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Can you hear me? Uh Yes, yes, I can hear you. Ok, thanks. Yeah. Um So maybe try presenting your screen. Uh OK. So you use at night? Yes. Yes, I can say um It's not in present time. Mo Yes, now it's, yes. Um So you still have a few minutes to seven. So just um wait for other people to join and then I'll introduce you and then we can start. So I will say that we will just um wait for a few minutes to seven and then um let others and then we can start. Sorry, I just saw on your slide now that it's consultant. I, I know I put um senior reg on this. So I would correct that. Yeah, that's, that's change role. So that's fine. Um But I hear my audio very well. Yes. Yes. Ok. Thank you. Uh huh. OK. Um Welcome everyone. It's seven o'clock already. So we'll start and others will join us as they come. So welcome to the welcome to the third session of the teaching series Basics of cardiothoracic surgery. Um The first session we spoke on cardio um cardiopulmonary bypass. On the second session we spoke on cardiac ology and today we'll be speaking about aortic diseases and aortic surgeries. And we talk today in um Mis Benjamin Owe who is a consultant, characteristic Surgeon at Castle Hospital um in the UK, and he will be taking us on this series. Um So it's going to be about an hour session. If you have any questions in between, please feel free to put it on the charts. And um um at the end of the teaching session, you will be happy to um answer this. You'll be happy to answer your question afterwards. Um um Yeah, so that's it. And um I will leave it to the floor just before we start. Also, let me just say that this is a se a session, a teaching series of about 10 sessions. So we have about seven sessions to go. Um This is the third session and subsequently other sessions will be announced as as uh in due course, the next session which is the second part of the cardiac physiology will be taking place actually on Monday um which is the 17th. The um the advance is already on the me page. You can sign up for it if you're interested. Um If you um we attended the first cardiac physiology course, it's a conation of that. It will be taken by um De Dine who is a um cardio trainee at hospital. So um be happy for you to sign off on that. Um I'll open up the floor now to Mister Benjamin who will, who will start the session on aortic diseases and aortic surgeries, Mister Ben Happy for you to reintroduce yourself as Ac Fit. Um Thank you very much for accepting the invitation to teach on this platform. I'm really grateful and um yeah, uh thanks for the kind introduction. So um I'm, I'm glad to be here to talk to all of us about um aortic diseases. Wow, it's not really basic cataract surgery, but uh everyone should be aware of what this involves and I will discuss some common things that will of interest to everyone here. Hopefully, and I'm happy to have questions later. If everyone is happy, I will just trying to share my slides. Now, can everyone see my slides, please? Can I wanna see my slides? Yes. Yes, you can. All right. Thank you. Uh So this is where I work. I work in Hall. It's um the Yorkshire region. Uh it's in the north of England and there's a little garden here when the weather is good, we come out here to have some rest. So I will hopefully go through this um outline and, and discuss some new stuff if we are interested about that. So I look at the aorta first. Uh is this big tube that connects the left ventricle to the whole body? So, uh if you can see my cursor, you go down here where the aortic valve lies and this complex from this sinotubular junction to the annulus. Here is what we call the aortic root. So the root contains the annulus, the valve leaflets, the sinus of valsalva and the sinotubular junction. Then it goes like a silica tube all the way down to the groins and in the head and neck. Here, we have the arch vessels and just before the brachycephalic artery here and after the subclavian artery on the left side here, that's is the aortic arch and just beyond the left subtalar artery down to the diaphragm, the descending thoracic aorta and blow diaphragm is the abdominal aorta t bio into the iliac vessels in we times. Now, it depends on the way you walk around the world. And the purview of the cardiac surgeon uh is nearly limited to just from the subclavian down to the a the root this area you we imagine can be dealt with in, in the vas are stenting. Nowadays, uh this will be available in every country. So all uh cat cat surgeons may still deal with this via open procedures. In some cases, you may still require that open procedures even in advanced centers. So what are the common diseases that could affect the uh aorta? The the common ones I'll discuss here is aneurysms when the aorta becomes enlarged beyond its normal expected size for age and sex or what we call the acute aortic syndromes, which are the emergent presentations of aortic diseases other conditions could be inflammatory or congenital. But what so we mostly deal with is the aneurysms, the acute aortic symptoms and some congenital conditions. Um So as surgeons, what we see mostly in the order, how we see they put this way, uh or uh in the order, how it's most in the can with our way is the one with the a Syndros. But these are things you need to identify and manage as an emergency. Then we have the aneurysms, we can, we can manage electively on the cold light of day. And the coarctation which is common in Children or missed in adults. So if I just go through quickly, what do we mean by acute aortic syndromes? So the iota if you have a histology of the Aortic Arctic wall, uh if you see my cursor, this is the lumen, this is where blood flows, which is always nice. This in yellow layer here is the intima in the tunica intima penny layer in the tial layer. And this area we have muscle mu muscle fibers is the media tunica media and the external one is the advent. So these all parts of the normal aorta. However, in a dissection, uh there has been a rupture, end of this intima and blood is flowing from the lumen of the aorta into the tunica media, creating eventually two lumens. So blood will flow here which we, as we we, we got as a true lumen and blood also flow here, which we got now the false lumen. And these are what leads to the consequence of what the dissection really uh leads to and why it's quite urgent to treat this patient. Otherwise they have end