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Can you hear me? Uh Yes, yes, I can hear you. Ok, thanks. Yeah. Um So it really try presenting your screen? Ok. Yes. Do you use at night? Yes. Yes, I can say um it's not in present mode. 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 was saying that we will just um wait for a few minutes to seven and then um let others join and then we can start. Sorry, I just saw on your slide now that it's consultant. II, know I put some on this. So I would correct that. Yeah, that's, that's, that's change role. So that's fine. Ok. Um But can you hear my audio very well? Yes. Yes. Ok. All right. Thank you. Uh OK. Um Welcome everyone. It's seven o'clock already. So we'll start and um 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 fourth session we spoke on cardio um cardiopulmonary bypass on the second session, we spoke on cardiac physio and today we'll be speaking about aortic diseases and aortic surgeries. And we talked today in um Mister Benjamin who is a consultant Catheter surgeon at 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 chart. And um um at the end of the teaching session, you will be happy to um answer this. You'll be a bit 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 all 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 middle page. You can sign up for it if you are interested. Um If you um we attended the first cardiac physiology course, it's a continuation of that. It will be taken by um David De who is a um cardio, a trainer 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 you see fit. Um Thank you very much for accepting the invitation to teach on this platform. I'm really grateful and uh yeah, 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. Well, it's not really basic cat 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 was just trying to share my slides. Now, can wanna see my slides, please. Can everyone see my slide? Yes. Yes, you can. All right. Thank you. Uh So this is where I work. Uh I work in Hall. It's um a 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. Um It's just 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 toward the ana. Here is what we call the aortic root. So the root contains the annulus, the valve leaflets, the sinus of uh salva and the sinotubular junction. Then it goes like a silica tube all the way down to the groin 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 subclonal artery down to the diaphragm, the descending thoracic aorta and blood diaphragm with the abdominal aorta to it bifurcates into the iliac vessels in recent times. Now, it depends on where you walk around the world and the purview of the cardiac surgeon uh is nearly limited to just from the subclavian down to the out the road. This area you a mission can be dealt with in, in the past stenting. Nowadays, uh this will be available in every country. So all surgeons may still deal with this via open procedures. In some cases, you may still require to 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 this 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 sorts will mostly deal with is the aneurysms, the acute symptoms and some congenital conditions. Um So as surgeons, what we see mostly in the old, how we see the out put this way, uh or uh in the old how is mostly the can put that way is the one in the atic. 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 night of day and the coarctations which is common in Children or missed in adults. So if I just go too quickly, what do we mean by acute aortic syndromes? So the aorta, if you have a histology of the aortic aortic 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, the tunica intima py layer, endo layer. And this area we have muscle mu muscle fibers is the media tunica media and the external one is the adventitia. So these all parts of the normal aorta. However, in a dissections, 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 regard as a true lumen and blood also flow here, which we got. Now the F lumen and these are what leads to the consequence of what dissection really uh leads to and why it's quite urgent to treat this patient otherwise, to have end organ malfunction and possibly die the intramural hematoma. So if you have muscle fibers, you also have blood supplies to these muscles. Uh most common blood supply, what we call the vasa vasorum. Uh these small blood vessels could rupture and when they rub short, they could lead to bleeding into the tunica media. And this patient will present maybe them with pain. Because why do they have pain? Because stretching when there's bleeding here, this space in the media expands and stretches the avenia. The anesthesia contains the um um pain fibers that we now per uh perceive as pain, a central chest pain. Uh We know that most of patients with these or these are in evolution. So you can be for some rupture here, you have bleeding into the media and it could eventually rupture into the room and they have like a dissection. So it could be in evolution. And that's why we manage uh this patient similarly to a dissection. And lastly, here is the PA U or the atherosclerotic ulcer. So, these are patients who chronic patients with atherosclerosis, very cal calcified vessels. And what happens is that this calcium and the vessels cause they're not really expansor as we know they're not really smooth muscle. Their calcium, uh which increase hypertension, this could rupture and easily blood flows into the media and forms a kind of a protrusion of a swelling