AHA: TAA incl hereditary aortopathy & BAV + TEVAR Flashcards
ongoing/subsequent imaging monitoring in BAV with aortic sinuses (root) or asc Ao diameter ≥4.0cm
lifelong TTE/CMR/CTA
interval by rate of progression & fam hx
(2a)
“1. In patients with BAV and a diameter of the aortic sinuses or ascending aorta of ≥4.0 cm, lifelong serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is reasonable, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history.” (2a)
ongoing/subsequent imaging monitoring in BAV s/p AVR with aortic sinuses (root) or asc Ao diameter ≥4.0cm
lifelong serial imaging
(2a)
“2. In patients with a BAV who have undergone AVR, continued lifelong serial interval imaging of the aorta is reasonable if the diameter of the aortic sinuses or ascending aorta is ≥4.0 cm.” (2a)
aortic root or asc Ao threshold to replace in BAV
\≥5.5cm (1)
\≥5cm with RF(s) for dissxn @ COE (2a) OR pt low-risk @ COE (2b)
\≥4.5cm with concomitant SAVR @ COE (2a)
A:h≥10 @ COE (2a)
Do the indications/size threshold to rx/replace aneurysm differ for aortic root v asc Ao in BAV/HTAD/Marfan’s/Loeys-Dietz/Turner?
NO
Do the indications to replace root v asc Ao for aneurysm differ for sporadic?
NO
How does the mgmt of the asc Ao in setting of root aneurysm differ in Marfan’s compared to other situations (sporadic or other HTAD/syndromes)?
replace the asc Ao WITH the rootkom
even if not aneurysmal / regardless of size
indication(s) to replace aortic root or asc Ao in BAV
- >5.5cm (1)
regardless of sx status - asx + 5.0-5.5cm + dissxn RF @ CVC (2a)
- asx + 5.0-5.5cm + low-risk @ CVC (2b)
- SAVR + ≥4.5cm @ CVC (2a)
Is it OK to spare the valve in a normally-functioning AV when replacing the aortic root or asc Ao in BAV?
YES (@ CVC)
(2b)
“4. In patients with a BAV who meet criteria for replacement of the aortic sinuses, valvesparing surgery may be considered if the surgery is performed at a Comprehensive Valve Center.” (2b)
initial mgmt of uncomplicated type B (desc) aortic dissxn
medical tx (1) i.e. anti-impulse tx:
1. IV β-blockade (esmolol) to HR 60-80 (AHA) / HR<60 (SESATS: ∝↓AEs)
2. vasodilators to SBP<120 (AHA)
initial mgmt of ANY acute thoracic aortic dissxn OR injury
anti-impulse tx:
1. IV β-blockade (1) (esmolol) > non-dihydropyridine Ca-channel blocker (2a) to HR 60-80
2. ± vasodilators to SBP<120 (1)
a-line in ICU (1)
pain control (1)
except in hypoTN/hypovolemic shock trauma pts (obviously)
A:h (Ao cross-sectional area : pt height) ratio threshold for aneurysm rx
≥10 cm2/m
in: sporadic, BAV, Marfan’s
Ao landing zones
all vessel landmarks are to the distal end of their origin in the chest & to the prox end of origin in the abdomen
- thoracic
- zone 0 = STJ to innominate artery
- zone 1 = to L carotid
- zone 2 = to L subclv
- zone 3 = to T4 / 2cm distal to L subclv
- zone 4 = to T6 / mid-desc Ao
- zone 5 = to celiac (prox origin)
- abdominal
- zone 6 = celiac to SMA (prox origin)
- zone 7 = SMA to renals (prox origin)
- zone 8 = renals
- zone 9 = infrarenal to Ao bifurc
- zone 10 = CIAs to EIA (prox origin)
- zone 11 = EIAs
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 0
asc Ao incl innominate:
STJ through distal origin of innominate artery
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 1
L carotid:
end of innominate artery through distal origin of L carotid
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 2
L subclavian:
end of L carotid through distal origin of L subclv
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 3
1st 2cm desc Ao:
end of L subclv + 2cm distal / through T4
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 4
