Invited commentary

Abstract

One reason surgeons look at how preoperative factors relate to surgical outcomes is to help them decide if the surgical treatment of a condition is better than the natural history of the disease. This information is especially important when the natural history of the disease is relatively benign. However, when the natural history of the disease is almost certain early death, as is the case in patients with acute type A aortic dissection, such an analysis may seem little more than an academic exercise. The simple fact is that most of us will operate on such patients regardless of presentation. Or will we? No doubt most of us have also on occasion decided not to operate on patients with acute type A aortic dissection who present with severe complicating factors such as shock, renal failure, rupture, severe neurologic damage or signs of intestinal ischemia. Such a decision is based on our intuitive belief, as well as our own anecdotal experience, that such patients face a prohibitive mortality, even withsurgery. The frank and open review by Apaydin et al of more than 100 patients presenting with acute type A aortic dissection in their own center provides us with some objective evidence that could be used to support making the difficult decision not to operate when the chance of meaningful survival with surgery seems hopeless. In this age of increasing pressure to practice evidence-based medicine and to justify clinical decisions with hard data, their report is very welcomed.