around the advantage there. Um And we'll see them in patients mostly come on in their age and we'll discuss how to manage them in the next following following slides. So I'll start with uh I think dissection, which is I would say the, the thing that everyone in A&E every doctor should be aware and this is a condition. Uh We discussed this or physiology already. It's just a tear within the intima. And so if he has a tear that has an entry point, this ward entry point is very important in the moment of this patient. The would also force lumen is very important in the moment of this patient. So we need to keep this in our minds. They could be acute, chronic or acute. So if a patient present 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 for a scan or something else. And they said, O2 months ago, I have some pain but you went to five days and you do a scan, you find a dissection from the scan that oh boy, yes, that's a colon dissection now because it's beyond two weeks. So we call it after, after two months is colon dissection between two weeks and two months of A and the moment varies slightly. Uh Now that's what we call type A and type B, which I will show you in next slide. So just to say type A here is the most of the cancer of the atic Syndros. So why is the section weakened? Uh because it has a high mortality rate. Uh 30% of patients who present, who has an infection with that at site. So if you don't have, if we have other people have infection, 30 of them would have died outside. They won't get hospital. Now when they get hospital, their mortality rate increases one per by the mortality rate is going to increase. So it's only 24% is added to the percentage presentation. So it goes higher and higher. Now, one of the earliest, this question of someone who had under section surprisingly was in England. Uh King George the second. So uh I said he was training in toilets. I don't know why. And uh he screamed and died. Uh The doctor saw him on the card autopsy and they found out he had a ruptured aorta and blood in his pericardium. So he had a tamp it from the to his card. And then that's when people started looking at what is this about? Why? If this, I started 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 I intersection but cat surgery in general in the, this, in this century, uh, from Texas heart to States. 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 won't say conflict, but I think they push each other and they really change the diamond, the barrier, they moved the barrier for surgery. And that is Denton Cooley gentleman here on the right who passed away following the the section he had the se two had. So at 90 years of age and died afterwards. And Michael Deba also is two gentlemen, walk in Texas, family pushed his frontiers. So how do we classify dissections? So there's two class patients Standford, which is very easy and debating. Uh So you can whatever you choose. But uh most people would just stand for quickly these days because it's quite easy to understand. So what's the stand for this uh uh uh intersection is any dissection that involves the ascending aorta or the arch to a simple? And when you say, what does that mean in involved with the? So the entity tear it with this arrow here. So blood leaks from here into the ascending aorta uh uh from the front to this in media and makes, makes a forced lumen and the first lumen can be limited only to here and stop there or can go all the way down to the groin. So once the first, the point is in the, in the, that's a type a dissection. So ascending large. However, if the entity tear is beyond the ascending alta and it is here, then it's a type B dissection. There is a called a non A non B. So when you have an entity tear somewhere around here and the hematoma is retrograde to the ascending. Sometimes it's difficult to tell where does it start from because this entity may not be very clear on the CT scans or imaging you've done. So say non A non 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 a typical type B. So you could have known a non B. But if this is good because for exams or any test, they will ask you these questions type A that is, can you do we produce the answers as adequate? If you understand the 12345, you better can story about them. So now what are these factors to develop a dissection? Uh Put the capitals is hypertension, hypertension, hypertension. Most of the patients who have a dissection are actually hypertensive and when they present or two, they are even more hypertensive. So it's a, it's like a vicious cycle because they have chest pain. They did option to their uh their, their uh tunica media, their end organs are now not getting enough blood because when blood goes to the fourth lumen, it could compress the vessel, 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 it is part of a dissection. The next common is the connective tissue disorders, uh which is most common is the S one gene. Um These patients are special but we that way because the way we manage them is a bit different from patients who are non syndromic dissections, something with tunnel syndrome down syndrome. Um Most patients with hepato sclerosis, um some patients may have an existing aneurysm which no one has seen before or is known and that aneurysm because it's a enlargement of the wall of the aorta that enlarged wall is abnormal and weakened. So, with increased choice that can fracture when it fractures that been breaking in tumor blood can flow into the media. And that's a dissection. Um by