organ malfunction and possibly die the intramural hematoma. So if you have muscle fibers, you also have blood supplies to these muscles. Um most common blood apply what we call the vasa vaso. Uh these small blood vessels could rupture and when they rupture, they could lead to bleeding into the tonic media. And this patient who present make them with pain cause why do they have pain? Because stretching when there's bleeding here, this space in the media expands and stretches the Aventis. The aia contains the um um pain fibers that we now uh perceive as pain, uh central chest pain. Uh We know that most of patients with this or these are in evolution, you can rupture hair, you have bleeding into the media and it could eventually rupture into the two. Do you have like a dissection? So, it could be an evolution and that's why we manage uh this patient similarly to a dissection. And lastly, here is the PA U or the pen atherosclerotic ulcer. So, these are patients who chronic patients with atherosclerosis, very calcified vessels. And what happen is that this calcium and the vessels cause they normal expansile as we know they not really smooth muscle. The calcium uh with, with hypertension. This could also rupture and easily blood flows into the media and forms a kind of a protrusion of a swelling around the a there. Um I will see them in patients mostly common in the arch and we'll discuss how to manage them in your next follow following slides. So I'll start with a dissection, which is I would say the the thing thing, everyone in A&E every doctor should be aware that is a condition. Uh We discuss this ology, whether it just a tear within the intima. And so if it has a tear as an entry point, this word entry point is very important in the m of this patient. The word also for women is very important in the moment of this patient. So we need to keep this in our minds. They could be acute, chronic or of acute. So if a patient presents within the first two weeks, uh we tend to call them as acute aortic dissection, I would treat them as such if they present um maybe comes for a cann for something else. And they said, O2 months, you have some pain but you went through the five days and you do a scan and you find a dissection from the scan like oh boy, yes, that's a coding dissection now because it beyond two weeks. So we call it after that. After two months, it is coding dissection between two and two months. We heard of acu and the moment varies slightly. Uh Now there's what we call type A and type B, which I will show you the slide. So just to say that A A I is in mostly because of the ACA syndromes. So why is the section of significant uh because it has a high mortality rate. Uh 30% of patients who present who has an infection will die at sight. So if you have, if you have older people have infection, 30 of them will have died outside. They don't get h through. Now when they get hospital, their mortality rate increases one lb. Since surgery, the the mortality rate is going to increase. So it's only 24% is added to the percentage pre presentation. So it goes higher and higher. Now, one the earliest disc question of someone who had under section so surprisingly was in England. Uh King George I second. So I said he was training in toilets. I don't know why and uh he screamed and died. Uh The doctor saw him and he had the autopsy and they found out he had a ruptured aorta and blood in his pericardium. So he had a tampon it from the bleeding to his pericardium. And then that's when people started looking at, what is this about, why is this and start thinking about what cost could have caused this before we go for that. I must give credit to the two people who really pushed not really a dissection but cataract surgery in general in the, this, in this century, uh, from Texas Heart to Street. I'm sure we've heard some stories about these two gentlemen who are remarkable surgeons who, who had uh, their own differences. A bit of, I would say conflict, but I think they push each other and they really change it. They damage the barrier, they moved the barrier for surgery. And that is d coolly who gentleman here on the right who passed away full in the detection he had de two had. So he at 90 years of age and died afterwards. And Michael de Bake also two G men walk in Texas and when he push his front. So how do you classify dissections? So there are two classifications stand for which is very easy and the baking. Uh So you can whatever you choose, but uh most people will just stand for quickly these days because it's quite easy to understand. So what's it stand for this uh AAA dissection is any dissection that involves the ascending aorta or the arch to a simple? And when you say involve, what does that mean involve me? The entity tear. So the nt tear it with this arrow here. So blood leaks from here into the ascending aorta uh uh from the delta into this ingram media and makes, makes a force movement and the movement can be limited only to here on the top there or can go all the way down to the coin. So it, once the force line entry point is in the send ter that's a type a intersection. So I send in large. However, if the tea is beyond the ascending outta and is here, then it's a type B dissection, there is an like called a non A non B. So when you have a to 10, somewhere around here and the hematoma is retrograde to the ascending. Sometimes it's difficult to tell where does it start from because this will not be very clear on the CT scans or imaging you've done. So we say non A number B or if it tells us here. So because then what it means that you cannot manage it like a typical type A and you cannot manage your typical type B. So you could have no A, no B. But if this is good because for the exams or any test, they will ask you these questions that A that on the C you do, we produce the answers as appropriate. If you understand the debating 12345, you better story about them. So now what the risk factors to develop a dissection that would then capitalize this hypertension, hypertension hypertension. Most of the patients who have a dissection are actually hypertensive and when they present or two, they are more hypertensive. So it's a, it's like a vicious cycle because they have chest pain. They, they r to their as their, their uh c media, their end organs are now not getting enough blood. Because when blood goes to the fourth lumen, it could compress the vessels, supplying the