T V

Table 7.2. Surgical decisions for Type A aortic dissection

Management of Aortic Valve

• Resuspend valve

• Leave aortic valve alone

Management of Coronary Arteries

• Reimplant coronaries

• Leave coronaries alone and place supracoronary graft

Management of Transverse Arch

• Place graft proximal to arch

• Replace arch of 70%, and is therefore the preferred treatment.

Ascending aortic dissection is a dangerous condition that requires treatment. The ECHO, CT, and angiogram are useful in establishing the diagnosis of acute aortic dissection and evaluating its characteristics. ECHO delineates the extent and location of the intimal tear in the ascending aorta, including coronary artery involvement and aortic valve competence. In a patient with suspected acute aortic dissection, an ECHO alone will diagnose a Type A dissection and mandate surgery. CT and angiograms, including coronary angiography, are generally not warranted preoperatively in an acute setting where the diagnosis is made by ECHO. The angiogram, however, remains the gold standard to delineate the extent and

location of the intimal tear, location of the false lumen, and specifics of the visceral vessels.

It is imp ortant to remember that on occasion there may be a Type B dissection which progresses retrogradely to dissect up into the transverse and then ascending aorta even though the actual tear is in the aorta distal to the take-off of the left subclavian artery. This condition still requires surgery because it may further dissect down to the coronaries or aortic valve or rupture into the pericardium. Blood pressure control is mandatory in these patients, and includes not only vasodilator treatment with Nipride but also beta blockers to decrease the force of contraction, thus decreasing dP/dT and sheer force exerted on the dissection. Hypertensive therapy with beta blockers and vasodilators is the mainstay of management for

Aortectomy

Fig. 7.5. Repair of Type A aortic dissection with valve resuspension. (a) Type A aortic dissection with aortic insufficiency. Right atrial-femoral artery bypass is established. (b) Longitudinal aortomy revealing true and false lumens. (c) Resuspension of aortic valve with two plegetted sutures at each commissure. (d) Inner and outer felt secured at proximal and distal aorta using a whip stitch. (e) Interposition tube graft placed between proximal and distal aorta.

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