| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2001;71:1249-1250
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, University of Virginia Medical Center, Lee St, Room 2753, Charlottesville, VA 22908, USA
e-mail: ilk{at}hscmail.mcc.virginia.edu
Moon and colleagues from Washington University School of Medicine reviewed 119 patients over a 15-year period who underwent surgical repair of acute type A aortic dissection. They asked the very appropriate question whether or not the extent of proximal or distal aortic resection would alter short-term and long-term outcomes. The authors did an excellent job with 98% followup in their patient series. Like any retrospective study, there are obvious difficulties in terms of comparing groups particularly since 18 different surgeons were involved without any of them doing more than 20% of the operation. However, it would be nearly impossible to do a prospective study on this entity since even the busiest centers usually perform less than 15 procedures a year.
For proximal dissections, the authors performed three different operations. These include aortic valve resuspensions, root replacements, and separate graft and valve replacements. Surprisingly, the separate graft and valve replacements had 50% mortality which is significantly higher than the mortality for the other two procedures. It is not clear why the mortality was so high in this group of 10 patients. The authors appropriately concluded that valve resuspension is a procedure of choice unless the sinuses are involved. Most aortic surgeons would agree with this. Certainly, patients with anuloaortic ectasia and Marfan’s syndrome would need root replacement even when presenting with acute aortic dissection. Fortunately, the authors have demonstrated that root replacement can be performed with essentially the same mortality as aortic valve repair. It should also be noted that there were no proximal re-operations in the group of patients who had aortic valve resuspensions. This clearly is an operation with long-term durability.
The more difficult question is what to do for the distal aorta. The authors demonstrated reasonable results with hemiarch resection particularly when the tear extended into the arch. They noted that the distal anterior reoperations occurred only in the patients who underwent aortic resections without hemiarch repair. Though this rate was not statistically significant, there certainly was a trend in this group that was troublesome. It seems the hemiarch approach may be appropriate as the authors stated in patients with Marfan’s syndrome or in whom the tear extends into the arch. The authors did not perform full arch repairs in acute dissections which is a reasonable operative strategy.
However, the most interesting question is the one the authors did not address. They described three time periods between 1984 and 1999. The operative mortality was essentially the same in each of the three time periods. Specifically, mortality was 21% from 1984 to 1988, and also 21% from 1994 to 1999. Certainly, cardiac surgery in general has gotten better over the span of 15 years. We have better aortic grafts, better perfusion techniques, and have developed, theoretically, better approaches to aortic dissection with the trend now toward more use of circulatory arrest for the distal aortic anastomosis. However, we have not impacted operative mortality. The authors state that most operative mortality related to the pre-existing conditions including shock as well as malperfusion syndromes. However, one would expect the mortality should have improved over the 15 years. The authors are not unique in this. Most centers, including our own, have not markedly improved operative results for acute aortic dissection. I wonder if our operative strategies may be wrong. Certainly, for the stable patient an aggressive approach to the arch with the use of whatever adjuncts are required may be appropriate. Long-term survival may be benefited by an aggressive approach to aortic arch tears. However, in patients who present with shock or malperfusion syndromes, it may be more appropriate to develop a less aggressive approach to the arch. Our group has not taken this approach presently but is considering it. There is a well-known surgical maxim which states that perfection is the enemy of good." It may be that we are trying to do too perfect an operation for the sickest of patients with acute aortic dissection.
Related Article
Ann. Thorac. Surg. 2001 71: 1244-1249.
This article has been cited by other articles:
|
|
 |
|
  D. T. Lai, D. C. Miller, R. S. Mitchell, P. E. Oyer, K. A. Moore, R. C. Robbins, N. E. Shumway, and B. A. Reitz Acute type a aortic dissection complicated by aortic regurgitation: composite valve graft versus separate valve graft versus conservative valve repair J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1978 - 1985. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
