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Ann Thorac Surg 2007;84:1069
© 2007 The Society of Thoracic Surgeons

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Correspondence

Should a Patient With Acute Aortic Dissection Type A Go to the Intensive Care Unit or Operating Room?

Department of Cardiac, Thoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, 30625 Germany

(Email: khaladj.nawid{at}mh-hannover.de).

To the Editor:

We read with great interest the article by Centofanti and coworkers [1] concerning the treatment of acute aortic dissection type A (AADA) patients. During a 24-year interval, 616 patients were operated on for AADA in a single center. In this retrospective study, the authors showed that shock, redo surgery, preoperative coma, acute renal failure, and age were independent preoperative predictors for in-hospital mortality.

By using the International Registry of Aortic Dissection (IRAD) database in conjunction with sophisticated statistical methods they identified 35 patients (5.7% of the entire cohort) with an expected mortality of 65.7%, and they postulated that this subgroup may have benefited from medical treatment instead of surgical treatment. Unfortunately the authors did not mention the exact timeframe of these operations. This is an important consideration, because preoperative, intraoperative, and postoperative strategies have strongly improved in recent years [2, 3].

Mortality, permanent neurologic dysfunction, and temporary neurologic dysfunction are the three major adverse outcomes after emergent or elective aortic surgery. In several studies, preoperative as well as intraoperative factors were strongly associated with these events. Therefore extensive research is focused on the reduction of adverse outcomes in these challenging patients [4].

The IRAD database reports indicate an early mortality of 58% in patients who for various reasons were medically treated for AADA. Unfortunately, information concerning the rationale for or against a conservative approach is incomplete (ie, with 32% not documented) [5]. Therefore it remains unclear whether these patients refused surgery or were refused operation due to significant co-morbidity or advanced age.

In our institution, all patients with AADA were accepted for surgery, even when ventilated, receiving inotropic support, or with unknown neurologic status. Our current mortality rate for the entire cohort is 20%. In our opinion, this is acceptable because 20% of these patients were hemodynamically unstable and 15% had new neurologic events.

Unfortunately it is not known how many patients were hospitalized with AADA due to chest pain or unclear neurologic symptoms and received conservative treatment. In case of death, autopsy is not routinely performed in all departments. The IRAD registry only includes patients with a definite diagnosis of AADA. Patients who die in referring hospitals for various complications (eg, cardiac tamponade, myocardial infarction, aortic rupture, and so forth) are missed.

Because the total incidence of AADA is unknown, medical treatment can not be seriously recommended for patients referred for emergency thoracic aortic surgery. We believe that the amount of expertise in the individual center, as well as already published data, do not support the author’s final recommendation. Nevertheless a database of these patients is valuable in this challenging disease.

We strongly believe that age alone should not preclude emergency operation. Medical therapy may be an option in patients with severe brain infarction or end-stage carcinoma, but every single case must be independently evaluated.

In our opinion, surgery in an experienced center is still the standard of care for patients with AADA, until evidence-based facts show advantages of alternative or less invasive treatment methods.

	References

Top References

 

1. Centofanti P, Flocco R, Ceresa F, et al. Is surgery always mandatory for type A aortic dissection? Ann Thorac Surg 2006;82:1658-1663discussion 1664.[Abstract/Free Full Text]
2. Hagl C, Khaladj N, Karck M, et al. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection Eur J Cardiothorac Surg 2003;24:371-378.[Abstract/Free Full Text]
3. Kallenbach K, Oelze T, Salcher R, et al. Evolving strategies for treatment of acute aortic dissection type A Circulation 2004;110:II243-II249.[Medline]
4. Khaladj N, Peterss S, Oetjen P, et al. Hypothermic circulatory arrest with moderate, deep or profound hypothermic selective antegrade cerebral perfusion: which temperature provides best brain protection? Eur J Cardiothorac Surg 2006;30:492-498.[Abstract/Free Full Text]
5. Tsai TT, Evangelista A, Nienaber CA, et al. Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD) Circulation 2006;114:I350-I356.[Medline]

This article has been cited by other articles:

				P. Centofanti, R. Flocco, F. Ceresa, M. Attisani, M. La Torre, L. Weltert, and A. M. Calafiore Reply Ann. Thorac. Surg., September 1, 2007; 84(3): 1069 - 1070. [Full Text] [PDF]

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): Nawid Khaladj Axel Haverich Christian Hagl Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Khaladj, N. Articles by Hagl, C. Search for Related Content PubMed PubMed Citation Articles by Khaladj, N. Articles by Hagl, C. Related Collections Great vessels Related Article