hospital aortic valve, we know that if patients with aortic valve, no aortic valve have three leaflets when they have two, that's a bicuspid aortic valve. Um because the flow dynamics to the valve, they are associated with a enlargement of the ascending aorta and that causes to weakening the wall. And they can also have a dissection. The last two. well, uh erogenic is very common. It is 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, putting the cannula, you could tear the aorta and you could leak into the intermed. You have a dissection on the table or if you're in a cat lab doing some stenting in the coronary arteries or doing any procedure in the aorta to get two wires. This why the drink alcohol. And next thing you have a symptom with also with trauma to the same mechanisms and how they present they present with sudden tearing, chest pain and diuretics to the back. Now, there are many conditions that present with chest pain. The first common one, if anyone comes to A and A with chest pain is M infarction. So M infarction and dissection are always intertwined. Many patients will go to the catalog first or stenting or have two point cent. 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 uh ma infarction, also think about your dissection. So uh if you can get it kicked on table uh uh uh uh ultrasound scan or if the history doesn't suggest if your EKG is normal um then quickly think about the C if possible. Um and dissections as I said earlier, mostly are incidental findings on CT scans. Now, patients with infection will have AAA con of, of, of, of problems. Uh One of them may come with a stroke. So you have chest pain and say I just 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 is not flowing through the to the the correct pathway, maybe more blood in the fourth lumen than two women. 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 salva, the fourth woman can compress the coronary artery, shave them off. OK. They could dis off the aorta themselves and you have an AMI. So the patients who have infarction following a defection may not make it hurt because they will die of acute infarction and the heart is gone some hemopericardium. So there will be blood on the pericardium. So that's only like a, let me say, I would say sometime we treat them as a a contained rupture dissection. And they're quite very important to know if you have that, you have to plan 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 sense of if that intima has ruptured or hematoma, the leaflets will lose their tone and lose their attachment to the aortic wall and they will prolapse and lead to acute ation 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 decomposition of this patient and acute heart failure, pulmonary edema very poorly and this patient uh will require urgent care. You because you have an organ ischemia in the upper limb, no pulses in the lower limbs. You have abdominal pain from abdominal abdominal ischemia or the renal functions. When you do a CT scan, you find that one kidney does not show up on the CT scan while your kidney show up because no contrast is getting there but no 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 a dissection and send to the arch is probably going to level the sub artery. They could have this the arteries to the uh to the spine shelved off and they have spinal occlusion and have paraplegia. Now, how do we investigate patients with a dissection? Uh nowadays, it's the most easy as uh well. No, I would say easy to do, quick to do uh available maybe in more centers. So be act scan. Um because there's no observer dependent dependency on this. Go to a CT scan, it's easy to use. It's reliable. You can live by the bedside though uh you can live for er l imaging. It shows the aorta very well. And um though it has its radiation risk, yes. And it's also contrast is given on kidney like contrast, but this is the most imaging people do. And the next common I would say will be Tor TTE or T echocardiogram each other of them. Now the echo will only show you up to the ascending. So the root and ascending aorta. So if you see a flap down the T on the on oe which we do in echocardiography, which we do in the can show sending aorta too. Uh So if you're on table and you think you have a dissection, then we have, you cannot go to see discount at time. So in a patient who is unstable to go to see the scan, then echo can be of use to make an impression of this intersection, MRI uh better for follow up of patients because uh they are less contrast and a patient is young or, or female or or or your yeah, mostly young patients cause you need scans every year and follow up. So you may do MRI cause to reduce the radiation risk. Uh I'll show you some guidelines, this this this thing you see here, guidelines from the society. So these are European guidelines just to. So once in a while, you see these guidelines showing the class of the class of of of accommodation, all this some of this information. And one thing we said about the uh imaging is that if you've started with Act scan, it's best to use Act Scan again next time because um each test have a bit of inter variability. So if you c scan, use scan all the time and it's better to be sure you can that we can, you can get up measurements in doing follow up. So patients with infection, if you mind, medically, most would die. Are you in hospital? If you do surgery, sometimes it high risk and it's talking about 20% of surgery. So it's having surgery with a better chance of surviving with surgery than medical