kidneys, the liver, the gut. And when the kidneys don't get enough blood, it releases the hormones and it goes to synthesize to stimulate more increased BP to get BP itself. And the cycle continues that way. So must be controlled in this patient and is part of a dissection. The next common is the connective tissue disorders. Uh which the most common is the muffins fi one gene. Um These patients are special but put that way because the way we manage them is a bit different from patients who are non syndromic dissections san with Tuna syndrome and Ellas Dalo syndrome. Um most patients have a sclerosis. Um Some patients may have an existing aneurysm which no one have seen before or is known. And that aneurysm because it's an enlargement of the wall of the aorta that enlarged wall is abnormal and weakened. So with increased stress, that amount what can fracture when it fractures. That mean breaking in tumor blood can flow into the media. And that's a dissection. Um by co aortic valve, we know that if patients with aortic valve, no aortic valve have three leaflets when they have two, that's a by cos aortic valve. Uh because the flow dynamics to the valve, they are associated with a enlargement of the ascending aorta and that causes a weaken in the wall. And they can also have a deer the last 20, well, uh, gen is very common, not very common, but it can happen in theater when you are putting on the heart for something else and you are in the aorta or putting in the cannula, you could tear the aorta and it could leak into the intermediate. You have a dissection on table or if you cut up doing some stenting in the coronary arteries or doing any procedure in the outta to get two wires. This why the try to drink alcohol. And next thing you have a the symptom with also with trauma to the same mechanisms and how they present they present with sudden tea and chest pain and di rati to the back. Now, there are many conditions that present with chest pain. The first common one, if anyone comes to any, any chest pain is murine infarction. So my infarction and dissection are always intertwined. Many patients will go to the car la first or stent in or have two point in ST and when all these are negative, people start thinking about a dissection. So we we always tend to advocate that if a patient is coming with chest pain, do not only think about um a Cron in function, also think about your dissection. So uh if you can get it click on table, uh uh uh uh some scan or if the history doesn't suggest if the EKG is normal. Um then quickly think about the sexual A CT scan if possible. Um um including dissections, as I said earlier, mostly are incidental findings on CT scans. Now, patient with infection will have AAA conundrum of, of, of, of problems. Uh One of them may come with a stroke, they may have chest pain and say I feel weak in one side of my body. And why is this? Because one of the arch vessels have been involved in dissection to blood flow into the, to the the create pathway, meaning more blood is in the fourth lumen and two lumen. And when the two lumen is obstructed, the patient have a stroke or if the, the the coronary arteries which attach to the sinuses of Baala, the 42 can compress the coronary artery. I mean, shave them off or they could take it off the aorta themselves. And you have an ami sadly, patients who have micro infarction, falling a defection may not make it worse too cause they die of acute maca infarction and your heart is gone some hemopericardium. So there will be blood around the pericardium. So that's only like a, let me say, I would say sometimes we, we treat them as a a contained rupture without the dissection. And they're quite very important to know if you have that. You have to plan your, your strategy to us how to approach these patients uh the valve leaflets could be prolapsed because the in the valve leaflets align on the intima on the um in the CS of bar sava. If that intimas ruptured or hematoma, the leaflets will lose their tone and lead, lose their attachment to the aortic wall and they will prolapse and lead to acute of regurgitation because the heart is not prepared for this. Compared to patients who have just normal A R from chronic disease, there will be a acute de competition of this patient and acute heart failure. Pulmonary edema is very poorly. Uh this patient uh will require urgent care. You also have any organ ischemia in the upper limb, no pulses in the lower limbs. You have abdominal pain from the abdo abdominal ischemia or the renal functions. When you do AC T scan, you find that one kidney does not show up on the CT scan when the kidney show up because no contrast is getting there, there, there's no blood supply to the kidney. So, you know each patient may need to go on a uh may need dialysis in the future if both kidneys are gone. And same thing for the for paraplegia, patients who have the section and to the arch, the probably going to live the sub artery. They could have this the arteries to the uh to the spine shaved off and they have spinal occlusion and have paraplegia. Now, how do we investigate patients with a dissection? Uh nowadays, the most easy as uh well, I would say easy to do quick do uh available. Maybe most center would be AC T scan. Uh because there's no observer dependent dependency on this, which CT scan it is easy to use. It's reliable. You can do it by the bedside though. Uh you can do a serial imaging, it shows the aorta very well. And um though it has its radiation risk, yes. And it's also contrast is given and kidneys only like contrast, but this is the most imaging people do. Now, the next common I would say will be Tor tt eot echocardiogram, which I have done. Now, the echo only show you up to the ascending. So the root ascending time. So if you see a flap down the t on the on oe which we do in echocardiography, which we do in theater can show sending aorta to uh so if you're on table and you think you have a dissection can be happy because you go to see this scan of the time. So the patient who is unstable to go a CT scan, then echo can be of use to make an impression of this intersection MRI uh better for follow up of patients because uh the less contrast and if patient is young or, or female or, or your most of your patients cause you need scans every year on follow up. So you may do MRI cause and to reduce the radiation risk. Uh I'll give you some guidelines, this, this this thing you see