Ann Thorac Surg 2008;86:1819-1820. doi:10.1016/j.athoracsur.2008.09.041
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Duke Cameron, MD
Department of Cardiac Surgery, Johns Hopkins Hospital, Blalock 618, 600 N Wolfe St, Baltimore, MD 21287
(Email: dcameron{at}jhmi.edu).
Most of the improvement in the life expectancy of Marfan syndrome (MFS) patients over the last 30 years is attributable to improved recognition and prophylactic replacement of ascending aorta and root aneurysm, an operation with low operative risk in the current era. However, as Girdauskas and colleagues [1] demonstrate, root replacement still leaves the patient with a diseased arch and descending thoracoabdominal aorta, particularly if dissection has already occurred before root replacement. Twenty eight percent (16 of 58) of their root replacement patients required reoperation within 4 years, and of course the number is likely to rise with longer follow-up. Dissection before root surgery was the strongest predictor of reoperation, and reoperation was usually for aneurysm in the descending aorta. Although early reoperative mortality was low (1 patient, 20%), mortality was 30% in this group at 3 years, and 3 more patients needed yet another reoperation.
The lessons are clear. First, operation before dissection remains the goal, because the "cat is out of the bag" once dissection occurs and a new, unfavorable "natural" history begins. The solution is not necessarily to operate at a smaller aortic diameter, but rather smarter, more selective use of the operation in patients identified to be at high risk, a strategy being investigated fervently. In contrast with Girdauskas' series in which nearly half of root replacements were performed emergently for acute type A dissection, our experience at Johns Hopkins is heavily weighted toward elective root replacement in the nondissected aorta, and the reoperation rate at 10 years is significantly lower (15%). Second, after root replacement, all MFS patients, and particularly those with dissection, need meticulous surveillance and follow-up. Whether arch replacement is advisable at the time of root surgery remains controversial. Several studies have shown that concomitant arch replacement is probably not warranted in the elective, nondissected MFS patient, a position we share. However, benefit might be seen in acutely dissected patients, but they are the patients at greater risk for complications of concomitant arch replacement. We hope that future studies will resolve this paradox and tell whether the cost of arch replacement at the first operation will be offset by a less complex reoperation.
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- Girdauskas E, Kuntze T, Borger MA, Falk V, Mohr FW. Distal aortic reinterventions after root surgery in Marfan patients Ann Thorac Surg 2008;86:1815-1820.[Abstract/Free Full Text]
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Distal Aortic Reinterventions After Root Surgery in Marfan Patients
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