therapy and how die. Either the, the, the aorta burst and ruptures. Those guys don't make down, down on the same. But they have, they can see with CPR or AMI with the MRI is on the led area as the anti descending artery, they may not make it, but on the right coronary artery, they could make it if you have a stroke. Yeah, stroke is not contraindicate for surgery. So you can still give them surgery and it could be in calic shock from severe uh agitation. Uh So when you get a phone call of a patient's a and with chest pain and you, you think it's a dissection from the scans, the one of the things you do is to make, make 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 the information BP is under control. Because if BP is very high, it just propagates dissection and worsen the patient every minute and every hour with good BP control, the zeal dissection or the 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 the patients in your center before a few hours while preparing the, preparing your team. Comment on labial infusion if BP is high to reduce the um the the sheer stress on the tic 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, you have a type B dissection and is uh say uncomplicated. So I mean, it's not, it's not rupture, there's no leak there, no pleural effusion. I think it's blood. Uh you can treat them medically. So, medically treatment of type B dissection that is beyond the left of behavior is BP medication. So we do the BP control and do serial scans and um then you can plan for a elective profile which is mostly a fever. So it's a stenting to your groin for this patient, a few patients who have mild perfusion, which will be a type dissection, then you may have to do a it was a high approach. So you might need to first um treat the mild perfusion. If possible, this can be done with the your colleagues in the interventional ology to guide wires to to perforate 1/4 outflow in two women. So quite complex procedures or you can do some debranching procedures to provide blood supply to the organ mass. Um ischemic before you go for surgery, surgery takes a few hours, 6 to 5 hours in the sometimes more, the longer you doing surgery, that organ is suffering more ischemia, your recover after the surgery. So what are the principles of surgery in patient with dissection? Uh First, you need to understand the extent of section, what am I going to do in how much would I take out? How much remain uh with, will the aortic go to be replaced? So that, that the valve and vasa uh would I need to do the arch also? Uh this thinking will guide you on how you know, you need to clamp the aorta, not clamp the aorta or you need to cool the patient down and do a circulatory arrest. So you need to do your scans well, with a colleague, if possible just to make a plan of what to do. But once you embark on the procedure itself, they it they you don't to vary a little too much from your plan. Otherwise you just love confusion and catastrophe. You need to, you need to supply your calculation strategy means put the way you put your pipes for your groin, which would be femoral conation, femoral art, femoral vein. It can lead to the axillary artery and the aorta or axilla and the right atrium, axillar artery and the femoral artery or you can call it centrally, which would be the aorta beyond the intersection and the right side of the heart. Uh Most people could push now but may not secretary arrest, but they could push down to 2425 degrees. And uh so it's best to start cooling, cooling, give you some protection to end organs. Um So you don't have to be, you can in case you do catastrophe, you're already in a safe area to manage this too quickly. Even if you have to do a short circulatory arrest to fix the catastrophe you encountered. You need to think about how you protect the heart with macular protection, which will be giving uh catia to the root to the right coronary catia or chia. Um Patient with a incompetence. You think about venting, you need to prevent the left ventricle to prevent the left ventricle distension that will lead to myocardial 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 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 the, we try to monitor them with dual arterial lines. So one arterial line on the left side of the body, on the right side of the body, but we know the right side of the body. You have the phallic left side of the body is the arch, arch and the left of pa. So you want to make sure if you were to climb the a to soften the arch, you need to know that the blood supply to the right side and brain is fine and left side is fine, which is the end of us. Now. Um I central bypass fem fem axillary, something called samurai. Uh That is mostly for the patient on table table postinduction, just crashes or collapses or BP goes down. You just need to summarize just like you cut through the out, put it come and go by it, but it's quite, it's quite dramatic. 