DISECCION AORTICA TIPO B

Arturo Evangelista

Variable All Type A Type B p-value

(n=1351) (n=846) (n=505)

Age (yrs) 62.4 61.3 64.1 <0.001

Male 67.5% 66.5% 69.1% NS

HTN 71.4% 68.5% 76.2% 0.003

Marfan 4.6% 5.4% 3.4% 0.10

Prior Heart 17.6% 16.3% 19.7% 0.13

Surgery

Iatrogenic 4.6% 5.5% 3.0% 0.04

Demographics and History

IRAD Investigators

IRADPhysical Exam (n=1351)

Variable

High BP

Low BP

Shock/Tamponade

Murmur AR

Pulse Deficit

Stroke

All

45.0%

11.0%

11.6%

31.2%

24.8%

5.5%

Type A

31.1%

16.0%

17.6%

42.1%

28.9%

7.5%

Type B

67.1%

2.9%

1.8%

14.2%

18.2%

2.2%

p-value

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

IRAD Investigators

0

20

40

60

80

100

<=2.9 3.0-3.4 3.5-3.9 4.0-4.4 4.5-4.9 5.0-5.4 5.5-5.9 6.0-6.4 6.5-6.9 >=7.0

Descending Aortic Diameter ≥ 6.0cm:

A Poor Predictor of Type B Aortic Dissection

Co

un

t

Trimarchi S, et al. J Am Coll Cardiol 2009;53: A452.

Descending Diameter

Eur J Echocardiog 2010;11;645-50

Three-year mortality of Type B AAS

Tsai TT, Evangelista A et al. Circulation 2006;114:2226-31

10,0%

22,4%

29,0%

17,2%

11,0%

23,8%

0,0%

10,0%

20,0%

30,0%

40,0%

Medical Surgical Endovasc.

In Hospital Follow-Up

p=ns

Registro Español del Síndrome Aórtico Agudo

Mortalidad Tipo BRegresión Logística Análisis Multivariado

Supervivientes

%

Exitus

%

OR ajustada Rango P

Shock 8,9 23,7 2,59 0,89-7,58 0,08

Déficit

neurológico

6,5 21,1 3,22 0,96-10,30 0,06

Isquemiamesenterica

0,8 23,7 41.74 4,89-356,37 0,001

Insuficiencia

renal

16,9 47,4 2,44 0,98-6,07 0,05

Modelado multivariado valor predictivo 81,2%

N:162 (31%

Compression Celiac Trunk and

Mesenteric Artery Ostia

ISQUEMIA MESENTERICA

Type B Dissection

Use of Endovascular tx and Mortality

12%

10%

20%

12%

0%

4%

8%

12%

16%

20%

1996-2000 2000-2008

Endovascular

Mortality

p=.004

p=.72

Long-Term Outcome of Aortic Dissection with Patent False Lumen

Cumulative Survival Free of Aortic Events

0.0

00

.25

0.5

00

.75

1.0

0

Su

rviv

al

0 1 2 3 4 5 6 7 8 9 10Follow up time (years)

Type A

Type B

Type A

Type B

140 patients

84 Type A

56 Type B

FU: 6.8 y

Type B Dissection

Predictors of Complications

• FL Size

• TL Compression

• False lumen flow

J AM Coll Cardiol 2007;50:799-804

Tsai TT, Evangelista A, N Engl J Med 2007;357:349-359.

Tsai T, Evangelista A et al. NEJM 2007;357:349-359.

Entry tear location and size by TEE / CT

Entry Tear Location and Size

10,008,006,004,002,000,00

tiempo de seguimiento hasta el evento final(muerte, cirugía o stant de la AD)

1,0

0,9

0,8

0,7

0,6

0,5

0,4

Cu

m S

urv

ival

3,00

2,00

1,00

,00

0 '>9 y proximal' 1'>9 y NO Proximal'2 '<10 y proximal'

3 '<10 y NOproximal'

Survival Function for patterns 1 - 4

Adjusted survival free from sudden death or surgical or endovascular treatment

Proximal > 10mm (n=47)< 10 mm (n=25)

Not proximal> 10mm (n=29)< 10mm (n=39)

< 10mm not proximal

< 10mm proximal

> 10 not proximal

> 10 proximal

n: 140

Descending Aorta Enlargement

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

Type A Type B < 10 mm > 10 mm

P<0,001p: ns

0.68 1.67

1.07 1.80

0.41 0.73

1.62 2.72

mm/y

Follow-up: 6.8 y

Usefulness of real-time three-dimensional transoesophageal echocardiography in the assessment of

chronic aortic dissection.

Eur J Echocard in press

Artur Evangelista, Rio Aguilar , Hug Cuellar, Martin Thomas, Ana Laynez, Jose Rodríguez-Palomares, Patricia Mahia,

Teresa González-Alujas, David Garcia-Dorado.

Tratamiento Médico Endovascular+

Médico

p

Mortalidad 4,4% 11,1% 0,2

Mortalidad

aórtica

2,9% 5,6% 0,7

Cirugía 4,4% 4,2% 1

Paraplegia 1,4% 2,8% 0,9

AVC 0 2,8 0,5

Diámetro Ao

mm

48±13 44±13 0,3

Diámetro FL

mm

27 ±10 14±16 <0,001

597 pacientes (DA tipo B >14 dias) 293 rechazaron

164 exclusión

140 randomizados

Trat. Endovasc: 39 dias (18-252)

Endovascular TreatmentLarge and proximal entry tear