here, guidelines from the European Society. So it a European guidelines just to once in a while you see this light guidelines and the class of the class of, of, of, of this from this information. And one thing we said about the uh imaging is that if you started with AC T scan, it's best to use a CT scan again next time because um each test have a bit of inter viability. So if you see scan, you scan all the time and it's better to treat and that we can, we can get adequate measurements in doing follow-up. So patients with infection, if you manage medically, most will die in are in hospital. If you do surgery sometimes is high risk and it's about 20% mortality rate surgery. So it's having surgery, but a better chance of surviving with surgery than medical therapy and how you can die either the, the, the aorta burst and the ruptures. Those guys don't make too down, down the, on the same, but they have car ta out. They could make up with CPR or AMI with the M I is on the led area as the an art. They may not make it, but on the right coronary artery, they could make it off too if you have a stroke, they stroke does not contraindicate for surgery. So we can still give them surgery. And they could be car shock from severe aortic regurgitation. Uh So when you get a phone call of a patient's a ne with chest pain, and you, you think it's a dissection from the scans. The one of the things you do is to make, making sure that BP is controlled, do not transfer patients with hypertension because the the medical team may not understand this. So you need to get that information. BP is under control because if BP is very high, it just complicates dissection and worsen the patient every minute and every hour with good BP control the external dissection or the pressure dissection is reduced. And we recommend the labetalol infusion with a beta blocker uh to be started in every patient being transferred with the exception to hospital before surgery. So even depends in your same time before surgery, the few hours might be paying the time your team commence on the infusion. If BP is high to reduce the um the the shear stress on the optic wall and also reduce the BP. And urgent surgery is recommended for everyone with type A dissection. So type a urgent surgery patient with type B, you have A, you have a type B dissection and is uh let say uncomplicated. So let me it's not no rupture, no leak, no blood effusion. I think it's blood, uh you can treat them medically. So medically treatment of type B dissection, that's beyond the sub left subclavian is BP medication. So we do the BP control and do C scans. And um then you can plan for a PA which is mostly a TIVA, it's extending through your groin. For this patient. A few patients who have mild perfusion, which would be a type dissection, then you may have to do a obviously a high grade approach. So you might need to first um treat the MD perfusion. If possible, this can be done with the your colleagues in the International radio to guide wires to, to perforate the force women to allow flowing to women. It's a quite complex procedures or you can do some deep branching procedures to provide blood supply to the organ ns um ischemic before you go for surgery because surgery takes a few hours, 6 to 5 hours in theater, sometimes more, the longer in theater during surgery that organ is suffering more ischemia, yoga will not recover after the surgery. So what are the principles of surgery in with dissection? Uh First, you need to understand the extent of perception. What am I going to do in the, how much will I take out? How much will remain uh with the will the aortic root to be replaced? So that that the valve in the center um would I need to do the arch also, uh this thinking will guide you on how you know, you need to clamp the aorta or not clamp the aorta or you need to cool the patient down and do a circulatory arrest. So you need to review your scans well, with the colleague, if possible, just to make a plan of going to do well, once you back on the procedure itself, they it, they you don't to vary too much from your plan. Otherwise you just love confusion and catastrophic. You need to, you need to plan your cal means within the way you put your pipes. Bye bye, your groin, which would be femoral conation, femoral femoral vein which can lead to the axilla artery and the aorta or axilla and and the right atrium, axilla artery and the femoral artery or you can call it centrally, which would be the aorta beyond the interception and the right side of the heart. Uh Most people will cool it now but you know, go arrest when it cool down to 24 25 degree. And uh so it's best to start cooling, cooling, gives you some protection to end organs. Um So you don't have to be, you can in case you in into cat, you already in a safe area to manage this too quickly. Even if you have to do a short c arrest to fix the cat, you en you need to think about how you protect the heart with marine protection, which would be that giving uh paraplegia to the root to the direct cats or optic catia, uh patient without the incompetence. You think about venting you to prevent the left ventricle, to prevent the left ventricle distension that will lead to mark Cardone necrosis and that heart will not recover after bypass. Uh or think of a team approach. So you need to discuss your plan with your surgical team, anesthetist, the vascular surgical team on call the interventional radiology team on call in case you need the help for some uh device or endovascular approaches to treat this condition. In ter we try to monitor them with dual two lines. So one or two line with the left side of the body or on the right side of the body. But we know the rest of the body having the brace, that of the body is the a ar and the less of pa. So you want to make sure if you to clamp the aorta to the ar you need to know the blood supply to the right side and brain is fine and the left side is fine, which is the end of us. Now. Um uh central bypass fe fa axillary, something called samurai. Uh that's mostly for the patient on table post induction, just crashes or collapses or BP goes down. You just need to summarize just like you cut through the out, put it come down and go by it, but it quite, it's quite dra but if you used to it, it's very simple. Um Some of the principles which I will discuss later. Uh Just mention them here, you make sure you excise the entry tear. So the chair that has the entry