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Clinic of Cardiac Surgery, University Clinic of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, Luebeck, 23538, Germany
(Email: joerg.babin-ebell{at}web.de).
We are writing with regard to the publication by Rampoldi and colleagues [1], which we read with great interest. However we believe that some aspects of this important article require further comments.
Of the 834 patients with acute type A aortic dissection, 148 patients (17.7%) were treated medically due to advanced age, severe comorbid illness, intramural hematoma, or refusal of intervention. In our opinion, advanced age is not generally a reason per se to refuse surgery. Studies have shown that emergency surgery in elderly patients with acute type A aortic dissection can be performed with a hospital mortality of 13% and 17.6% [2, 3], which is less than the hospital mortality of 23.9% shown in the article [1]. The authors have also previously reported that in-hospital mortality of patients less than 75 years of age, at least in female patients, is not increased compared with a patient group between the ages of 66 and 75 years [4]. As the authors stated, "... risk analysis is not beneficial in young patients, who generally all go to surgery ..." Where do the authors set the border between young and advanced age, taking into account that a 70-year-old man has a mean further life expectancy of approximately 12.5 years and a women of this age has approximately 15.5 years?
With regard to intramural hematoma (IMH), why was this pathology an indication for medical treatment, as IMH is considered as a precursor of classic dissection, leading in about 47% of cases to acute aortic dissection and in the same percentage to aortic rupture [5]?
In our opinion the only reason for medical management of acute type A aortic dissection is the refusal of surgical intervention by the patient.
Furthermore, how many patients undergoing medical treatment had presented symptoms of acute renal failure, hypotension, or cardiac tamponade? Both acute renal failure and hypotension may be clinical signs of cardiac tamponade, which is an absolute indication for immediate surgical intervention.
In our opinion, the overall "medically treated" in-hospital mortality rate of 58.1% is even poorer in comparison with the reported surgical in-hospital mortality of 23.9% in the late postoperative course.
Undoubtedly, patients presenting with acute type A aortic dissection represent a high-risk group of patients with a mortality rate of 1% to 2% per hour early after symptom onset [5]. Therefore urgent surgery is the only treatment of choice in this life-threatening situation, and in our opinion, medical treatment is only indicated when the patient refuses surgical intervention.
In summary, the data presented by Rampoldi and co-workers [1] give the surgeon important data for the advice and information of the patient about the risk of the operation, but not for the decision making to operate on the patient or not. The series of 148 patients is probably the largest series of patients treated medically in type A aortic dissection and it would be of major interest to have a model for the probability of death for medical treatment in this disease, which could be compared with the model of death for operative treatment.
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  S. Trimarchi, V. Rampoldi, International Registry of Acute Aortic Dissection, T. Tsai, J. V. Cooper, E. M. Isselbacher, C. A. Nienaber, and K. A. Eagle Reply Ann. Thorac. Surg., March 1, 2008; 85(3): 1140 - 1141. [Full Text] [PDF]
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