mid-desc Ao:
T4 through T6
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 5
low/distal desc Ao:
T6 to prox origin of celiac
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 6
celiac axis:
celiac to prox origin of SMA
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 7
SMA:
SMA to prox origin of renals
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 8
renals:
renals
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 9
infarenal Ao:
end of renals to Ao bifurc
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 10
CIAs:
Ao bifurc to prox origin of EIAs
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
Ao zone 11
EIAs:
from prox origin of EIAs
AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view
aortic root anatomic definition
sinuses of Valsalva
= annulus to STJ
AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view
asc Ao anatomic definition
STJ to prox origin of innominate
AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view
aortic arch anatomic definition
innominate through L subclv artery (prox origin to distal origin)
AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view
desc thoracic Ao anatomic definition
end of subclv to diaphragmatic hiatus
AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view
classifications of Ao dissxn acuity/chronicity:
hyperacute
(by SVS/STS 2020 Reporting Standards)
<24h
from sx onset
classifications of Ao dissxn acuity/chronicity:
acute
(by SVS/STS 2020 Reporting Standards)
2w (1-14d)
from sx onset
classifications of Ao dissxn acuity/chronicity:
subacute
(by SVS/STS 2020 Reporting Standards)
3mo (15-90d)
from sx onset
classifications of Ao dissxn acuity/chronicity:
chronic
(by SVS/STS 2020 Reporting Standards)
> 3mo (>90d)
from sx onset
DeBakey aortic dissxn classification
Type I = asc tear + desc
Type II = asc tear only
Type IIIa = desc tear thoracic only
Type IIIb = desc thoracic tear + abd
Stanford aortic dissxn classification
type A = involving asc (± desc)
type B = involving desc only
regardless of site of entry tear
recommended measurement of thoracic Ao diameters
inner-edge to inner-edge
unless wall abnormalities e.g. atherosclerosis, discrete wall thickening: outer-edge to outer-edge
recommended measurement of aortic root diameter
maximum sinus to sinus
aortic root or asc Ao threshold to replace in non-syndromic HTAD
≥5.0cm (1)
≥4.5cm with RFs OR concomitant <3 surg @ COE (2a)
risk factors (“high-risk features”) for aortic dissxn in BAV
- FH of dissxn @ <5.0cm
- rapid Ao growth (≥0.3cm/y)
- Ao CoA
- “root phenotype”
risk factors (“high-risk features”) for aortic dissxn in non-syndromic HTAD
- FH of dissxn @ <5.0cm
- FH unexplained sudden death <50yo
- rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y)
risk factors (“high-risk features”) for aortic rupture in desc TAA
- rapid Ao growth (≥0.5cm/1y)
- +sx
- genetic aortopathy
- saccular aneurysm
- ♀
- infxs/mycotic aneurysm
risk factors (“high-risk features”) for aortic rupture in TAAA (thoracoabd Ao aneurysm)
- rapid Ao growth (≥0.5cm/1y)
- +sx
- significant ∆ in appearance/morphology
- saccular aneurysm
- PAU
risk factors (“high-risk features”) for aortic dissxn in non-syndromic HTAD
- FH of dissxn @ <5.0cm
- FH unexplained sudden death <50yo
- rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y)
risk factors (“high-risk features”) for aortic dissxn in Marfan syndrome
- FH of dissxn
- rapid Ao growth (>0.3cm/y)
- diffuse aortic root & asc Ao dilation
- marked vertebral artery tortuosity
risk factors (“high-risk features”) for aortic dissxn in Loeys-Dietz syndrome
