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a Cardiovascular Center "E.Malan", IRCCS Policlinico San Donato, via Morandi 30, San Donato Milanese 20097, Italy
b University of Michigan, Ann Arbor, MI 48128
c Massachusetts General Hospital, Boston, MA 02114
d University of Rostock, Rostock, D-18055 Germany
e University of Michigan, Ann Arbor, MI 48128
(Email: satrimarchi{at}yahoo.it).
We would like to thank Drs Babin-Ebell and Misfeld [1] for their interest and comments regarding our article on a score to predict surgical mortality in acute type A aortic dissection (AAAD) [2]. We reported on 834 patients with AAAD, of which 148 (17.7%) had medical management due to different reasons such as advanced age, severe comorbid illness, intramural hematoma (IMH) or refusal of the intervention.
Advanced age is not generally a reason to refuse surgery. Data from the International Registry of Acute Aortic Dissection (IRAD) indicate that the age where the surgical mortality is higher than the medical is greater than 85 years old. However, it seems reasonable that in patients who are 85 years old or greater, a presence of comorbidities could be valuated differently than in a younger patient.
An IMH acutely detected in an ascending aorta needs a surgical approach, leading up to the same percentage of aortic rupture when compared with classic AAAD [3], but many of these patients are initially valuated and managed by cardiologists, and there may be a tendency to watch the very old patient, hoping IMH will regress.
Preliminary IRAD data regarding AAAD patients medically treated showed that age greater than 70 years old, presence of shock, and renal failure were predictors of medical management, as well predictors of in-hospital mortality, which in our work was 58.1%.
In AAAD patients, benefit of surgery is clearly defined, but IRAD shows that patients can present marked differences in age, history, and clinical scenarios that can lead to different management, also among aortic referral centers.
In an attempt to characterize AAAD patients, according to various clinical presentations and surgical outcome, we further stratified patients who were unstable (ie, patients with cardiac tamponade, shock, congestive heart failure, cerebrovascular accident, stroke, coma, myocardial ischemia, or infarction, or a combination of these, and electrocardiograms with new Q or segment ST elevation, acute renal failure, or mesenteric ischemia and infarction at surgery) and stable patients, or those who did not have these conditions.
Surgical mortality was nearly two times that in unstable patients (30.0% vs 15.5%; p < 0.0001), compared with stable patients, confirming that preoperative variables are primary factors in determining surgical outcome.
Acute dissected patients represent a heterogeneous group, in which initial clinical presentations seem to be strictly associated with in-hospital outcome. Of consequence, this could potentially justify individual decisions and on the other hand underline the necessity to stratify these patients. The IRAD is an observational registry that reports data from 18 aortic referral centers around the world in which there is no standard protocol for diagnosis and management of dissections present, and therefore treatment represents individual approaches. Although difficulties and limitations are obviously present, we believe that the IRAD is a great resource to better understand aortic dissection.
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