1. Thoracic Surgery Brian Schwartz, CCP Perfusion Technology II

2. Dissections Aortic Dissection:Aortic Dissection: Occurs when blood penetrates the aortic intima and forms an expanding hematoma within the vessel wall, usually separating the intima and mediaOccurs when blood penetrates the aortic intima and forms an expanding hematoma within the vessel wall, usually separating the intima and media

3. Classification of Aortic Dissections DeBakey ClassificationDeBakey Classification Depends on the location of the intimal tear and the section of the aorta involvedDepends on the location of the intimal tear and the section of the aorta involved Type I: The intimal tear is located in the ascending aorta and involves the ascending and descending aorta as well as the archType I: The intimal tear is located in the ascending aorta and involves the ascending and descending aorta as well as the arch Type II: The tear is in the ascending aorta, involving only the ascending aorta stopping before the innominate arteryType II: The tear is in the ascending aorta, involving only the ascending aorta stopping before the innominate artery Type III: The intimal tear is located in the descending aorta and the dissection involves the descending portion of the aortaType III: The intimal tear is located in the descending aorta and the dissection involves the descending portion of the aorta

4. Classifications

5. New Classification for Aortic Dissections Stanford ClassificationStanford Classification Type A: Dissections that involve the ascending aorta regardless of where the intimal tear is located and regardless how far the dissection propagatesType A: Dissections that involve the ascending aorta regardless of where the intimal tear is located and regardless how far the dissection propagates Type B: Dissections that involve the aorta distal to the origin of the left subclavian arteryType B: Dissections that involve the aorta distal to the origin of the left subclavian artery

6. Stanford Dissections Type A Type B Type A

7. Various Types of Aortic Dissectons

8. Risk Factors for Aortic Dissections History of hypertensionHistory of hypertension Advanced age (patients over the age of 60)Advanced age (patients over the age of 60) Sex…Males are 5 times more likely than womenSex…Males are 5 times more likely than women Marfan’s SyndromeMarfan’s Syndrome Congenital Heart Disease (Coarctation of aorta, biscupid aortic valve)Congenital Heart Disease (Coarctation of aorta, biscupid aortic valve)

9. The difference between aortic aneurysm and dissection An aortic aneurysm involves the dilation of all three layers of the blood vesselAn aortic aneurysm involves the dilation of all three layers of the blood vessel

11. Aortic Aneurysm

12. Repair of Ascending Aortic Dissection/Aneurysm Normal cannulation sites if surgeon is able to clamp the aortaNormal cannulation sites if surgeon is able to clamp the aorta If pathology involves the innominate artery, surgeon must cannulate femoral arteryIf pathology involves the innominate artery, surgeon must cannulate femoral artery Need to cool patient to 18 degrees (deep hypothermia)Need to cool patient to 18 degrees (deep hypothermia) Shut off pump (circulatory arrest) while surgeon repairs the aortaShut off pump (circulatory arrest) while surgeon repairs the aorta

13. Aortic Root Replacement

14. Repair of Ascending Aortic Dissection/Aneurysm Retrograde Cerebral PerfusionRetrograde Cerebral Perfusion Utilized when surgeon can’t cannulate aortaUtilized when surgeon can’t cannulate aorta A technique used during circulatory arrest procedures to help reduce neurological problemsA technique used during circulatory arrest procedures to help reduce neurological problems Deliver oxygenated blood through the SVC to perfuse brain in a backward fashionDeliver oxygenated blood through the SVC to perfuse brain in a backward fashion Pressures and Flows are extremely importantPressures and Flows are extremely important Pump Flows between 500cc/min to one liter/minPump Flows between 500cc/min to one liter/min CVP no more than 25mmHgCVP no more than 25mmHg Communication with surgeons is a MUST:Communication with surgeons is a MUST: ClampsClamps Blood Return and Blood ColorBlood Return and Blood Color TimeTime

15. Safe Period During Circulatory Arrest