ul><li>It is the commonest cause of death, killing as many as 70%, often in their twenties or thirties. </li></ul><ul><li>The strongest predictors of likelihood of dissection are aortic root dimension and its rate of change. </li></ul>
  3. 4. TREATMENT <ul><li>Currently, prevention relies on replacing the ascending aorta before it dissects and ruptures. </li></ul>
  4. 5. PITFALLS If a mechanical valve is incorporated the patient is committed to life-long anticoagulation. Valve sparing operations have been devised and modified but these remain exacting to perform and prone to failure. Bioprosthetic replacement is a less technically exacting means of reducing thromboembolic risk but at the price of likely eventual valve failure with the need for reoperation.
  5. 6. INNOVATION <ul><li>The development of a bespoke external aortic root support (EARS) using imaging and computer aided design to fit the individual patient's ascending aorta has been achieved </li></ul>
  6. 7. SURGICAL PRODECURE <ul><li>The chest was opened through median sternotomy. </li></ul><ul><li>The aorta was completely dissected from the aorto-ventricular junction to the origin of the brachiocephalic artery. </li></ul><ul><li>Cardio-pulmonary bypass was available. </li></ul><ul><li>The EARS was brought to the operating table on the former, a model of the patient's own aorta. </li></ul>
  7. 8. TECHNICAL DETAILS <ul><li>The </li></ul><ul><li>longitudinal seam at the front is opened. </li></ul>
  8. 9. TECHNICAL DETAILS <ul><li>The support is placed around the aorta. </li></ul><ul><li>Note that the material extends proximal to the coronary arteries to the aorto-ventricular junction. </li></ul><ul><li>It is engineered to have high hoop strength preventing ‘annular’ dilatation. </li></ul>Copyright ©2010 The European Association for Cardio-thoracic Surgery
  9. 11. MRI image at the level of the aortic valve closure with aortic diameters measured by the radiologist superposed along with the traced outline
  10. 12. Diagnosis & Follow up <ul><li>MRI image shows a cross-section of the aorta at the level of closure of the aortic valve cusps. </li></ul><ul><li>It ensures that the levels are comparable within each patient and at the same point in the cardiac cycle (diastole). </li></ul><ul><li>An image is selected of the aortic arch to show a maximum transverse diameter at diastole because a frequent question is whether supporting the ascending aorta shifts the point of maximal stress to beyond the supported segment. </li></ul>
  11. 13. CRITERIA FOR AORTIC ROOT REPLACEMENT <ul><li>Prophylactic aortic root replacement is recommended to patients with MFS when the root size reaches 50 mm. </li></ul><ul><li>The cumulative risk for dissection or rupture increases four times when the aneurysm size exceeds 60 mm. </li></ul><ul><li>Prophylactic surgery is advised when the aorta is less than 50 mm for patients with rapid aneurysm growth, family history of early dissection or sudden death, and moderate-to-severe aortic insufficiency. </li></ul>
  12. 14. ENDOVASCULAR APPROACH <ul><li>QUESTION OF THE DAY???? </li></ul><ul><li>OPINION OF EXPERTS. </li></ul><ul><li>ONLY CASE REPORTS ARE AVAILABLE IN LITERATURE FOR TYPE A DISSECTIONS. </li></ul>

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