Fellow Education Lecture Series 07252020 Arun K Singhal MD PhD Associate Professor Cardiac Surgeon Department of Surgery Divison of Cardiothoracic Surgery University of Iowa Health Care ID: 1035921
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1. The Aorta 101American College of Cardiology, Iowa ChapterFellow Education Lecture Series07/25/2020Arun K. Singhal, MD, PhDAssociate Professor, Cardiac SurgeonDepartment of Surgery, Divison of Cardiothoracic SurgeryUniversity of Iowa Health Care
2. The PlanAnatomic ApproachImagingSpecial Cases
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4. The AortaThe Aorta is the largest artery of the body which carries the oxygenated blood from the left ventricle and supplies it to all the parts of the body.The aorta initially is one inch wide in diameter.The aorta is classified as a large elastic artery.
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6. THE AORTAAscending Aorta – NeuroectodermAortic ArchThoracic (Descending) AortaAbdominal AortaCan be divided into four sections:MesodermThe first 3 sections are confined to the thoracic cavity and together create the Thoracic Aorta.– The Aorta terminates at the level of L4 by bifurcating into the left and right common iliac arteries.
7. Figure 1. Segments of the ascending and descending aorta. rPa = right pulmonary artery. European Heart Journal, Volume 35, Issue 41, 1 November 2014, Pages 2873–2926, https://doi.org/10.1093/eurheartj/ehu281
8. FemaleMaleNormal Anatomy (Caucasian)19-23 mm21-25 mmDilated/Ectatic Aorta (1.5 x normal)≈ 35≈ 40Aneurysm (2x normal)≈ 40≈ 45
9. Loren F. Hiratzka. Circulation. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease, Volume: 121, Issue: 13, Pages: e266-e369, DOI: (10.1161/CIR.0b013e3181d4739e)
10. Ascending AortaOriginates from the upper end of the left ventricle Continues as an arch of aorta at the sternal angleAbout 5 cm longEnclosed in the pericardium andBegins at level of the lower border of left 3rd costal cartilage, runs upwards, forwards and to the right to continue as the arch of aorta at the level of sternal angle.
11. Ascending AortaThe Annals of Thoracic Surgery 2013 95S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Fig 26. Hazard curves showing increasing risk of biological aortic valve replacement (AVR) failure after approximately 7 years but declining risk with repair.
12. IntroductionAortic dissection is a serious condition in which there is a tear in the wall of aorta.In aortic dissection, blood seeps into the media separating the media. The outer layer also contains media and adventitia.During an aortic dissection the inner layer of aorta tears, letting blood in where it usually doesn’t go.This causes the inner and middle layers to separate or dissect.If the blood bursts through the outer wall of aorta, it’s life-threatening and needs immediate repair.
13. Figure 6. Flowchart for decision-making based on pre-test sensitivity of acute aortic syndrome. AAS = abdominal aortic aneurysm; AD = aortic dissection; CT = computed tomography; MRI = magnetic resonance imaging; TOE = transoesophageal echocardiography; TTE = transthoracic echocardiography.European Heart Journal, Volume 35, Issue 41, 1 November 2014, Pages 2873–2926, https://doi.org/10.1093/eurheartj/ehu281
14. Loren F. Hiratzka. Circulation. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease, Volume: 121, Issue: 13, Pages: e266-e369, DOI: (10.1161/CIR.0b013e3181d4739e)
15. Goals of Aortic DissectionPatient SalvageNo TamponadeNo MIFix ValveIdentify and seal the tearLong-term survivalIntramural HematomaDo Nothing
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17. Management of Acute Aortic Root and Ascending Aortic Dissection—RecommendationsClass ITimely diagnosis is recommended utilizing cross-sectional imaging techniques or TEE. The latter can be performed in the operating room before sternotomy if needed to confirm the diagnosis. (Level of evidence B)Ascending aortic replacement (including resection of primary aortic tear) should be performed for patients with acute type A aortic dissection [1] (Level of evidence B)An open distal anastomotic, hemiarch or total arch replacement technique is effective for the distal reconstruction of an acute type A dissection [1]. (Level of evidence B)Ascending aortic and aortic arch replacement is indicated for patients with acute type A aortic dissection and a primary or secondary tear within the arch that involves or extends beyond the left common carotid arterial ostium with marked dilation of the aortic arch (>50 mm). (Level of evidence C)
18. Management of Acute Aortic Root and Ascending Aortic Dissection—RecommendationsClass IAortic root replacement is indicated for patients with acute type A aortic dissection and a primary tear that extends or originates in the left or right coronary sinuses or marked dilation (>45 mm) of the aortic root below the sinotubular junction. (Level of evidence C)Arterial inflow cannulation for cardiopulmonary bypass during type A dissection repair should perfuse the true lumen directly. (Level of evidence C)Long-term radiologic surveillance after aortic dissection with or without surgical reconstruction should be performed at regular intervals of at least every 6 months for the first year and then annually. (Level of evidence C)Long-term annual echocardiographic surveillance is recommended for patients in whom an aortic valve-preserving reconstruction or bioprosthetic valve replacement was performed. (Level of evidence C)
19. Descending Aortic DissectionAggressive Acute Medical ManagementArterial LineAnti-Impulse control IVSwitch PONPO 24 hoursAggressive MonitoringRepeat CT before discharge3, 6 monthsRepair Guidelines unclearGrowthEnd-organ concerns
20. The Story ContinuesFigure 2. Freedom from reoperation based on late β‐blocker therapy. Operative survivors were divided into two groups based on whether they were taking β‐blocker medication at late follow‐up. Kaplan‐Meier analysis demonstrated a lower reoperation rate in the group receiving β‐blockers.
