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Eur J Cardiothorac Surg 2005;27:632-633
© 2005 Elsevier Science NL
Oxford Heart Center, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
* Tel.: +44 1865 220269; fax: +44 1865 220268. (E-mail: swestaby{at}ahf.org.uk).
In this paper from the renowned Mount Sinai Aortic Surgery Group, Halstead and Colleagues advocate a more radical approach to aortic root pathology in acute Type A dissection. Their concluding sentence states that "These results support an aggressive policy of composite root replacement in acute Type A dissection". Is this really the case?
The study design does not test the hypothesis that root replacement with a prosthetic valved conduit provides better short or long-term results than supracoronary aortic replacement with valve re-suspension. This is a retrospective analysis and comparative study of two difference circumstances. Patients with more extensive root involvement (Group B) and aortic regurgitation (in 82% of cases) were treated by prosthetic valved conduit root replacement. Those without root involvement or dissection limited to the non-coronary sinus received the less taxing approach of supracoronary aortic replacement (Group A) and valve re-suspension if prolapse occurred. More complex patients undergoing aortic arch replacement were excluded from the series so we do not know whether the more radical approach to the aortic root increased mortality in prolonged operations. Hospital mortality was satisfactorily low for both groups demonstrating that aortic root replacement can be performed safely by experienced surgeons in dissection patients. Long-term outcome was the same for both operations and similar but not better than contemporary series where valve re-suspension by glue repair or other methods has been employed preferentially [1,2]. Obviously, aortic root replacement reduced the risk of late aortic root re-operation but prosthetic valve related complications were the trade off. The text also implies that some patients with Marfan syndrome or pre-existing aortic dilatation did not undergo root replacement possibly accounting for the greater re-operation rate and some deaths in these patients.
We fully agree that the primary tear should be completely excised and that this usually requires the open-ended technique with hypothermic circulatory arrest. Equally, all Marfan patients and others with annulo-aortic ectasia require more extensive root surgery. However, in the discussion, the authors argue that composite graft replacement should be applied more often even when the aortic valve is morphologically normal and fully competent as it was in 56% of Group A patients. This is contrary to the basic principles of cardiac surgery where preservation of a well functioning cardiac valve is invariably preferable to replacement.
The International Registry of Acute Aortic Dissection collected data from a number of major teaching hospitals [3]. In patients with a mean age of 62 years, the surgical mortality was 27% with a 15% incidence of major neurological complications (similar to the Mount Sinai series). Thus, in general cardiac surgical practice where the great majority of patients undergo supracoronary aortic replacement (possibly with a cross-clamp in place), one in four patients die. Accordingly, the principle goal of aortic dissection is to achieve hospital survival and mortality is unlikely to be reduced by a more complicated procedure performed under emergency conditions. For many years, the UK Cardiac Surgical Database recorded a mortality of around 20% for elective aortic root replacement. Other series identify prolonged cardiopulmonary bypass and cross-clamp time as risk factors for hospital mortality in dissection surgery [4,5]. The operation performed should therefore reflect the ability of the surgeon and be tailored to achieve survival with the understanding that the patient can always be referred to an experienced aortic centre should late complications ensue.
Given the reservations about the conclusions in this paper, it is worth reiterating the incontrovertible basic principles of aortic dissection surgery. First, the primary tear should be completely excised to reduce the risk of both operative and late complications. This can rarely be achieved with an aortic cross-clamp in place and may require partial or complete aortic arch replacement particularly when the tear begins in the aortic arch. Secondly, competence of the aortic valve must be restored preferably preserving a morphologically normal native valve. The surgical options include: (a) conventional re-suspension of the commissural pillars with supracoronary graft replacement of the ascending aorta; (b) on occasions, replacement of a pathological native valve with repair of the aortic sinuses; (c) full aortic root replacement with a prosthetic valve conduit; or (d) valve sparing aortic root replacement by re-implantation into a tube graft (David procedure). Experienced aortic surgeons now have a leaning towards the last option just in the same way that many valves are now conserved in the elective surgery of annulo-aortic ectasia where conventional root replacement has been superceded.
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  A. L. Estrera and H. J. Safi Editorial comment: Proximal reconstruction during Type A aortic dissection Eur. J. Cardiothorac. Surg., January 1, 2007; 31(1): 41 - 42. [Full Text] [PDF]
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