tear, otherwise able to excise the nt tear and you just replace whatever you replace blood flow to the tear. And that affection because the maintain is blood flow to the abnormal channel and causing that expansion of abnormal that pathway, which most that compresses the normal pathways. And you need to think about if we're gonna replace the valve or repair the valve. And we advocate these days for an open distal anastomosis because the layers are, you can actually see the layers very well. They're not damaged by the cost lamp and the recurrence of ane on the area is less. The first aim for surgery in the section is to save the patient's life. Any anything else fancy is just adding um extra sugars to coffee. The first thing to treat the life. So do what's necessary to save that life in your hands. As based on your capabilities, you don't need to go to do everything at the same time. So it won't mean everything I I explained. Your main aim is just to save that life. So how do I save this life? Now? It is a rupture. I can get on bypass and take it away and take the patient quickly need tampon out, tampon out and do the surgery needs some MRI and to graft that vessel that been that have been damaged with the graft and we, and we excise the tear, the stroke quickly gets on bypass and we establish blood flow to the vessels and it, it is a, I replace the valve or repair the valve. So how do, how do to achieve this? You must excise the 10, you must ensure that you're, we're establishing flow in the true lumen, you must. So when you a flu to, you think about hardware obliterate the fourth do most times. Once we establish for two lumen, the four do ob because there's no more fluid. So it cuts off and to do which is now wi will compress the fourth lumen and over weeks and months that first from how big, how big it was will just become flattened and disappear. And also you must restore the competence of the aortic valve. So this I call us again on techniques for aortic aortic surgery generally uh for in a dissection, uh you can try to repair the valve and the to repair. We commonly do if possible in good hands. Uh they will remove the learning implantation techniques which people call Jacob and David's. Um as we go further, we stand them. So this just mean you are preserving the native valve of replacing native valve. So they are sparing aortic surgeries if you can perform them, doing dissection conditions fine. Uh but not that you must not do that. If patient has dissection, these are better for aneurysms when you planned and you relax and you in good position for clean dissection. Yes, possibly. But I one of the advice is for like a dissection. Uh but you must make sure you do an open Dismas technique and they recommend that a two, a combination for ail artery to be first choice, but it's slower to get to. It's not very if, if you are, the patient is not doing very well, the femoral artery is the best is the next fastest or go central. If it's safe to do so, you would not want to do a central correlation if you have a per color collection because there'll be, there could be an impending rupture. Once you open your sternum, you you pick up rupture uh to have cannulas in some vessels before you open the sternum. But if none of these are looks say do so open the sternum, open your pericardium and can come it centrally and go ahead with surgery just a few images for now. Uh You can see there are two layers here. So this will be the intima here. This is your valve, this is intima and this is the four lu that been created by blood flowing through here. Normally, this is one layer, but now that one layer is gone, you can see this one layer here. But now you have two layers. So blood flows through here and flows through here and good blood flows through this force area, it compresses any vessels by side because the two remains in the middle. But the first, the first is around this, these vessels here and can compress them and lead to symptoms. They get so in to open aorta. Look for the once you see the entry point, you know where it is, then you can excise the air of the aorta and now you have a clean area, no entity tear there. You can ask the most your dark gra you can only use to this end of the aorta. I have replaced the aorta. Uh So people commonly, which I I would also commonly use a Teflon. Teflon is a strip of uh uh material like a clot just to reinforce your suture line with you. Cause one thing I do, the second one is that you suture a lot and suture a lot. Yeah, holes, hose, hose bleed and after surgery, six hours on bypass, you have copy from prolonged bypass time. The whole clo clo profile patient is dred a lot of bleeding. If you use the they put, they help to prevent those bleeding cause they, they form a bit of a compress on this weakened tissue. Would you have a fight dissection? This look clean on picture, this look clean on picture. In reality, this will be bruised. You see all looking dark red, uh black and you know the way here. So the way I know that su of this. Well, so, uh you just make sure you, you, you deal with that. Um If you look here, this is a surgery done. This is a penile procedure. I just expose it. And the a new valve here, you can see the valve leaflet is a mechanical valve leaflet there. A mechanical penthouse procedure. It means you are placing the, the root of that in between the valve, the root itself and you're using this up to the, this the bra artery of the ascending aorta. Uh You're gonna be getting implants, the coral arteries, the left main coral arter, this is the right coral artery and putting them back on the graft itself. And this a modified penance procedure. This is the most common surgery. You, you have an infection in every gentleman's hands is just, the valve is fine or not fine. In this case, the valve is fine. So the same valve is there and this place both this hand to that junction. So this less extensive this, this you can sometimes do the clamp on. So you put a clamp here. Uh So the device here all here is fine. You know, then they got to this point here after strain, it got to this point here. Then you can think clamp off go on deep c uh c race for a few minutes and suture it back here. And this is a modification, thereby, the valve is leaking. You want to avoid doing this which is more extensive, right? You are to switch your this back to this. You put a new valve in the road and replace the valve. The as about the