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Commentary: The surgeon and the tailor. A continuous partnership

  • Ruggero De Paulis
    Correspondence
    Address for reprints: Ruggero De Paulis, MD, Department of Cardiac Surgery, European Hospital, Via Portuense 700, 00149 Rome, Italy.
    Affiliations
    Deptartment of Cardiac Surgery, European Hospital, Unicamillus International Medical University, Rome, Italy
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Published:December 24, 2020DOI:https://doi.org/10.1016/j.jtcvs.2020.12.087
      Tailoring the right operation for the right patients contributes to better results. However, specific anatomical presentation might prevent choice by requiring a determined surgical approach.
      See Article page 1698.
      The proper treatment of acute type A aortic dissection remains a surgical challenge that presents significant operative mortality. In this peculiar emergency clinical condition, both surgical dexterity and surgical strategy play an important role in the final result. Different clinical presentations associated with variable anatomical tissue destruction explain the significant difference in mortality and overall results that are present in the majority of the reports in the literature.
      Lau and colleagues
      • Lau C.
      • Robinson B.
      • Farrington W.J.
      • Rahouma M.
      • Gambardella I.
      • Gaudino M.
      • et al.
      A tailored strategy for repair of acute type A aortic dissection.
      report their personal experience in a substantial number of patients over a 22-year period. In two-thirds of cases, they adopted a conservative strategy of root sparing and hemiarch, whereas in the remaining cases a more extensive root and/or arch replacement was carried out. A careful tailoring of the operation to a patient's baseline profile in term of age and associated comorbidities, coupled with clinical and anatomical features at presentation, was instrumental in achieving an extremely low operative mortality and outstanding overall results, irrespective of the conservative or extensive form of treatment.
      The importance of a conceptual approach is especially important in this specific type of pathology where the correct evaluation of the risk to benefit ratio needs to be immediately correlated with the extent of the surgery that is awaiting the patient. A perfect but extensive and long surgery might not be endured by an old and frail patient; alternatively, a conservative surgery might not be resolutive for a young patient with connective tissue disease. The higher incidence of major adverse events and major adverse pulmonary events despite a conservative approach, further highlight the right choice of limiting the influence of surgery in a population at higher risk. However, a proper surgical strategy is only 1 face of the coin. Once the correct strategy has been put into action, perfect execution of the operation is of paramount importance. It is well known that a conservative approach might fail for recurrent root dissection with valve prolapse and consequent insufficiency, or for progressive arch enlargement due to the continuous perfusion of the false channel through the pinhole entry tears of the distal suture line. A conservative operation, apparently simple, still requires the necessary experience to guarantee stable and lasting results. To this extent, Lau and colleagues
      • Lau C.
      • Robinson B.
      • Farrington W.J.
      • Rahouma M.
      • Gambardella I.
      • Gaudino M.
      • et al.
      A tailored strategy for repair of acute type A aortic dissection.
      should be congratulated for achieving good 10-year results in their conservative approach without the help of glue or the use of Teflon (Chemours, Newark, Del) felt within the dissected layers.
      Another example of good tailoring, just like the higher incidence of major adverse events and major adverse pulmonary events in patients with conservative approach, is the greater rate of late distal reintervention in patients with extensive surgery at the index operation. In this context it represents a marker for a more severe pathology rather than an incomplete treatment.
      Tailoring is a good strategy but requires fine clinical judgment, uniform standards in decision making, a good amount of experience, and a consistent surgical technique. Nevertheless, the anatomical presentation often takes the lead and indicates the road. What if a frail, old patient presents with a dilated and dissected root with a tear into an already aneurysmatic arch? The tailor watches the surgeon who takes his or her time and goes out in a more difficult situation of a root and arch replacement.

      Reference

        • Lau C.
        • Robinson B.
        • Farrington W.J.
        • Rahouma M.
        • Gambardella I.
        • Gaudino M.
        • et al.
        A tailored strategy for repair of acute type A aortic dissection.
        J Thorac Cardiovasc Surg. 2022; 164: 1698-1707.e3

      Linked Article

      • A tailored strategy for repair of acute type A aortic dissection
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.
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