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Eur J Cardiothorac Surg 2006;30:199-200
© 2006 Elsevier Science NL
Letter to the Editor |
Division of Cardiac Surgery, University of Verona, OCM Borgo Trento, Piazzale Stefani 1, 37126 Verona, Italy
Received 31 March 2006; accepted 4 April 2006.
* Corresponding author. Tel.: +39 045 8072476; fax: +39 045 8073308. (Email: fsant{at}yahoo.com).
Key Words: Aortic dissection • Suture technique • Elderly • Aortic valve
We thank Dr Ates for his remarks and interest in our work [1]. Indeed type A aortic dissection may occur with so myriad and nonspecific presenting symptoms and signs to be overlooked initially in up to 40% of cases [2]. Still, rapid diagnosis is imperative due to the potentially catastrophic nature of the illness and the exceedingly high mortality if not diagnosed early in the course. A winning strategy implies a high suspicion index and the development of rapid and reproducible diagnostic pathways based on local logistics, thus avoiding useless or even potentially harmful tests. Rapid surgery should be performed before any hemodynamic instability or deterioration develops. If this can easily be accomplished for patients first admitted and evaluated in-house, as also mentioned by Dr Ates, it may not be the case for those referred from other hospitals. This perspective may imply active re-training of internists, cardiologists, and emergency room personnel to develop a higher suspicion index toward dissection in an attempt to promote a more expeditious referral and intervention. This sole approach, by lowering preoperative dissection co-morbidity, might represent a very efficacious tool to improve results.
Concerning the preferred technique for suturing aortic tissue during dissection repair, we agree that separated pledgetted suture can favor a better exposure of potential site of bleeding compared to long teflon felt [3]. We applied this technique occasionally although still convinced that the use of a teflon felt strip, not too redundant, can work similarly well and be less time consuming.
One of the aims of surgery for acute type A aortic dissection, which applies equally well to elderly patients, is to restore the functional anatomy of the aortic root, trying to spare the aortic valve whenever possible unless destroyed by the dissection process and/or involved by organic lesions [4]. Indeed, 85% of the dissected elderly patients operated upon at our institution had their aortic valve preserved [1]. We believe, however, that in this subgroup with limited reserve, the threshold to perform an aortic valve replacement has to be kept low should any degree of aortic regurgitation be present, thus avoiding to add another dismal variable to an already usually difficult postoperative course.
References
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