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Ann Thorac Surg 1997;64:1675-1677
© 1997 The Society of Thoracic Surgeons

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Discussion

Discussion

The first 300 words of the full text of this article appear below.

See also page 1669.

DR RANDALL B. GRIEPP (New York, NY): I congratulate Dr Deeb and his colleagues for bringing to our attention the difficulties in managing a very high risk group of patients: those with acute type A dissection and malperfusion. The authors' conclusion that delayed operation is preferable to immediate surgical intervention is a provocative one and must be critically examined, because it represents a significant change from the policy in most surgical units.

By way of comparison, I examined our experience with acute type A dissection over the past 10 years. All of our patients were operated on as soon as possible, with the diagnosis being made primarily on the basis of clinical examination findings and confirmed by transesophageal echocardiography. Of 120 patients, 18 died, for a 15% surgical mortality. Thirty-seven patients had malperfusion; the mortality in them was 27%, constituting over half the deaths occurring overall. In the group without malperfusion, the mortality was 10%. Our experience differs from that of Dr Deeb and his colleagues of Ann Arbor: Although our immediate surgical treatment of patients with malperfusion resulted in a 27% mortality, which is not dissimilar to his statistic for the delayed approach to malperfusion, it differs markedly from the mortality of 89% in the malperfusion patients Dr Deeb treated with early operation.

To try to explain the differences in our results, I would like to direct a number of questions to Dr Deeb. In the immediate surgical group with the very high mortality rate, was there some delay in getting patients to the operating room occasioned by difficulties in transferring them from another institution, with diagnostic procedures, and so on, so that the consequences of malperfusion would have become well established by the time of operation?

Was the extent of the operation in these . . . [Full Text of this Article]