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Ann Thorac Surg 1995;59:590
© 1995 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Herz-, Gefäß- und Thoraxchirurgie, Herz-Kreislauf-Klinik Bevensen, Römstedter Straße 25, 29549 Bad Bevensen, Germany

See also page 585.

Because of its increasing success surgical repair of type A aortic dissection has become the treatment of choice. The St. Louis group has contributed another fine series with excellent surgical results. However, it is still unclear which spectrum of diagnosis is necessary for the decision for operation.

It is widely accepted that the chronic form of dissection rather resembles aneurysmal disease with respect to symptoms, surgical approach, operative risk, and late outcome. In general there is enough time for an appropriate preoperative screening including invasive methods as, for example, coronary angiography. However, in acute type A dissection the necessity of the latter and the role of invasive aortography are discussed controversially. There is agreement that the preoperative tests have to be expeditious, avoiding hypertension and, if possible, direct manipulation of the dissected vascular wall impending to rupture. Several groups have suggested that echocardiography, especially the transesophageal form, could confirm diagnosis quickly and with high accuracy. Since we repeatedly experienced patients dying during transportation, during diagnostic procedures, or while waiting for a gap in the running operation program, in 1987 we proposed to decide for operation immediately after establishment of the diagnosis without other invasive examinations [1].

In 1995 Creswell and colleagues state that there were no fatal complications associated with invasive diagnostic measures and recommend more liberal use of preoperative coronary angiography, referring to their excellent surgical results. However, the design of the study includes only surgical patients having already survived all diagnostic procedures. An excellent surgical outcome does not imply that the preoperative diagnostic measures must have been adequate.

I believe that the decision regarding the diagnostic spectrum has to consider the individual situation of our patients. In a very early stage of the disease (<48 hours), in young patients without risk factors for coronary artery disease, in the presence of significant pericardial effusion, coronary angiography even can be obsolete.

Again Creswell and associates have to be congratulated for their excellent results, especially in cases with repair of dissection combined with coronary bypass grafting. In patients in whom urgency of the disease does not allow preoperative invasive investigation, intraoperative coronary angiography might be an answer to the problem.

Reference

1. Laas J, Schlüter W, Hendrickx DP, Haverich A. Acute type-A dissection of the aorta: which diagnostic modes remain for surgical indication? Eur J Cardiothorac Surg 1987;1:169–72.[Abstract]

This Article 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joachim Laas Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Laas, J. Search for Related Content PubMed Articles by Laas, J. Related Collections Related Article