21. Figure 3. Freedom from reoperation based on late systolic blood pressure (SBP). Operative survivors were divided into three groups based on SBP at late follow‐up (SBP<120 mmHg vs SBP 120–140 mmHg vs SBP>140 mmHg). Kaplan‐Meier analysis demonstrated less need for reoperation in patients with SBP <120 mmHg compared with those with SBP of 120 mmHg to 140 mmHg or SBP >140 mmHg.
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26. Ascending Aorta and Aortic Arch—RecommendationsClass IAll patients with suspected thoracic aortic disease on the basis of family history, symptoms, or physical examination should have the entire thoracic aorta imaged. (Level of evidence C)All patients with a bicuspid aortic valve should undergo imaging of the thoracic aorta [1]. (Level of evidence B)All patients with Marfan syndrome or Loeys-Dietz syndrome or mutations associated with aortic disease or dissection should have the entire aorta imaged and appropriate blood testing performed for genetic mutations [1]. (Level of evidence B)First-degree relatives of young patients with a bicuspid aortic valve or genetic mutation associated aortic disease of the thoracic aortic disease should be advised to be further investigated. (Level of evidence C)
27. Ascending Aorta and Aortic Arch—RecommendationsClass IAll patients for whom planned elective valvular surgery is planned and who have associated thoracic aortic disease should undergo preoperative cardiac catheterization [1]. (Level of evidence B)Additional testing to quantitate a patient’s comorbid status and develop a risk profile is recommended. These tests may include for particularly high-risk patients CT of the chest if not already done, PFTs, 24-hour Holter monitoring, noninvasive carotid screening, brain imaging, echocardiography, neurocognitive testing, and assessment of degree of frailty. (Level of evidence C)Intraoperative TEE is recommended for all patients undergoing surgery for thoracic aortic disease. (Level of evidence C)
28. Ascending Aorta and Aortic Arch—RecommendationsClass ISurgical repair is recommended when the ascending aorta or aortic root exceeds 5.5 cm if the patient has no genetically based aortic disease and is otherwise a suitable candidate for surgery [1]. (Level of evidence B)Patients with genetically associated aortic diseases, including those with a bicuspid aortic valve, should undergo surgery at diameters exceeding 5.0 cm unless a family history of aortic dissection is present, then it is acceptable to lower the threshold to 4.5 cm. Alternatively, patients with a maximal ascending aortic area (πr2, cm2) to height in meters ratio exceeding 10 should be considered for surgery [1]. (Level of evidence B)Patients with a growth rate exceeding 0.5 cm per year should be recommended to undergo surgery if no other limitations apply [1]. (Level of evidence B)
29. Ascending Aorta and Aortic Arch—RecommendationsClass IFor patients with Loeys-Dietz syndrome or confirmed TGFBR1 or TGFBR2 mutation should be evaluated for repair of the aorta when the diameter exceeds 4.2 cm. (Level of evidence C)For patients undergoing cardiac surgery other than for aortic indications, aortic repair is recommended when diameter exceeds 4.5 cm [1]. (Level of evidence B)Aortic diameters should be measured at right angles to the axis of flow, which requires the use of three-dimensional reconstructive software. The maximal diameters at each segment of the aorta should be reported. Echocardiography measures internal diameters while CT and MRI measures external diameters, and thus some allowance should be made for echocardiographic measurements being smaller. (Level of evidence C)
30. Ascending Aorta and Aortic Arch—RecommendationsClass ISeparate valve and ascending aortic replacement are recommended for patients without significant aortic root dilation, for elderly patients, and for young patients with minimal dilation in whom a biological valve is being inserted or a bicuspid valve is being repaired [1]. (Level of evidence B)Patients with Marfan, Loeys-Dietz, and Ehlers-Danlos syndromes and root dilation should undergo excision of the sinuses in combination with a modified David valve reimplantation procedure if technically feasible or insertion of a valve graft conduit [1]. (Level of evidence B)For more complicated arch reconstructions requiring extended periods of circulatory arrest, use of adjunctive brain perfusion techniques is recommended [1]. (Level of evidence B)
