Preoperative pleural effusion in acute type B aortic dissections: simple, fast … but not enough.

Abstract

Perfection is not attainable, but if we chase perfection we can catch excellence. –Vince Lombardi In their article, ‘Pleural effusion: A potential surrogate marker for higher risk patients with acute type B aortic dissections’, Reutersberg et al. [1] examined the potential relationship between the presence of pleural effusions (PEff) on admission X-rays and the development of complications (early or delayed) in patients with acute type B aortic dissection (TBAAD), reviewing data from the International Registry on Aortic Dissection (IRAD). The paper explores the ‘nebulous’ world of risk assessment and survival stratification, which are well recognized as key elements in the decision-making process, especially in urgent or emergency settings. A risk index model could help physicians predict complications and provide them with tools and information to determine the most appropriate treatment strategy, especially for high-risk patients [2]. Despite the scope of the problem, most of the recent attention towards stratification in TBAAD has targeted predictors of potential aortic growth and adverse events, both in the acute and the delayed phases. However, most of them failed except for aortic size at presentation, which has been concretely associated with adverse events, whereas total false lumen thrombosis has been shown to be a protective feature [3]. The study of Reutersberg et al. [1] underlines once again how important risk stratification may be for evaluation of survival: In such a heterogeneous condition, identification of a tangible predictor is critical to lead and coordinate decisions across the different cardiovascular specialties that generally manage TBAAD. However, at the same time, this experience highlights the difficulty of identifying specific parameters that may unquestionably affect one specific outcome. By using the large cohort analysis of the IRAD registry, Reutersberg et al. [1] tried to evaluate the role of PEff on survival and complications. Indeed, it is easily detectable, it is reproducible and it has frequently been considered a surrogate marker of acuity and a clinical method to identify patients at higher risk of complications and death [4]. In this IRAD retrospective analysis, nearly 46% of the patients enrolled with a diagnosis of TBAAD did not have chest X-rays at the time of admission; among the remaining 1252, a total of 17.9% (n = 224) presented with PEff. Moreover, sometimes it is difficult to differentiate PEff from an aortic haematoma. In fact, patients with PEff were older with significantly more complications and a higher rate of periaortic haematomas, and they more frequently underwent aortic repair because of aortic rupture. Though attractive and of striking importance, a predictor that can be easily identified does not necessarily translate into an unquestionable parameter to be applied in clinical practice. A pleural effusion may be too generalized a parameter to be intimately correlated to survival: As propensity score matching demonstrated, PEff was not an independent risk factor for survival, and multivariable analysis revealed that multiple preoperative parameters played a key role in predicting increased mortality, in particular, rupture/shock/mesenteric ischaemia. Thus, it seems that nothing has changed over the course of the decades from the original ‘deadly triad’ [5].