- FH of dissxn (esp @ young age or small Ao diameter)
- rapid Ao growth (>0.3cm/y)
- severe extra-aortic features
- certain pathogenic variants
- women with TGFBR2 & small body size
risk factors (“high-risk features”) for aortic dissxn in Turner syndrome
- Ao CoA
- Ao dilation
- BAV
- HTN
imaging surveillance of Marfan syndrome (starting @ dx)
TTE @ dx + 6mo to assess growth rate 🠆 Q1Y (1)
postoperative imaging surveillance for Marfan syndrome s/p aortic root replacement
MRI > CTA Q1Y x2y 🠆 Q2Y
(for distal TAD)
medical mgmt of Marfan syndrome
β-blocker and(2a)/or(1) ARB @ max-tolerated doses
medical mgmt of Loeys-Dietz syndrome
β-blocker and/or ARB @ max-tolerated doses (2a)
aortic root threshold to replace BOTH root & asc Ao in Marfan syndrome
replace root AND asc Ao together
≥5.0cm (1)
≥4.5cm with RFs @ COE (2a)
A:h≥10 @ COE (2a)
aortic arch/desc Ao threshold to replace in Marfan syndrome
≥5.0cm (2a)
initial imaging w/u of Turner syndrome
TTE + cMRI @ dx to assess for BAV, root/asc dil, CoA, other congen heart defects (1)
🠆 if no dilation or RFs TTE or MRI Q10Y (1)
if ASI>2.3 aortic imaging (NOS) Q1Y (1)
initial imaging w/u of Loeys-Dietz syndrome
TTE @ dx + 6mo to assess growth rate 🠆 Q1Y (1)
MRI or CTA head to pelvis @ dx (1) + Q2Y (2a)
aortic root or asc Ao threshold to replace BOTH root & asc Ao in Loeys-Dietz syndrome
replace root AND asc Ao together
TGFB3: ≥5.0cm
else: ≥4.5cm
TGFBR1/2 with RFs: ≥4.0cm
else = SMAD3, TGFB2, TGFBR1/2 without RFs
aortic arch/desc Ao threshold to replace in Loeys-Dietz syndrome
TGFBR1/2 or SMAD3:
≥4.5cm (2b)
aortic root or asc Ao threshold to replace in Ehlers-Danlos syndrome
UNKNOWN
“shared decision-making” @ COE
ASI (aortic size index)
max Ao diameter (cm) / BSA (m2)
(used for Turner syndrome ≥15yo: rx ASI≥2.5)
AHI (aortic height index)
max Ao diameter (cm) / height (m)
(used for sporadic TAA: rx AHI≥3.21 @ COE)
aortic root or asc Ao threshold to replace in Turner syndrome
ASI≥2.5 with RFs (2a)
ASI≥2.5 (2b) (without RFs)
(aortic size index = max Ao diam / BSA)
can replace root or asc Ao alone, or can do both together
goal BP for medical mgmt of sporadic TAA
SBP<130
DBP<80
⇒ ↓MACE (1)
aortic root or asc Ao threshold to replace in sporadic TAA
aortic root OR asc Ao:
+sx (1)
≥5.5cm (1)
rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y) (1)
≥5.0cm @ COE (2a)
A:h≥10 if h>1σ above/below μ @ COE (2a)
ASI≥3.08 OR AHI≥3.21 @ COE (2b)
asc Ao only:
≥5.0cm + concomitant SAVR (2a) OR other concomitant <3 surg (2b)
≥4.5cm + concomitant SAVR @ COE (2a)
aortic arch threshold to replace in sporadic TAA
+sx (1)
≥5.5cm + low-risk (2a)
hemiarch with aTAA rx extending into prox arch (2a)
elephant trunk with aortic arch aneurysm rx extending into prox desc Ao (2b)
hybrid or endovascular if high-risk for open surgery (2b)
desc Ao threshold to replace in sporadic TAA
≥5.5cm (1)
<5.5cm with RFs (2b)
≥6.0+cm if high-risk for surgery (2b)
Ao threshold to replace in h/o repaired dissxn or IMH with residual chronic TAD
≥5.5cm (1)
pt risk factors for ↑cxs with open desc TAA rx
age ≥75yo > 65-75yo
CKD3 or ESRD/HD
COPD with FEV1≤50%
h/o stroke
pt risk factors for ↑cxs with endovascular desc TAA rx
fxnal status (dependence)
thoracoabd extent
“pulm dz”
need for EIA access (instead of CFA)
zone 1/2 landing
recommendation for TEVAR v open rx of desc TAA with Marfan, Loeys-Dietz, Ehlers-Danlos syndromes
NONE
AHA does not specify
so do open
general/big-picture recommendation for TEVAR v open rx of desc Ao TAA/type B dissxn
TEVAR (1)
EXCEPT in genetic aortopathy EXCEPT in acute type B dissxn