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Ann Thorac Surg 2007;84:1069-1070
© 2007 The Society of Thoracic Surgeons
a University of Turin, C.so Bramante 88, Turin, Italy
b University of Catania, via Citelli, Catania, 95124 Italy
(Email: paolocentofanti{at}tiscali.it; calafiore{at}unich.it).
There is no doubt that aggressive surgical treatment of type A aortic ascending dissection (AAD) saved a large number of lives compared with medical therapy only.
We believe that emergency surgery is the elective option for most type A aortic dissections. In our center, surgery was never denied as long as there was a possibility for it to successful. In the last 2 decades the observed early mortality rate (25%) remained stable and is similar to that reported by different authors.
In their letter to the editor regarding our article [1], Khaladj and coworkers [2] quoted a reference that shows their experience in treating acute aortic dissection type A by the Division of Thoracic and Cardiovascular Surgery of Hannover Medical School [3]. The overall early (30-day) mortality was 24% with no statistically significant differences between four groups as a function of time (1990 to 1994, 1995 to 1997, 1998 to 2000, and 2001 to 2003). The early death causes they reported were: myocardial failure (44%), cerebral ischemia (25%), multiorgan failure (10%), and abdominal ischemia malperfusion-related (6%). In the discussion section, the authors of this report confirm that early mortality in patients with AADA is mainly determined by the general status of the patient at presentation.
In our retrospective study, 35 patients had an expected mortality of 58% or higher; a qualitative analysis of these patients showed that 19 of these patients had a cardiac tamponade, and surgery was inevitable concerning life expectancy. However, for the other 16 patients (2.6% of the entire cohort), optimized medical management could be considered a better option.
It is very important to underline that the natural history of this disease is different from the history of patients managed with standard medical therapy.
Optimized medical management means early diagnosis and prompt intensive care unit hospitalization. Target goals for treatment are a heart rate of less than 80 beats per minute, a systemic blood pressure of less than 120 mm Hg, a diastolic pressure of less than 80 mm Hg, and a cardiac index of more than 2.5 L/min–1/m–2. Simultaneously all metabolic disturbances are medically corrected, and the utility of invasive procedures is evaluated (ie, organ reperfusion using percutaneous fenestration and stenting).
Deeb and coworkers 4] experience with this management shows that there is a 5% risk of rupture and death during an average 20-day delay period versus an 89% risk of death in patients who undergo immediate repair with type A dissection complicated by malperfusion and who have signs of end-stage organ failure.
We are in agreement with Khaladj and coworkers [2] that age alone should not preclude an emergency operation (eg, the type A aortic dissection in a hospital surgical mortality score for an 85-year-old patient is 26.3%, but if this patient is in shock and has a history of previous cardiac surgery (redo), the mortality score overtakes the 58.3% and we believe that the medical management could be a good option).
We believe the mortality rate that occurred in patients with type A dissection not receiving surgery (58%) in the International Registry of Aortic Dissection (IRAD) group is overestimated because it also included patients without optimized medical therapy (ie, death prior to planned surgery).
We hope that if our type A mortality score will be validated by the scientific community that more experience will be made with optimized medical management in high-risk groups of patients, and that there will be another option for these unlucky patients.
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