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Original Articles: Adult Cardiac

Invited Commentary

First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192 Japan

(Email: tkazui{at}cvc-ohno.or.jp).

In this study, the authors [1] described a one-stage technique for extensive replacement of the thoracic aorta in a series of 51 patients with chronic aortic dissection. The series comprises mostly patients requiring reoperation after previous repairs of acute type A aortic dissection. The authors have used bilateral thoracotomy and arch-first technique in these patients with commendable clinical results. They claim that this one-stage procedure is superior to the conventional two-stage procedure and frozen elephant trunk technique (hybrid procedure) for extensive chronic aortic dissection confined to the thoracic aorta.

The results of the present study generally attest to the appropriateness of the use of a branched aortic graft and antegrade selective cerebral perfusion through the right axillary artery for total arch replacement procedure. Although the points raised by the authors are well taken, a few issues need to be clarified. First, the postoperative pulmonary dysfunction seems to be relatively high in this series, probably because of the bilateral thoracotomy and hypothermia. Are there any exclusion criteria for this extensive approach on the basis of the preoperative pulmonary function test? Second, one of the concerns with unilateral cerebral perfusion through the right axillary artery is possible hypoperfusion of the left cerebral hemisphere. How do the authors preoperatively and intraoperatively determine that the cerebral perfusion in the left hemisphere is adequate? Third, how do the authors avoid injury to the patent left internal thoracic artery graft during the procedure?

Considering the fact that extensive reoperation on the distal aorta, remaining ascending aorta, aortic arch, and descending aorta is often required in the late postoperative period in some patients after limited ascending aortic replacement for acute type A aortic dissection (Debakey type 1 aortic dissection), total aortic arch replacement with the elephant trunk technique could be justified in selected patients at the time of the initial surgery to avoid the extensive reoperation on the ascending and aortic arch.

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1. Kouchoukos NT, Masetti P, Mauney MC, Murphy MC, Castner CF. One-stage repair of extensive chronic aortic dissection using the arch-first technique and bilateral anterior thoracotomy Ann Thorac Surg 2008;86:1502-1509.[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): Teruhisa Kazui Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kazui, T. Search for Related Content PubMed PubMed Citation Articles by Kazui, T. Related Collections Great vessels Related Article