valve leaving the corner is intact if the tear does extend to the coral osteo, OK. The next topic we'll talk about quickly. Uh is the intramural hematoma. It just mean the first film has ruptured the blood in the tunica media and this high she on CT scan, you see blood nicely here in this aorta which enlargements compare this size to this size. So this patient actually has aneurysm of that in the aorta appen. I can see this swelling, this area of darkness uh on here is blood. So it's swelling around the aorta that the hematoma intramural hematoma. And this scan which is no contra I can see a bit of contrast is quite, quite enhance around it. So that shows that yeah, there's some blood there. So that's the internal hematoma. Um What predicts that there will be complications if you cannot control the BP, you know, this might be complicated. And besides above 11 millimeters need to think about uh procedure for this patient. If having effusions on both sides, they have pain rupture or I know came here to treat them as a type a dissection. So same like type dissection or then surgery is recommended. BP control is also recommended plus one indication. Uh But in also is how you see the aorta, like you see the aorta and you see this out, pouching out, out patch everywhere in the aorta commonly in the arch. Uh these patients mostly we don't treat them surgically. We just give them medical, my BP control and follow them up with scans. However, if they not uh as uh show features of an intramural hematoma or a dissection or having pain, then you may need to reimage them and consider surgery. Uh patient with Contin rupture very, very rare. Uh but they have conti rupture and it's in the ascending A. So it's recommended it in descending. A stenting is recommended uh traumatic aortic injury, we may not survive if they do come to you for the surgery. If they're in the area of the I atomic table for stenting, the TV is be but it fast and less. Um then you're stay on bypass forever. Now to do a, a aneurysms, uh this is enlargement of the aorta, simple uh form enlargement, Sular enlargements, whatever type the walls are all. Uh There are two aneurysms and not force aneurysms. So they can, well, can you what of just five? Now, the alta grow in life as you get older, your outta grows and it a normal size is 0.9 M in men and 0.7 in female. However, in patient with Ma syndrome, it could be quite faster and to 1 71 per year in patients. This even faster. Uh there is a variant and they can go as fast as 10 minutes a year. So that is above 14. Then we, we see that that is enlarged and you, we we are monitoring for, for life though because anytime your enlarged, it could rupture at any time. So according to the guidelines, we have what we say it's an indication to deal with these procedures. And these indications are based on if the patient is syndromic or non syndromic symptom means you had a have min syndrome, Loy di syndrome tunnel syndrome or familial uh conditions in your family or else in your family. So, if you have Marin syndrome, the ward at this time is 3 50. So if you want Marin Syndrome, no valve problem and 50 millimeters, we offer him surgery. Uh So in the American guidelines, this has gone down to 45 actually. So in the American guidelines that came out last year in 2020 last year, early this year, um If you're out 45 and you can offer safe surgery, the muffin patient offer them surgery. Now they say also say if your patient has my phones and a senior out there is 45 and have risk factors. What is risk factors, hypertension, family, history of uh distention or rapid go or cauc patient? Uh yeah. Um you should offer them surgery at a lower size. Now, I by cosmetic valve, we know that I said earlier that by aortic valve, uh deal with aortic enlargement. A the aneurysms if they are 50 if the valve is fine, we replace the, the aorta. However, if the valve is stenotic or regurgitant. So if it has severe stenosis or severe aortic agitation who requires surgery for his valve is 45 is 45 or for 50. But basically, we, I'm thinking now is that the numbers, these numbers are those figures that we need to take them lower because so is now to be safer because these numbers are made because the risks of surgery must be less than the risks of the, of this, the the the condition of rupture or lead complications. So if so which is higher, they need to do surgery. So that's why because becoming safer tend to be the the dimension size nowadays. Um Yeah, so we've done, we've done studies, several studies show that this study done in the US by uh Mr Ee and his colleague there. They found out if the aneurysm is going slowly once you get to, you see the, the this is the risk of complications, 5% 6% 7% as it gets to 55.9 centimeter in size, it's exponentially increasing in size. That's kind of complication, which will be rupture dissection or whatever it is. That's why that cut off of 5.5 been coming into place as the cut off for any aneurysm. So once I get to six or you quickly better that a and for mal patients also the done studies. Ok, mal patient actually, it even goes four times faster uh which is higher four times. So that's why you need to replace uh patients with ma syndrome earlier than normal patients. So that's why the in, in, in, in, in this patient, when you're taking history, you need to ask questions, look at the features of clinical examination of, of patient with he has AM or syndromic tall patient. Um um we uh arm span, buy feed uvula, stuff like that. And if a patient has this condition, you need to put them on scans, you to monitor them with scans uh to be yearly scans to see the growth of the aorta uh in the, in the, in the, in, in, in Europe we use is what we use is three millimeter per year. So if the aorta goes more than two m per year, that's a rapid growth. And we tend to offer them procedure because the A is going in a rapid way and uh you might need to treat them often. So medications that you brought these days beta blockers, they said if you start on beta-blockers early, uh it has a protective uh is protective in to reduce the increase in size of these aortas over time. So if potential in have indication for that put on beta blockers, you just reduce the on the aorta and reduces aortic expansion uh for coarctation. The most thing we do for collation is mostly if they are amenable is stent in these days, that's what we prefer. Um However, if that's not possible, then