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 entity tear is definitely you excise the entry tear. Otherwise, if you excise the entity tear and you just replace whatever you replace blood flow to the entity tear and that infection because the main thing is blood flow to the abnormal channel and causing that expansion of abnormal that pathway, which most times compresses the normal pathways. And you need to think about if you're going to 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 gland and the recurrence of annuities on that area is less. The first aim for surgery, infection 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 be everything in. I was playing. You may aim is just to save that life. So how do I save his life? Now? It is a rupture. I can get on bypass and take away and the patient quickly tampon tampon that and do the surgery needs an MRI and to graft that vessel that have been, that have been damaged with a graft and and excise. The entity tear in the stroke quickly gets on bypass and we establish blood flow to the vessels and it is A I replace the valve or repair the valve. So how do you, how do you achieve this, you must excise the time, you must ensure that you are, we are establishing flow in the true lumen. You must. So when you improve to women, you think about how the forced woman, most times, once you establish true women, the forced woman ate because there's no more fluid than lumen. So it clots off and two women which is now pressurized will compress the forced lumen and over weeks and months, that first woman from how big, how big it was will just come flatten and disappear. And also you must restore the competence of the aortic valve. So these are kind of again on techniques for aortic aortic surgery generally uh for in a dissection, uh you can try to repair the valve and the two repair we commonly do if possible in good hands. Uh They remove the learning implantation techniques which people call Jakob and Das. Um as we go further, we understand them. So this just mean you are preserving the native valve of the native valve. So they are valve sparing aortic surgeries if you can perform them during dissection conditions, fine. Uh but we not did. You must not do that if patient has dissection, these are better for aneurysms or your plan and your relax and in good position for clean dissection. Yes, possibly. But I will advise it for like dissection. Uh But you must make sure you do an open dis asthmatics technique and they recommend as a two, a, a combination for a 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 is safe to do so, you will not want to do a central correlation if you have a collection because it will be, it could be an impending rupture. Once you open your sternum, you will leave the P rupture to have can in some vessels before you open the sternum. But if none of these are looks say do so open the sternum, open the pericardium and can come 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 intima and this is the first lumen that have 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 close to here and good blood flows through this first area. It compresses any vessel by itself because the two remains in the middle. But the first, the first lumen is around this, these vessels here and can compress them and lead to symptoms they get so in to open the aorta look for the, once you see the entry point, you know where it is, then you can excite the area of the AORTA and now you have a clean area, no entry there. And you can estimate your dark, which you can only use to this end of the aorta. I have replaced the AORTA. Uh So people commonly, which II would also commonly use a Teflon. Teflon is a strip of uh uh material like a clot just to reinforce your suture line. Why? Because one thing I do, the section is that you suture a lot and suture a lot, your holes, your hose, hose bleed. And after surgery, six hours from bypass, you have coagulopathy from prolonged bypass time. The whole profile patient is drained a lot of bleeding. If you use this Teflon, they put, they help to prevent those bleeding because they, they form a bit of a compress on this weakened tissue which you have a fight dissection. This look clean on picture this, look clean on picture. In reality, this will be bruised. You see you all looking dark red, uh black and you know, they know we here. So they're not very, they're not as sweet as this. Well, so, uh you just make sure you, you deal with that. Um If you look here, this is a surgery done. This is a Ben procedure. I just expose it and there's a new valve here. You can see the valve leaflet, it's a mechanical valve leaflet. There's a mechanical ben procedure. It means you are placing the, the root of that in the valve, the root itself. And you're using this conduit up to the, this the artery after the ascending aorta, uh you're gonna be plants. The coral is the left main coral. It is the right coral and passing them back on the graft itself and it is a modified procedure. This is the most common surgery you see of an infection in every gentleman's hand, it's just the valve is fine or not fine. In this case, the valve is fine. So the same valve is there and also place above this an junction. So it's less extensive. This this you can sometimes do the clamp on. So you put a clamp here, uh sort of the valve here, all here is fine, you know, then switch out the graft to this point here. After it got to this point here, then you can take clamp off, go on deep sec arrest for a few minutes and switch all it back here. And this is a modification hereby. The valve is leaky. You want to avoid doing this, which is more extensive. You have this back to this. You put a new valve in the road and replace the valve, the aorta, the valve leaving the corner is intact if the tear does extend to the coronary. Ok. The next topic we'll talk about quickly uh is the intramural hematoma. It just mean the person has ruptured the blood in the tunica media. And this high CT scan, you see blood nicely here in this aorta which enlarge can compare this size to this size. So this patient actually has a new of the