gives a summary of various guidelines in the management of aortic disease

1. COMPARISION OF
MANAGEMENT PROTOCOLS FOR
AORTIC DISEASE
Dr Kunwar Sidharth Saurabh
M.Ch CTVS (Resident)
VMMC & SJH

2. RECAP OF AHA/ACC VALVULAR HEART DISEASE
GUIDELINES (2014/2017)

8. WHAT IT TALKS ABOUT??
• IT COMPARES THE THREE BROADLY ACCEPTED GUIDELINES ALL OVER
THE WORLD –
• EUROPEAN SOCIETIES
• AMERICAN SOCIETIES
• ASIAN SOCIETIES
• IT SUMMARISES THE DIFFERENCE IN OPINION WHICH EXISTS
AROUND THE WORLD IN MANAGEMENT OF THE AORTIC DISEASES.

9. IMAGING MODALITY
• CHEST X-RAY –
• POSSIBLE TO DETECT AORTIC DISEASE
• NORMAL DOESN’T RULES OUT POSSIBILITY
• INCOMPLETE INFORMATION

10. ULTRASONOGRAPHY
• First test to be performed in
screening programmes for aortic
disease.
• Although TEE is considered
superior to TTE, both have
limitations as they cannot
visualise all aortic segments and
Linear artefacts can be confused
with Aortic Flaps.

11. COMPUTED TOMOGRAPHY
• Plays a central role in –
• Diagnosis
• Risk stratification
• Management of aortic disease
• First Line technique in Acute
Aortic Syndromes for its-
• Speed
• Availability
• Sensitivity
• Specificity

12. MAGNETIC RESONANACE IMAGING
• More advantageous than CT in-
• No radiation exposure
• Enables lumen to be evaluated in
cases with severely calcified
leisons.
• Disdvantages-
• Lower spatial resolution
• Inability to visualise osseous
structures
• Long imaging time

13. ACUTE AORTIC SYNDROMES

14. Point to be noted..
In regard to aortic dissection , all the three guidelines
accept the
STANFORD and the DeBAKEY “Anatomic” classifications

15. Point to be noted

16. • The American and European societies encompasses 3 inter-related
conditions with similar clinical characteristics and include-
• Aortic dissection
• Intramural hematoma
• Penetrating atherosclerotic ulcer
• Asian Societies decided on not using the term IMH in the clinical setting.

17. • The European societies writes about the D-dimer levels in case of low
clinical probability of acute aortic syndrome, as ruling out the
diagnosis.

18. The guidelines broadly coincide in the treatment of AAS

21. Point to note -
• Asian guidelines advise medical treatment provided that IHM is
<11mm and aortic diameter <50mm.

25. THORACIC AORTIC ANEURYSM

29. ABDOMINAL AORTIC ANEURYSM

32. MARFAN SYNDROME
• FOR DIAGNOSIS AND FOLLOW UP
• American societies recommend-
• 2d echo every 6 month
• Annual imaging for diameters
• European societies recommend-
• 2d echo yearly
• Baseline MRI
• MRI every 5 years or every year if there is root aneurysm
• Asian socities recommend regular follow up without specific dates.

37. Special considerations in Pregnancy
• Risk of aortic dissection
• Strict BP control
• Monthly 2d echo
• Delivery in a setup having CTVS facilities
• MRI if imaging required
• Elective caesarean section
• Prophylactic surgery

38. Some Important aspects of aortic disease
management from European Guidelines
• Measurement of aortic root and ascending aorta in the 2D mode
should be at 4 levels –
• Annulus
• Sinuses of Valsalva
• STJ
• Tubular ascending aorta
• Measurement should be taken in parasternal long axis view from
leading edge to leading edge at end diastole except the aortic annulus
which is measured at mid-systole .

39. • These measurements are of utmost importance as they will have
surgical consequences, hence it it important to differentiate three
phenotypes of “ascending aorta” –
• Aortic root aneurysm – sinuses of Valsalva >45mm
• Tubular ascending aneurysm – sinuses of Valsalva 40-45mm
• Isolated AR – all diameters <40mm
• Definition of anatomy of aortic valve cusps and assessment of aortic
valve repairability should also be provided
• In a patient of AR, having BSA <1.68, LVESD should be indexed and cut
off is set at 25mm/m2

40. • Root aneurysms need to have root replacement with or without
preservation of native valve but definitely with coronary
reimplantation.
• Tubular ascending aortic aneurysm require only a supracommisural
tube graft replacement without coronary reimplantation.
• Although valve replacement is the ideal procedure, valve sparing
surgery should be considered in patients who have Type 1 or Type 2
mechanism of AR.

41. • In patients with Moderate AR who undergo CABG or mitral valve
surgery,the decision to treat aortic valve is controversial, as ata shows
that progression of AR is very slow in patients without aortic
dilatation.