Tailoring the Surgical Procedure Is a Delicate Process to Have Optimal Gain From the Surgery

Abstract

We read the article by Eusanio and colleagues [1Di Eusanio M. Berretta P. Cefarelli M. et al.Total arch replacement versus more conservative management in type A acute aortic dissection.Ann Thorac Surg. 2015; 100: 88-94Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar], which compares conservative versus aggressive surgical modalities for pathologic conditions of the aorta. We appreciate their effort. However, we consider that there are some conflicting parts that should be reconsidered. Although standard surgical techniques are specified in this study, there is no information about the experience of the surgical team. The other conflicting part is about follow-up imaging. The authors declared the lack of follow-up imaging as a limitation. However, they should use imaging modalities to evaluate false lumen patency and to decide on reoperation. How could they reoperate on the patients without follow-up imaging? The authors suggested that the results of extended total aortic replacement (TAR) are satisfactory in patients with sufficient physical conditions with similar rates of mortality and major adverse events. They also recommend total aortic arc replacement. We wonder: if the rates of mortality and major adverse events are similar in the two groups, how can authors suggest a more aggressive surgical procedure to such patients? Cardiopulmonary bypass (CPB) time is a well-known prognostic factor for postoperative outcomes as described in current literature. In the present study, CPB time was longer in the TAR group with the similar postoperative outcomes. Isn’t this a little bit conflicting? How can the authors explain this controversy? The study doesn’t include new techniques such as frozen elephant trunk or endovascular methods, which together with and debranching procedures are important modalities and may be considered for patients with intact aortic valves [2Shrestha M. Bachet J. Bavaria J. et al.Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the vascular domain of EACTS.Eur J Cardiothorac Surg. 2015; 47: 759-769Crossref PubMed Scopus (214) Google Scholar]. They not only decrease operation time but also decrease morbidity and mortality in the postoperative period [2Shrestha M. Bachet J. Bavaria J. et al.Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the vascular domain of EACTS.Eur J Cardiothorac Surg. 2015; 47: 759-769Crossref PubMed Scopus (214) Google Scholar, 3Bell D. Bassin L. Neale M. Brady P. A review of the endovascular management of thoracic aortic pathology.Heart Lung Circ. 2015 Jun 10; ([Epub ahead of print])http://dx.doi.org/10.1016/j.hlc.2015.05.008Google Scholar]. What will be the authors’ recommendations for these treatment options? In conclusion, it will be helpful if the authors can clarify these controversies. In addition, further studies with new-generation techniques are necessary in this field. Total Arch Replacement Versus More Conservative Management in Type A Acute Aortic DissectionThe Annals of Thoracic SurgeryVol. 100Issue 1PreviewSurgical management of aortic arch in type A acute dissection (TAAD) is controversial. This study compared short-term and long-term outcomes of total arch replacement (TAR) interventions versus more conservative arch management (CAM). Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 101Issue 3PreviewWe appreciate the specific comments and questions from Selcuk and colleagues [1] on our recently published article on total arch replacement (TAR) versus more conservative arch management (CAM) during type A acute aortic dissection (TAAD) [2]. Full-Text PDF