aorta up initial. You can see this swelling. This area of darkness on here is blood. So it's swelling around the aorta. That's the hematoma intramural hematoma. And this scan, which is not contour, I can see a little bit of contrast is enhanced around it 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. Uh Besides above 11 millimeters need to think about uh procedure for this patient if having effusions on both sides of impending rupture or ischemia to treat them as a type a dissection. So, same like type infection or surgery is recommended and BP control is also recommended. Plus one indication. Uh in the ulcers is how you see the aorta like you see the aorta and they see these out parts, out parts, out part everywhere in the aorta, commonly in the arch. Uh these patients mostly we don't treat them surgically, we just give them medical management, BP control and follow them up with scans. However, if they now uh uh uh show features of an intramural hematoma or a dissection or having pain, then you may reimage them and consider surgery. Uh patient with Contin rupture very, very rare. Uh but they have Contin rupture and it's in the ascending aorta. So it is recommended it was in descending aorta. Stenting is recommended. Uh traumatic aortic injury, we may not survive if they do come to you over the surgery. If they're in the area of the idiot is suitable for stenting. The TV is, but it's faster and less. Um Then you don't stay on bypass forever. Now to quickly do an aortic aneurysms. Uh It is enlargement of the aorta, simple uh enlargements, enlarge whatever type the walls are all. Uh There are two aneurysms and force aneurysms. So they can even both you can of justify. Now the el grows in life as you grow older, the grows and is a normal size, 0.9 millimeters in men and 0.7 in females. However, in patient with, it could be quite faster and we also 11 mi per year in patients, especially with lo digs even faster. Uh There there is a variant and it can go as, as fast as 10 ma year. So he is above 40. Then we we see a di attack enlarge and you be monitoring for, for life though because anytime you attack enlarge, it could rupture at any time. So according to 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, it means you had to have Min syndrome, logistic syndrome, tunnel syndrome or familial uh conditions in your family or in your family. So if you have Marfan syndrome, the ward at this time is still 50. So if you want Min syndrome, no valve problem and 50 mill we offer them surgery. Uh So in the American guidelines, this has gone down to 45 actually. So in American guidelines that came out last year, in 2020 last year of the early this year, um if you out age 45 and you can offer safe surgery, the patient offer them surgery. Now, let's say, also say if your patient has MS and is 45 and you have risk factors, what are these factors? Hypertension, family, history of uh dissection or a code or lactation? Uh Yeah. Um you should offer them surgery at a lower size. Now, I bioptic valve, we know that as I said earlier that by causing aortic valve uh with aortic enlargement, ays, if they are 50 valve is fine, we replace the, the aorta. However, the valve is stenotic or so, a patient has severe stenosis or severe aortic conation who requires surgery for his valve is 45 aorta, 45 for 50. But recently I think now is that the numbers, these numbers are those figures. Yeah, when you take them lower because so now predicated to be safer because these numbers are made because the weeks of surgery must be less than the risks of the, of the, the, the, the condition itself rough lead to complications. So if surgery, which is higher, they do surgery. So that's why because surgery is becoming safer, tend to be reducing the, the dimension size nowadays. Um, yeah, so we've done, we've done studies, studies show that this study done in the US by uh Mr and his colleagues there. They found that if the uh the is going slowly, once you get to, you see, this is the risk of complications, 5% 6% 7% as you get to 55.9 centimeters in size, it's exponentially increasing in size. That's kind of complication, which would be rupture dissection or whatever it is. And that's why that cut off of 5.5 been come into place as the cutoff for any aneurysm. So once I get to six of it, OK, we pay that aneurysm and for patient also OK. 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 syndrome earlier than normal patients. So that's why 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 a or syndromic tall patient. Um um uh uh a sp bifid uvula, stuff like that. And if a person has this condition, you need to put them on scans, you to monitor them with scans. Uh it could be yearly scans to see the growth of the aorta uh in the, in the, in the e in, in, in Europe, we use, we always use three millimeter per year. So if the aorta grows more than 3 m per year, it's a rapid growth and we tend to offer them procedure because the aorta is going in a rapid way and um we might need to treat them often. Some medications are brought these days beta blockers. They said if you start on beta blockers early, uh it it has a protective uh is protective in to reduce the increase in size of these aortas over time. So if you in have indication for that, put on beta blockers, you just reduce the share on the aorta and reduce the expansion uh for coarctation. The most thing we do is mostly if they are amenable stent in these days, that's what I prefer. Um However, if that's not possible, then they have uh a surgery uh quickly go