they have uh a surgery uh quickly go through the last few slides. Uh So this is the aorta surgically. We have zones of the aorta. This are the zone 01234. Now this is ac scan of aortic dissection. This will commonly see just in one flap, uh see this line that the flap uh the two lumen is always a bigger lumen. So I don't know why but because blood flows there potentially causes uh just flows there called the tea. So you have blood in the fourth lumen and less blood in two lumen. So when you have and two supply the main vessels. So when you have blood in two, do the organs that the body supplies are uh uh we is. However, in this scan, we have blood in both lumen quite blue, but this is smaller than the post lumen just image. Now, so this is the standard procedure with everyone has mostly done. If you look at be that section is called and place from this uh similar junction here, like also with valve and all the way to the arch, you don't do a flush as much like this. So you go under the arch here and replace it because most times in what we see, we find tear here and we find tear around here. So that way we excise the tear in the arch. I put uh osmosis like a AAA ali osmosis or in this way. And most people do at night cause dissections. I know why they come at night. They don't come in the day when you are ready. Now, this is a pen before. So the valve for the valve, they replace the valve, replace the whole root with the graft conduits and the most the cornu then cook who worked in the UK and do this procedure whereby initially it didn't do anything good. But it for most, for a no, no dissection for aneurysms, you excise, the uh you make it AAA ton of the graft to go into the commissions or the uh sign of a dys and replace the coronary artery and just leave that alone. Then the on David in Toronto develop of doing that, did this and this a tube graft that goes into the grave into the and got itself and your valve lies within the tube graft, the chi graft ends on the root. So stabilizes the road and you have this. So most important do this, this there because you have got it stabilize and there's no more native tissue exposed that can enlarge over time. Uh This is like a, well, when in the days you have what we call an elephant trunk tend to car patch, take off this and put the curve of the extending aorta there uh as to multi vessels. Well, with the advent of materials from, from from the companies now like can have a branch graft that have three branches. We what we call de branching. We could depre the vessels and leave this trunk like an elephant trunk intending aorta for future in in vascular procedure, call it like a v. But now they have a landing zone, they could land any stent into this gut. So that avoids landing a stent on a weakened wall of the aorta. It called an elephant trunk. It's actually a floating elephant floating because there's no stents in this uh trunk um in people have done many techniques. So um we have tried, OK, how about ane on the aorta cut to the aneurysm and put a suo with dark on. This doesn't work these days. It's important to wrap, put a wrap around the aorta and then if you wrap it that way, the OTA doesn't expand anymore. But this is surgery, it's safe to do a replacement to replace the aorta if you can. Um Now we're going towards more complex stuff. Now, these are arch procedures. Now, the arch was a a difficult area in surgery because how do we take the blood away from the brain and put it back on? How do we achieve that? So that has been very, quite complex. So we try to cool the body down to 18 degrees at 10 degrees. You have like 35 40 minutes, you can safely do surgery quickly and you have to stitch quickly to make sure you get the head and neck vessels back. Otherwise, if you take longer, the head, your risk of strokes is higher. And if there's no, there's no joy doing surgery and playing, cannot walk or is it gonna wake up just a fail of care? So, that was a big problem. But these days, we have a lot of devices and of techniques whereby we can um monitor the brain force with cerebral oximetry. Uh we can so we can take one vessel at a time. So take this one first anastomosis here, the blood is flowing, we still leave this blood flowing into these vessels by putting tubes through them. So we supply what we call anti soluble perfusion. So if you have an intake cycle of whe is in the brain and you supply blood to the left side, you should supply the right side of the brain. That's what we we rely on. And we monitor this with device on the skull to test if that's working properly. And we can take the one vessel out anastomosis here back on circulation. Next vessel, same thing, a neck vessel, same thing, we can deploy the neck and the vessels easily while we're pulling down, then we can ask the most since the vessels are not away from the arch here, we're gonna ask the most quite near to us. Instead of going all the way here to us the most, which is very difficult. I, we're gonna deploy a stent with the car. Has we call the frozen elephant trunk down to the, uh, descending. All these are tied off and we done the surgery, anything you don't need to do in the future like here now, there's still a tear and 10 in aorta just take this enlar A can still enlarge over time. But because they have this, this stent graft here, you can come in from the groin and land the stent into a two Domene and expand this in the future. So this is the evolution from the eighties when Hans Boss would die last year, sadly, develop the elephant trunk all the way. Now we have 50 ft stuff on the shelf. We can do many things with these devices. Uh This is a new device that just came out recently. Uh they call the MD si won't bore you with this. It's also a way you can uh you can stent the arch. So you can see you produce a a not a cover 10 A N ST but you can ask the most here on zero where you can see, I think you say 10, the A can put this 10, this 10 expands and compresses your, see your, your force movement down here. But up here is com and when it's composed against a series of with time clots off and it first few minutes. No, no more. No, does not exist anymore. I can try, try to deploy stents here afterwards. So if you are tired or not tired, if you don't do any extensive surgery, pulling down too much, you can try to do this procedure. Deploy this in 10 minutes. Switch your hand here in 15 minutes, you're done. I know what the device is meant to