Ann Thorac Surg 2006;81:1351-1352
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Leonard N. Girardi, MD
Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, 525 E 68th St, M-424, New York, NY 10021
(Email: lngirard{at}med.cornell.edu).
Approximately 20% of all patients diagnosed with acute type A dissection will have some form of cerebral malperfusion. Earlier reports of patients undergoing surgical repair in this setting have produced rather dismal results with mortality as high as 30% to 50%. Because of the limited success reported in these previous studies, some advocate nonoperative or delayed surgical management for patients with central nervous system malperfusion. In this small series, Pocar and colleagues [1] describe their experience with emergency surgical repair of acute type A dissection in patients presenting with coma. In a highly selected group of patients presenting with this advanced form of cerebral malperfusion, immediate surgical repair of the dissection resulted in complete neurologic recovery in 80% of their patients. One additional patient had substantial improvement in his neurologic status and there were no surgical mortalities. Importantly, all patients had postoperative cerebral imaging and none had evidence of hemorrhagic conversion or progression of cerebral edema with varying periods of anticoagulation, cardiopulmonary bypass, and profound hypothermic circulatory arrest. These results are outstanding and reinforce the belief that a majority of patients with peripheral vascular malperfusion will benefit from primary aortic repair.
The title of this article is appropriate in that coma "might not preclude" emergency surgery in this setting. All patients presenting with dissection and coma had a full neurologic evaluation including computed tomographic scanning of the brain. Those with no clinical or radiographic evidence of advanced cerebral edema or hemorrhage were offered immediate surgery, all within 9 hours of presentation. All were relatively young (< 66 years of age), and none had hemodynamic compromise or shock. The authors commendably report denying surgery to an additional 3 patients who had evidence of more advanced cerebral injury, either significant cerebral edema or intracranial hemorrhage.
What can we learn from this article that will allow us to achieve similar outcomes for our patients with dissections and central nervous system malperfusion while avoiding the 15% incidence of aortic rupture that can occur in patients who are triaged to a strategy of delayed surgical management? Patients presenting with neurologic deficits, especially coma, and an acute type A dissection deserve a full neurologic and radiographic examination prior to being turned down for repair. The additional time needed to image the brain does not significantly delay the time to surgery and does not increase the risk in the preoperative period. For those without obvious intracranial hemorrhage or significant cerebral edema, either by examination or imaging, reestablishing flow into the true aortic lumen with immediate surgical intervention seems appropriate with a high likelihood of neurologic recovery. The probability of full neurologic recovery may be dependent on age, and in some cases, surgical technique. Reports with larger cohorts of similar patients may help identify additional risk factors that may further alter our surgical approach.
Patients with evidence of more advanced cerebral injury may ultimately come to surgery but may benefit from a period of medical therapy to allow resolution of their cerebral edema and declare their neurologic status more fully. However even after aortic repair, most of these patients will be left with permanent deficits that are unlikely to improve. An aggressive and thoughtful surgical approach to the patient with coma secondary to dissection should allow us to minimize the number of patients experiencing fatal aortic rupture while providing the opportunity for maximum neurologic recovery.
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- Pocar M, Passolunghi D, Moneta A, Mattioli R, Donatelli F. Coma might not preclude emergency operation in acute aortic dissection Ann Thorac Surg 2006;81:1348-1352.[Abstract/Free Full Text]
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