to the last few slides. Uh So this is the aorta surgically, we have zones of the aorta. These are the zone 01234. these are a CT scan of aortic dissection. This will commonly see just in one flap. Uh You see this line at the flap, uh the two lumen is always the bigger lumen. So I don't know why, but because blood flows there potentially causes uh just flows there called the tear. So you have blood in the fourth lumen and less blood in two lumen. So when you have and two men supply the main vessels. So when you have blood in two lumen, the organs that the body supplies are uh uh this. However, in this scan, we have blood in both lumen quite low, but this is smaller than the post lumen just image now. So this is a standard procedure where everyone has mostly done. If you look at get that decision is called and place from this and similar junction here like also with a valve and all the way to the arch, you don't do a flush arthrosis 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'll put uh osmosis like AAA oblique atmos all in this way. And almost people do at night because dissections, I don't know why they come at night. They don't come during the day when you are ready. Now, this is a pen before. So a a replace the valve, replace the whole root with the graft conduits and the most the corna then cook who worked in UK uh Brompton download this procedure whereby initially he didn't do anything good, but it is promoted for aneurysm, no dissection for aneurysms. You excise, the, uh you make a AAA tongue of the graft to go into the commercials or the uh signs of the sinuses and replace the coronary artery and just leave that alone. Then the David in Toronto developed instead of doing that, did this and did a tube graft that goes into the gut into the and go itself and your valve lies within the tube, the t end on the road. So it stabilizes the road and you have this. So most people do this this day because you have good is stabilized and there's no more native tissue exposed that can enlarge over time. Uh This is like a well when in the days they didn't have what we call an elephant trunk to patch, take off this and put a cuff off the extending aorta there. Uh have to, well, with the advent of materials from, from the companies now, like I have a branch graft, they have to get branches, we what we call debranching. We could debranch the vessels and leave this trunk like an elephant trunk in the out for future in the they call it IV. But now they have a landing zone, they could land any stent into this gut. So that avoids landing stents on a weakened wall of the aorta. It's called an elephant. It's actually a floating elephantum floating because there's no stents in this uh trunk um in people who have do many techniques. So um have tried, OK, have a news on the A cut to the A and put a suit with D this doesn't work these days, supporter to wrap, put a wrap around the aorta and then if you wrap it that way the does not expand anymore, but this is so it is safe to do a replacement or the aorta, you can um now we are 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 there has been very, quite complex. So we try to cool your body down to 18 degrees at 18 degrees. You have like 35 40 minutes, you can safely do surgery quickly and you have to quickly, quickly to make sure you get the head and neck vessels back. Otherwise, as you stay longer, the head, your risk of stroke is higher. And if there's no, there's no joy doing surgery and plan cannot walk or is, is gonna wake up. It's just, it's just failure of care. So that was a big problem. But these days, we have a lot of devices, a lot of techniques whereby we can um monitor the 0.4 ce oximetry. Uh We can, we can take one vessel at a time. So take this one first that the most here the blood is still flowing. We still leave this blood flow into these vessels by putting tubes through them. So we supply, we call it called anti cerebral perfusion. So if you have an intact cycle of will in the brain and you supply blood to the left side. If you supply the right side of the brain, that's what we we rely on. Uh we monitor this with device on the skull. So test if that's working properly, uh We can take the one vessel out as the most here on circulation. Next vessel, same thing, our next vessel, same thing. We can the neck and the vessels easily while we're cooling down. Then we cannot the most. Since the vessels are now away from the arch here, we're gonna have the most quite near to us instead of going all the way here to which is very difficult and we cannot deploy a stent with the house. We call it frozen elephant trunk down to the uh the in the all these are tied off and or done the surgery, anything you don't need to do in the future like here now, there's still a tear and turn in aorta. Just take this enlarge, aorta can still enlarge over time. But because they have this, the stent graft here, you can come in from the groin and land the stent into a two do and expand this in the future. So this is the evolution from the eighties when Hans Sports who died last year, sadly, developed the elephant trunk all the way. Now we have stuff on shelf. We can do many things with these devices. Uh This is a new device that just came out recently. Uh We call it AM DSI won't bore you with this. It's also a way you can uh you can stent the arch so you can see AAA not a covered stent, a naked stent, but you can ask the most here at zone zero where you can see, I think it's a 10, the arch, you can put a stent, this stent expands and compresses