Total arch for type A dissection?
2015; Elsevier BV; Volume: 151; Issue: 2 Linguagem: Inglês
10.1016/j.jtcvs.2015.03.058
ISSN1097-685X
Autores Tópico(s)Cardiac Valve Diseases and Treatments
ResumoCentral MessageTotal arch for type Adissection is not recommended for a majority of patients undergoing emergent dissection repair.See Articles page 341, 351, and 361.See Editorial Commentaries page 349, 359, and 374. Total arch for type Adissection is not recommended for a majority of patients undergoing emergent dissection repair. See Articles page 341, 351, and 361. See Editorial Commentaries page 349, 359, and 374. There's too much confusion, I can't get no relief.—Jimi Hendrix, “All Along the Watchtower” I'm like Mr Hendrix in “All Along the Watchtower.” The appropriate approach to acute DeBakey type I dissection repair is quite confusing, and the literature guiding which type of surgery is best certainly doesn't give me any relief. In this issue of the Journal of Thoracic and Cardiovascular Surgery, Omura and colleagues1Omura A. Miyahara S. Yamanaka K. Sakamoto T. Matsumori M. Okada K. Okita Y. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement.J Thorac Cardiovasc Surg. 2016; 151: 341-348Abstract Full Text Full Text PDF Scopus (96) Google Scholar attempt to assuage Little Jimi's (and the cardiothoracic surgeon's) plight by presenting their data on acute DeBakey type I dissection repaired with either total arch replacement (TAR) or nontotal arch replacement (non-TAR). They attempt to clarify whether the extent of arch replacement affects early or late outcomes with respect to perioperative morbidity and mortality and the need for late reintervention. Long-term survival is also analyzed. Is there still “too much confusion” after we read this article? Omura and colleagues1Omura A. Miyahara S. Yamanaka K. Sakamoto T. Matsumori M. Okada K. Okita Y. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement.J Thorac Cardiovasc Surg. 2016; 151: 341-348Abstract Full Text Full Text PDF Scopus (96) Google Scholar are to be congratulated for excellent short- and long-term outcomes in a high-risk cohort of patients. The in-hospital mortality was 12.5%, and the rate of new neurologic deficits was 7%. There was no difference in either of these parameters regardless of whether a patient underwent TAR, despite the significant selection bias against the non-TAR group (significantly more preoperative shock, need for preoperative cardiopulmonary resuscitation, older age). The results are even more impressive when considering that nearly half of the 197 patients analyzed underwent TAR with a mean antegrade cerebral perfusion time of 124 minutes. The actuarial 10-year survival was approximately 80% for all patients, and the freedom from reoperation was approximately 87% for the entire cohort. Again, there was no significant difference in survival or need for reintervention regardless of the surgical approach. The effectiveness of aggressive TAR repair becomes obfuscated, however, when one dives more deeply into the details of the data and tries to extrapolate these results into meaningful real-world practice for the surgeon confronted with the task of dissection repair. The 3 most important questions unfortunately are still left unanswered: (1) Which patients should undergo TAR? (2) Does TAR actually reduce the need for late aortic reintervention? (3) Do patients who undergo TAR live longer? Omura and colleagues1Omura A. Miyahara S. Yamanaka K. Sakamoto T. Matsumori M. Okada K. Okita Y. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement.J Thorac Cardiovasc Surg. 2016; 151: 341-348Abstract Full Text Full Text PDF Scopus (96) Google Scholar recommend TAR for 4 specific groups of patients: those with an enlarged aortic arch (not defined), severe dissection involving the supra-aortic orifices, younger patients, and those with connective tissue disorders (CTD). As a high-volume aortic center, this group was able to perform complex TAR repair without any increase in perioperative mortality or neurologic injury. The data supporting these recommendations are clouded, however, by the decision to exclude from analysis 8 patients with CTDs and to include distal aortic growth (along with distal reintervention) in their calculations of freedom from distal aortic events. Seven of the 8 excluded patients with CTDs underwent TAR. Five of these 8 went on to need additional surgery on the residual aorta. When one repeats univariate analysis by including these patients, the advantage of TAR in preventing distal aortic events is lost. Furthermore, when one analyzes the non-TAR group for downstream surgery after type I repair, we find that a majority of these reoperations were actually on the distal arch. Only 1 late reoperation in the non-TAR group was needed distal to the left subclavian artery. Given that only 15% of patients after type I repair go on to need additional surgery for their residual dissections,2Halstead J.C. Meier M. Etz C. Spielvogel D. Bodian C. Wurm M. et al.The fate of the distal aorta after repair of acute type A aortic dissection.J Thorac Cardiovasc Surg. 2007; 133: 127-135Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar it is difficult to recommend complicated TAR for acute type I dissection on the basis of these biases. Could we make better use of these data by taking advantage of their excellent computed tomographic imaging program to analyze the diameter of the arch at the time of the index procedure to define better the patients to whom we should offer TAR? Should we pool data on those with known CTDs undergoing type I repairs to see whether their long-term survival and freedom from reoperation are truly improved with complex TAR repair? One critical piece of information provided by Omura and colleagues1Omura A. Miyahara S. Yamanaka K. Sakamoto T. Matsumori M. Okada K. Okita Y. