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Original Articles: Cardiovascular

Invited Commentary

Department of Cardiothoracic Surgery, University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria

(Email: martin.czerny{at}meduniwien.ac.at; michael.grimm{at}meduniwien.ac.at).

The authors [1] report on their long-term results of non-Marfan patients operated on for acute type A dissection with histologic evidence of cystic medial necrosis. This is a valuable clinical report addressing a timely topic. We would like to comment on some issues that might improve the understanding and thereby the prevention of late adverse events in primarily nonsurgically treated dissected aortic segments.

One of the major aspects and messages this report adds to our understanding is that patients after successful treatment for acute type A dissections remain patients and are not cured, irrespective of the underlying cause of the dissection. This is of crucial importance, because it implicates aftercare. It remains of utmost importance that all patients are included in an outpatient program where a strict algorithm with regard to completion computed tomography scans as well as therapy to lower blood pressure on the basis of β-blocker administration is performed. Thereby, the rate of patients reaching a critical diameter of primarily nontreated aortic segments may be reduced, and if applicable, endovascular solutions may be applied—at least within the arch and the descending thoracic aorta.

Furthermore, the report encourages the important issue of performing a histologic examination in each patient undergoing operation for acute type A dissection, because the histologic pattern itself may influence the perception of the treating physician for the years to come in these patients.

The issue of extensive resection and replacement of the aortic arch, especially in younger patients—at least in our opinion—has to be regarded with caution, because invasiveness of the procedure itself is augmented and the long-term benefit with regard to reduction of reoperations remains speculative. However, innovative approaches such as antegrade stent graft placement during hypothermic circulatory arrest or several other variants of distal arch or proximal descending repair remain an attractive alternative in these situations.

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1. Girdauskas E, Kuntze T, Borger MA, et al. Long-term prognosis of type A aortic dissection in non-Marfan patients with histologic pattern of cystic medial necrosis Ann Thorac Surg 2008;85:972-977.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Martin Czerny Michael Grimm Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Czerny, M. Articles by Grimm, M. Search for Related Content PubMed PubMed Citation Articles by Czerny, M. Articles by Grimm, M. Related Collections Great vessels Related Article