your. See your, this is your first woman down here, but up here is compressed and when it is composed is a series of time clot off and it does not no more. No, does not exist anymore. I can try to deploy stents here afterwards. So if you are tired or not tired, if you don't do any extensive surgery cooling down too much, you can try to do this procedure blood this in 10 minutes. Sit around here in 15 minutes. You done know what the device is meant to do. Uh This is, this is called it just when you switch your under, I just need to be careful. You will see again into the first lumen. So you've done your surgery, your S your distal Asthmo is contrast in your first lumen in the arch of this or, or, or sending a called the D phenomenon. And that's what A MD as is meant to uh uh to treat by uh putting the stents here to eliminate that pain. Um Yeah, defic scar, a patient with a 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 terrible looks it look like. You think, I think the descending aorta is all a mess there, huge aneurysm blood everywhere. And what you just need is just to get blood flowing in the right place. Once blood flow in the right place in the right lumen, all this will will disappear with time. I think this is the surgery for this patient. So this is this is a schematic diag on the surgery that patient had. So uh I think this is my was my last slide. So tic disease is quite is is we have them now. They're all around us. Most people who died on uh because of the the ability of chit and go and process and because aortic surgeries now is so specialty. They love experience in tic surgery. A lot of interest in a 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 or 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 Benda was very extensive and very detailed presentation. I know the time is not quite enough to go through everything, especially the procedure procedures. But it, it, it's a lot. Yeah, it's quite expensive. But we'll see. We'll see. Well, on that time we can get on that topic to just describe procedures themselves. Yes. Yes. Hopefully. So we, um, this is just like the, a 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 up the well. Ok. Ok. So someone has, has a question. Yeah, an alternative or second line drug for controlling BP aside. Labetalol. Yeah. Y yes. So, uh, we, if you, if you have a dissection, I agree to patient. We, we prefer a bit to know why first because it's intravenous patients with dissection are having surgery with need by mouth. So if you give any beta blockers, but intravenous now, if you use what people come use GTN infusion, which is quite very common. GTN infusion, give but GTN, yes, we do BP but it increase the shear stress of called the rebound effect. Unlike labetalol, we doesn't do that. And the commonest drug we have is labetalol. Esmolol is short acting to a beta blocker. So you have to keep it quite often. But labetalol and an infusion pump can last a bit longer. However, um if you di on shelf fine, uh you have to use what you have and uh you get the as the main thing. Another question here is, yeah. So for intramural hematoma, uh from question from uh Clinton or um you know, like a type a dissection if you have an intramural hematoma, uh that is expanding. So it's getting bigger in size from severe scans, severe scans will be done at least in a week. So you come today, do a scan in one week and it's bigger in size or a patient has pain or worsening pain or persistent pain or an organ dysfunction. So, maybe having is more drowsy. So maybe having had uh cerebral ischemia or have abdominal pain or the kidney function is deranged and worsening. You need to deal with that patient. And that's why we do so for them. So we do for them is they just ascending aorta replacement for most of the patients. If you extend into the arch and arch also enlarged and dilated, you must do a arch replacement. So all based on the extent of the enlargement of the area of the AORTA, you might replace the whole of the AORTA if you need to be. Thank you, Doctor Ben. Any other questions? Um I've put up the feedback form on the chart. So please um fill up 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. Yeah. Ok. So if I'm charging, what happen? So uh yeah, so the elephant trunk, uh it provides you to do this procedure as a stage one preparing for this stage two, which would 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, see you. And so artery is very posterior on the front of patients is very posterior and deep in the chest. It's very hard to sit out there. And when you sit out there and there's 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 throw his one where the 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 potential of elephant trunk over uh all that straight grafts we had in the past. So it gives you a chance for a stage two procedure and make the procedure itself much, much easier than previously. Um, your recommendation. Uh Well, the ee everything, everything needs done. 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? An family? Yes, that, that would be great. Um So yeah, II think I have your email address if you. Ok. Yes, you can share the email with them and I can find site and materials to share with you guys. Yeah. Yeah, that's it. 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 Ben. It's very good and insightful. Um Don't forget to fill fill your feedback form guys. It's when you finish it, you'll be able to get a CT of attender, 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.