31. The location at which the aorta is abnormal (see section 2).The maximum diameter of any dilatation, measured from the external wall of aorta, perpendicular to the axis of flow, and the length of the aorta that is abnormal.For patients with presumed or documented genetic syndromes at risk for aortic root disease measurements of aortic valve, sinuses of Valsalva, sinotubular junction, and ascending aorta.The presence of internal filling defects consistent with thrombus or atheroma.The presence of IMH, PAU, and calcification.Extension of aortic abnormality into branch vessels, including dissection and aneurysm, and secondary evidence of end-organ injury (eg. Renal or bowel hypoperfusion).Evidence of aortic rupture, including periaortic and mediastinal hematoma, pericardial and pleural fluid, and contrast extravasation from the aortic lumen.When a prior examination is available, direct image to image comparison to determine if there has been any increase in diameter.IMH indicates intramural hematoma; and PAU, penetrating atherosclerotic ulcer.Table 5. Essential Elements of Aortic Imaging Reports
32. Loren F. Hiratzka. Circulation. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease, Volume: 121, Issue: 13, Pages: e266-e369, DOI: (10.1161/CIR.0b013e3181d4739e)
33. The Usual SuspectsBeta BlockerACEARBStatinEnd point is ”rate of progression”
34. Advice for Activity with an Aortic Aneurysm0: Body Building, weightlifting, Scuba Diving, Skydiving1: Ice Hockey, Rock Climbing, Windsurfing, Surfing 2: Basketball, Racquetball/Squash, Sprinting, Skiing, Soccer, Baseball/Softball, Motorcycling, Sailing3: Touch/Flag Football, Biking, Jogging, Swimming, Hiking, Horseback Riding4: Tennis, Treadmill, Stationary Bike5: Modest Hiking, Bowling, Golf, Skating, Snorkeling, Brisk Walking** MODERATION IS KEY!We tend to advise to try to avoid bearing down with heavy weights. Instead, low weight with higher repetition would be better. Vascular Surgery at UIHC says less than 20 pounds and Cardiothoracic Surgery will recommend less than 50 pounds. The evidence is limited.Recreational activities are also something to think about. We had a patient email about roller coasters. There is evidence in the literature of dissections from the extreme rides where it is 0 to 100 kind of thing. Again, do not avoid fun and amusement parks all together, but rapid accelerations/decelerations or the older rides that really shake you up might not be the best idea.
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36. Aortic ArchIts location is in the superior mediastinum.The aortic arch is a continuation of the ascending aorta and begins at the level of the second sternocostal joint.It arches superiorly, posteriorly and to the left before moving inferiorly.The aortic arch ends at the level of the T4 vertebra(i.e. at level of sternal angle).The arch is still connected to the pulmonary trunk by the ligamentum arteriosum.Remnant of the fetal ductus arteriosus
37. Branches of the Arch of AortaThere are three major branches arising from the aortic arch.Proximal to distal:Brachiocephalic trunk: The first and largest branch that ascends laterally to split into the right common carotid and right subclavian arteries. These arteries supply the right side of the head and neck, and the right upper limb.Left common carotid artery: Supplies the left side of the head and neck.Left subclavian artery: Supplies the left upper limb.Occasionally, a fourth branch eitherthyroidea ima or vertrebral artery may originate from the arch of aorta.
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39. Descending AortaThe descending aorta is the section of the thoracic aorta which is contained in the posterior mediastinum.It originates leveled along with the lower boundary of the T4 vertebra, consistent with the aortic arch, and also terminates anterior to the lower boundary of the T12 vertebra within the aortic hiatus.It initially begins to the left of the vertebral column but approaches the midline as it descends. It leaves the thorax via the aortic hiatus in the diaphragm, and becomes the abdominal aorta.
40. Descending AortaFor patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended. 371,382,468 (Level of Evidence: B)For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible. 371,469 (Level of Evidence: B)
41. Descending AortaFor patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present. 371 (Level of Evidence: C)For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure
42. Special CasesPregnancy With or without genetic diseaseCounseling before pregnancyAdverse events during Pregnancy/DeliveryGenetic DiseaseMarfans/Loeys-DietzBicuspid – family testingPoor Endovascular repair optionsCoarctation
43. The PlanAnatomic ApproachAscending AortaThe Rest of the Aorta ImagingMethodologyStandard ReportSpecial CasesBicuspidPregnancyGenetic Diseases
44. ANSWER KEYGuidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation. 2010;121:e266-e369.ACC/AHA Pocket Guideline Based on the 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal (2014) 35, 2873–2926
45. THANK YOUEmailArun-Singhal@uiowa.edu