0910_El-Hamamsy.pdf

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1、Open Management of Type A DissectionsIsmail El-Hamamsy,MD PhDRandall B.Griepp Professor of SurgeryDirector of Aortic SurgeryMount Sinai Health System Icahn School of Medicine at Mount SinaiNew York,NYMalaisrie et al.JTCVS 2021AATS GuidelinesAcute Aortic RegurgitationCoronary MalperfusionAcute Aortic

2、 DissectionEarly survival dictated by malperfusionLate survival dependent on aortic growth Cannulation Strategy Brain protection Management of malperfusion Management of the aortic root Distal extent of repair Decision Points Cannulation Strategy Cerebral protection(DHCA?ACP?RCP?)Malperfusion Manage

3、ment of the aortic root Distal extent of repair Decision PointsMANAGEMENT OF THE AORTIC ROOTManagement of the Aortic RootExtension of dissection below sinotubular junction Detachment of one or more commissuresProlapse of aortic valve cusp(s)Dilatation of sinotubular junction or aortic annulusVast ma

4、jority of aortic valves are normal prior to the dissectionMechanisms of Aortic RegurgitationFor most patients,a sinus-preserving approach is enoughValve ResuspensionResuspension of the aortic valveAvoid reentry tearsInner felt strip or adventitial overlay to avoid“Neomedia”patch Valve Resuspension T

5、ips34F LDS-5 months after resuspension of the aortic valvePatent false lumen in the root Rapidly growing root aneurysm PANE(proximal anastomotic new entry tear)When indicated by root aneurysm OR entry tear in the root OR young patient ageAlso consider:Genetic disorder,valve pathology,extensive disse

6、ction,RCA tear Aortic Root Replacement?Patients with syndromic aortopathy should have their roots replacedAortic Root Replacement20%at 20 yearsUnacceptably high rate of reintervention in syndromic patients with supracoronary graft aloneRylski B et al.Circulation 2014Fate of the Aortic Root in Connec