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Multidisciplinary Thoracic Aortic Rounds History Feedback Content Format
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Multidisciplinary Thoracic Aortic Rounds Foothills Medical
Centre
2016 CCS/CSCS/CSVS Joint Position Statement on Open and
Endovascular Thoracic Aortic Surgery Jehangir Appoo
Multidisciplinary Thoracic Aortic Rounds Foothills Medical Centre
January 29th, 2016 Multidisciplinary Thoracic Aortic Rounds
History Feedback Content Format Why 18mins ? long enough to be
serious and short enough to hold peoples attention Why 18mins ?
long enough to be serious and short enough to hold peoples
attention Speakers have to think about what they want to say. What
is the key point they want to communicate? a clarifying effect
brings discipline Why 18mins ? long enough to be serious and short
enough to hold peoples attention Speakers have to really think
about what they want to say. What is the key point they want to
communicate? a clarifying effect brings discipline Cognitive
Backlog act oflisteningcan be as equally draining as thinking hard
about a subject the more information we are asked to take in, the
heavier and heavier it gets. Eventually, we drop it all, failing to
remember anything we've been told. CCS/CSCS/CSVSJoint Position
Statement onInterventions for Thoracic Aortic Disease
CCC Oct.2015 Toronto Canadian Journal of Cardiology, In Press 2014
Topics: Size thresholds, Genetics, Medical Therapy, Diagnostic
Imaging Surgery and Endovascular Interventions not covered Process
Proposal for Position Statement accepted
Nationally Representative Primary Panel Cardiac & Vascular
Surgery Focus on novel and emerging technical aspects of thoracic
aortic disease interventions Structured and focused literature
review Not expert consensus opinion Primary literature Existing
systematic reviews when present Creation of summary tables Process
GRADE criteria Quality of Evidence: Low, medium, or high
Cohort studies, RCTs Recommendations: graded as strong or weak
Quality of evidence Balance btw desired and undesired effects
Values and Preferences Process Voting by Primary Panel
Review by International Secondary Panel Review by CCS Guidelines
Committee Review by CCS, CSCS, and CSVS Executive *avoided use of
centres of expertise term in Recommendation Primary Panel Jehangir
Appoo (Co-chair) University of Calgary
John BozinovskiUniversity of British Columbia Michael ChuWestern
University Ismail El-HamamsyUniversity of Montreal Tom L. Forbes
University of Toronto Michael MoonUniversity of Alberta Maral
OuzounianUniversity of Toronto Mark PetersonUniversity of Toronto
Jacques Tittley McMaster University Munir Boodhwani
(Co-chair)University of Ottawa Secondary Panel Joseph E. Bavaria
University of Pennsylvania Francois Dagenais Laval University Mark
Farber University of North Carolina Chad Hughes Duke University
Thoralf Sundt Harvard University Sections Aortic valve preservation
and repair
Aortic valve replacement in the young Perfusion techniques for
aortic arch surgery Total and Hybrid Arch repair Extended repair
for type A dissection Total endovascular arch repair Descending
thoracic aortic aneurysms Acute type B dissections Chronic type B
dissections Document contains total of 20 Recommendations
Highlights Today Aortic valve preservation and repair
Aortic valve replacement in the young Perfusion techniques for
aortic arch surgery Contemporary total and hybrid arch repair
Extended repair for type A dissection Total endovascular arch
repair Descending thoracic aortic aneurysms Acute type B
dissections Chronic type B dissections 8 recommendations Share some
data behind recommendations Aortic Valve Preservation Functioning
Aortic Valves in Root Aneurysms 17 Free Margin Plication
Reimplanation and BAV repair Total Follow-up Time: 11,274
pt-years
Meta-Analysis Takkenberg Ann Thorac Surg 2015 N = 2,891 Patients
Total Follow-up Time: 11,274 pt-years Early Mortality Pooled
Estimate: 1.53% (0.90 2.3) Endocardits Pooled Estimate: 0.23%/pt-yr
(0.08 0.44) Thrombo-embolism Pooled Estimate: 0.33%/pt-yr (0.2 0.4)
Late AV Reoperation Pooled Estimate: 1.2%/pt-yr (0.6 2.0) PROACT
Trial Mechanical Valve
Outcome Low INR Regular INR P-value Neurologic Events 2.07%/pt-yr
1.46 %/pt-yr 0.38 All TE 2.67%/pt-yr 1.59 %/pt-yr 0.16 TE +
Thrombosis 2.96%/pt-yr 1.85 %/pt-yr 0.17 Total Mortality
1.48%/pt-yr 1.46%/pt-yr 0.97 Total Bleeding 6.62%/pt-yr 4cm False
Lumen > 22mm Large proximal entry tear >1.0cm #7 We recommend
that patients with uncomplicated acute type B aortic dissections be
managed with hypertension and pain control and radiologic
surveillance. (Strong Recommendation, Medium quality evidence)
Values and Preferences: If patients remains uncomplicated early
follow up imaging at hrs and 1-4 weeks is recommended to detect
early signs of aneurysm expansion and radiologic malperfusion. #8
We suggest that endovascular repair be considered for patients with
uncomplicated type B aortic dissections to improve aorta-specific
endpoints (Weak recommendation, Low quality evidence) Values and
Preferences: The Instead XL trial which randomized patients in the
delayed phase (2-52 weeks) showed decreased aorta specific 5-year
mortality and improved aortic remodelling. The ADSORB trial which
randomized patients in the acute phase (< 2 weeks) showed
improvement in aortic remodelling at one year. Summary: Evolution
in open and endovascular aortic surgery Improved patient outcomes
Rapid change thus, little high quality evidence to make strong
recommendations New Recommendations: Valve Repair.with caution in
regurgitant valves Extended arch at time of Type A.distal tears,
aneurysm strong recommendation Asymptomatic Type B
Dissections.consider early TEVAR weak recommendation Highlights
Today Aortic valve preservation and repair
Aortic valve replacement in the young Perfusion techniques for
aortic arch surgery Total and hybrid arch repair Extended repair
for type A dissection Total endovascular arch repair Descending
thoracic aortic aneurysms Acute type B dissections Chronic type B
dissections
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