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement.J Thorac Cardiovasc Surg. 2016; 151: 341-348Abstract Full Text Full Text PDF Scopus (96) Google Scholar that may be as valuable as what type of surgery is needed is the impact of long-term follow-up imaging. Omura and colleagues1Omura A. Miyahara S. Yamanaka K. Sakamoto T. Matsumori M. Okada K. Okita Y. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement.J Thorac Cardiovasc Surg. 2016; 151: 341-348Abstract Full Text Full Text PDF Scopus (96) Google Scholar took ownership of these cases after surgery and should be commended for showing us that this level of commitment can largely eliminate the nearly 15% incidence of fatal late aortic rupture as a cause of death.3Kimura N. Tanaka M. Kawahito K. Yamaguchi A. Ino T. Adachi H. Influence of patent false lumen on long-term outcome after surgery for acute type A aortic dissection.J Thorac Cardiovasc Surg. 2008; 136 (1166.e1-3): 1160-1166Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar They were able to identify and act on problems before rupture ensued. To their credit, none of the patients needing second procedures on the aorta died of their reoperations. We clearly, however, have much work to do. Large database analysis of contemporary type I dissection repair still shows a soberingly high mortality of 20% in all comers.4Easo J. Weigang E. Hölzl P.P. Horst M. Hoffmann I. Blettner M. et al.GERAADA study groupInfluence of operative strategy for the aortic arch in DeBakey type I aortic dissection: analysis of the German Registry for Acute Aortic Dissection Type A.J Thorac Cardiovasc Surg. 2012; 144: 617-623Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Common sense dictates that this mortality, and the neurologic injury rate, would be even higher if we tried to apply TAR more aggressively, especially in those centers less experienced in complex arch surgery (which is actually where most patients with type I dissection actually undergo surgery). Perhaps innovative approaches such as the frozen elephant trunk approach to acute type I dissection will prove efficacious in significantly reducing the need for complex late aortic reintervention. Time will tell. Before we can expect any relief from the literature in providing more patient-specific guidelines for the appropriate type of surgery for acute type I dissection, however, we will need to eliminate the confusion generated by selection bias. We have to dive deep into the data to make certain we don't convince ourselves of the necessity for complexity when a keep it simple approach that provides excellent short-and long-term outcomes seems to suffice. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacementThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 2PreviewThe present study aimed to determine the impact of the extent of graft replacement on early and late outcomes in acute DeBakey type I aortic dissection. Full-Text PDF Open ArchiveDecision making in acute DeBakey I aortic dissection: Balancing extensive arch reconstruction versus mortalityThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 2PreviewManagement of the aortic arch in acute DeBakey I aortic dissection remains a clinical challenge. Debate persists regarding whether a less aggressive non–total arch reconstruction (non-TAR) or a total arch reconstruction (TAR) is the optimal surgical reconstruction for these acutely ill patients. Increasingly, in most aortic centers of excellence, the extent of arch reconstruction is determined according to a “tear-oriented” paradigm. In their report in this issue of the Journal, Omura and colleagues1 report their results of patients undergoing either TAR or non-TAR for acute DeBakey I aortic dissection according to a decision algorithm that is based on such a tear-oriented paradigm. Full-Text PDF Open ArchiveLong-term behavior of aortic intramural hematomas and penetrating ulcersThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 2PreviewFor intramural hematoma and penetrating atherosclerotic ulcer, long-term behavior and treatment are controversial. This study evaluates the long-term behavior of intramural hematoma and penetrating atherosclerotic ulcer, including radiologic follow-up and survival analysis. Full-Text PDF Open ArchiveTiming is everythingThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 2PreviewChou and colleagues1 from the Yale group report their early and late outcomes from intramural hematoma (IMH) and penetrating atheromatous ulcers (PAU) in the thoracic aorta. This experience spanned 20 years and included 105 patients, of whom 55 and 53 had IMH and PAU, respectively. This study updated their experience in 2002,2 and it maintains a continued aggressive stance with open interventions. In the report, Chou and colleagues1 provide several definitive conclusions that warrant comment: Full-Text PDF Open ArchivePreoperative characteristics and surgical outcomes of acute intramural hematoma involving the ascending aorta: A propensity score–matched analysisThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 2PreviewWe aimed to evaluate the preoperative characteristics and surgical outcomes of acute type A intramural hematoma. Full-Text PDF Open ArchiveAggressive surgical repair for ascending intramural hematoma is still a great optionThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 2PreviewIntramural hematoma (IMH) of the ascending aorta is a type of acute aortic syndrome. It has been suggested that IMH should be reconsidered as aortic dissection with thrombosis of the false lumen, because the indications and treatment for both are the same.1 The pathophysiologic mechanisms of dissection and its variants such as IMH, have been classified into 5 types because the condition represents a heterogeneous population of patients (Figure 1).2 Full-Text PDF Open Archive
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