Invited Commentary

Abstract

There continues to be significant interest in the nonoperative management of intramural hematoma of the ascending aorta, particularly among centers in the Far East. These authors [1Watanabe S. Hanyu M. Arai Y. Nagasawa A. Initial medical treatment for acute type A intramural hematoma and aortic dissection.Ann Thorac Surg. 2013; 96: 2142-2146Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar] have provided us a valuable glimpse into the natural history of this condition, because the preferred treatment algorithm in their center over the study interval was medical management. Only those with frank rupture or uncontrollable malperfusion underwent operation. Even tamponade was managed without operation! The results were remarkably good—at least in the short term. Only 1 patient died within 30 days, and operation had been recommended but declined. A second patient died more than 2 months after admission, again after surgical intervention was recommended and declined. Still, in the long run, 27 of the 59 patients experienced an “aortic event” between 4 days and 3 years after diagnosis. If you see the “glass as half full,” that means that 55% of the patients were spared an operation; if your perspective is the converse, this approach only delayed the inevitable in the other 45%. Either way we are fortunate to have this data set. What do their data mean to surgeons in the rest of the world? For those of us in North America, the appetite for a 1-month hospitalization and half a dozen computed tomographic scans will likely be modest except under the most extraordinary circumstances. Still there may be another lesson here. There are mounting data indicating that surgical outcomes in the treatment of acute aortic syndromes are superior in centers treating the condition more frequently and in the hands of surgeons who do the same [2Chikwe J. Cavallaro P. Itagaki S. Seigerman M. Diluozzo G. Adams D.H. National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality.Ann Thorac Surg. 2013; 95: 1563-1569Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar]. The observation that no patient decompensated in less than 4 days with an intramural hematoma or thrombosed acute dissection supports the argument for regionalization of the treatment of this condition. It is likely that the low-volume dissection surgeon in the low-volume dissection hospital would be quite willing to transfer such patients absent the threat of medicolegal liability. In my opinion, the results of this study support such a practice. Initial Medical Treatment for Acute Type A Intramural Hematoma and Aortic DissectionThe Annals of Thoracic SurgeryVol. 96Issue 6PreviewThere are contradictory reports on outcomes of patients treated for Stanford type A acute intramural hematoma (IMH) and acute aortic dissections (AAD) with thrombosed false lumens. We evaluated short-term clinical outcomes and predictors of adverse outcomes. Full-Text PDF