do. Uh This is, this is co just when you switch your hand, just need to be careful. Yeah, you will see again into the four lumen. So you've done your surgery, your anastomosis, your distal anastomosis contrast in your first lumen in the arch or this or, or or sending a the phenomenon. And that's what a MD as is meant to uh uh to treat by uh putting the stent here to eliminate that thing. Um Yeah, did a CT scan of patient with the dissection? You can see, uh you can see blood here. You can see leak of blood here. You can see how the lumen is compressed. You can see how table looks, it look like. You think it, I think it's descending all mess there huge aneurysm blood everywhere and what you just need just to get blood flow in, in the right place. When blood flow in the right place in the right lumen, all this will disappear with time. Uh I think this is the surgery we did for this patient actually. So this is this a schematic diagn the surgery that patient had. So uh I think this my, with my last slide. So artic disease is quite is is we have them now, they're all around those most people will die too. Uh because of the the ability of conduit and graft and esses. And because aortic surgery is not a subspecialty, a lot of experience in a surgery, a lot of interest in the surgery, we can offer patient um, um, surgery with improved outcomes compared to uh 20 years ago. Thank you for listening. Thank you very much, Doctor Ben. Um, does anyone have any questions if you have any questions? Um, we are not able to um, put on mute yourself. So just pop it up on the, on the messages on the message chart, on the chart and, and we'll be able to answer it. Thanks very much, Doctor Banda was very extensive and very detailed presentation. I know the time wi is not quite enough to go through everything, especially the procedure procedure, but it, it's a lot. Yeah, it's quite extensive but we'll see, we'll see. Well, at that time, we can get on that topic to just describe procedures themselves. Yes. Yes. Hopefully. Um, this is just like the basic introduction to everything I think. Um, later on, we will do more specific um, topics and have more time to dissect to dissect it OK. Does anyone have any questions? Uh, I must have any questions? Ok. I'm going to put off the well. Ok. Ok. So someone has ask the question there, an alternative or second line drug for controlling BP aside. Labetalol. Yeah. Yes. So, um, we, if you, if you have a dissection, I go to the patient. We, we prefer a bit of why first because it's intravenous parents with dissection are having surgery with knee by mouth. So if you give any beta blockers, but intravenous, now, if you use what people call this GTN infusion, which is quite very common GTN infusion give. But GTN, yes, you need BP but it increases the shear stress of, of the rebound effect. Unlike labetalol, we doesn't do that. And the commonest drug we have is labetalol. S is shortacting to the betablocker. So you have to give it quite often, but labetalol and, and the infusion pump can last a bit longer. However, um if you have on the shelf fine, uh you have to use what you have and um you get potential theater as the main thing. And that question here is, yeah. So for intramural hematoma, uh from question from uh Clinton or Kena, um you do not have a type a dissections if you have an intramural hematoma, uh that is expanding. So it's getting bigger in size from C scan C scans will be done at least in a week. So you can come today, you do scan your one week and it bigger in size or patient has pain or worsening pain or persistent pain or end organ dysfunction. So you maybe experience having is more drowsy. So maybe you having had uh cerebral ischemia or have abdominal pain or the kidney function is deed and worsening. You need to deal with that patient. And that's why we do sort for them surgery we do for them is the just ascending aorta replacement for most of the patients. If it extends into the arch and arch, also, also the en enlarged and dilated, you must do arch replacement. So all based on the extent of the enlargement of the area of the aorta, you mean to replace the whole of the aorta if need to be. Thank you, doctor. Be any other questions? Um I've pulled up the feedback form on the chart. So please um fill out the feedback form, um fill the feedback form and um so that you can get your certificate of attendance and just also as a as an announcement, the fourth session of this series will be taking place on Monday 6 p.m. the middle page. So you can sign up for it. It's um the second part of the cardiac physiology that we started on Monday. Um There's another question. Ok. So what happens? So, uh yeah, so the elephant trunk, uh it provides you to do this procedure as a stage one pre pay you for this stage two, which will be a standard procedure. Now, for the elephant trunk, if you su your suture, your, your distal suture line on the aorta will be around zone you. And this zone pi artery is very posterior and the patient is very posterior and deep in the chest. It's very hard to suture there. And when it suture there and any trouble, it bleeds to get back there is difficult and it's a nightmare. So the elephant has made it possible for us now to, to a zone one where the aorta is closer to us and deploy the stent down. So it make it a bit easier for a previously difficult procedure. So that's the pro elephant trunk over uh all like straight craft we had in the past. So it gives you a chance for a stage two procedure and make it posted yourself much, much easier than previously. Um I'm looking for your recommendation. Uh Well, yeah, ee everything everything needs the many documents online. You can uh ok, I can, I can drop my email, you can send me an email. I can, I can, I can find some site to, to refer you to. Is that ok? And you feel me? Yes, that, that would be great. Um So yeah, I I think I have your email address if you can share the email with them and I can find site and materials to share with you guys. Yeah. That's, that's it. Ok. I think um we are just in time actually one minute left if there are no other questions. Thank you very much, Doctor Ban. Very good and insightful. Um Don't forget to fill, fill your feedback forms guys, it's when you feel it, you'll be able to get it, as I said and don't forget to sign up for the session four, which is on Monday. Thank you, everyone. Thank you doctor and see you. Thank you guys. Thank you.