Ann Thorac Surg 2002;74:81-82
© 2002 The Society of Thoracic Surgeons
Invited commentary
Robert A. Dion, MDa
a Department of Cardio-Thoracic Surgery Academisch Ziekenhuis Leiden Thoraxchirurgie K6S Albinusdreef 2-Leiden PB 9600 NL-2300 RC Leiden, The Netherlands
e-mail: rdion{at}lumc.nl
The surgical treatment of acute type-A aortic dissection remains a challenge, and, as underlined by the authors, ultimate success heavily depends on expeditious referral and diagnosis, refined and adapted technique, and last but not least, aggressive follow-up. This report does not address a very large cohort of patients. Nevertheless, it allows the reader to follow the evolving management of one experienced and dedicated colleague over the last 20 years.
Hospital events still heavily depend on the preoperative condition of the patient—here, particularly, the presence of shock and/or myocardial or visceral malperfusion, which explains the persistence of a disappointingly high overall hospital mortality of 19.2%. However, the authors report a spectacular reduction since 1997 in spite of their nearly uniform preference for total arch replacement. Open distal anastomosis, biological glue, improved cerebral protection, and anterograde arterial perfusion apparently have made the difference. However, 4 of the 42 patients having undergone aortic valve resuspension using glue developed wall necrosis needed reoperation; which poses the following questions. To glue or not to glue? Less formaldehyde or bioglue?
Glue is controversial but so helpful and time sparing at operation! Selective cerebral perfusion—the Kazui method—has proven its value, also here with only five patients (4%) suffering from a cerebral vascular deficit. Still, I miss a sophisticated on-line neuromonitoring (like somato-sensory evoked potentials?) which would better individualize cerebral perfusion. And it does immediately detect malperfusion when cardiopulmonary bypass is initiated and during cooling, wherever the cannulation site.
When the intimal tear is not found in the ascending aorta and in young patients with Marfan’s syndrome, the authors promote total arch replacement (TAR) (+ modified elephant trunk) above hemiarch replacement (HAR), except in compromised and/or aged patients. The rationale is that 15% of ascending aorta replacement patients and 13% HAR patients have needed a reoperation on the arch at follow-up, and the mortality of reoperation via sternotomy has been 14% (3/21). This strategy does not appear to be supported by the comparative overall freedom from reoperation at 5 and 10 years after TAR versus HAR. However, it makes sense if it does not increase hospital mortality while decreasing the incidence of feared reoperation via sternotomy. Furthermore, the strategy facilitates reoperation for potential distal thoraco-abdominal pathology thanks to the elephant trunk maneuver. Dr Kazui and his group have to be commended, not only for their impressive surgical results but also for a clear-cut and sound message in a still controversial and evolving field.
Related Article
-
Surgical outcome of acute type A aortic dissection: analysis of risk factors
- Teruhisa Kazui, Naoki Washiyama, Abul Hasan Muhammad Bashar, Hitoshi Terada, Takayasu Suzuki, Kazuhiro Ohkura, and Katsushi Yamashita
Ann. Thorac. Surg. 2002 74: 75-81.
[Abstract]
[Full Text]
[PDF]
