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J Thorac Cardiovasc Surg 2001;122:1049
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Surgery for acute aortic dissection in octogenarians

2831 Sackett St
Houston, TX 77098

To the Editor:

The recent report ¹ by physicians in Siena, Italy, of their unsatisfactory results of operations in octogenarians with acute aortic dissection, and the accompanying editorial comment ² suggesting that, ergo, surgeons in the United States should not perform such procedures, raise two important issues not addressed in either article.
The first is the relevance and general applicability of the information on which we rely. Although Siena is certainly a center of Italian culture, architecture, and cuisine, it is unclear how directly the results of cardiovascular surgery in that city relate to the results of similar procedures in major centers in the United States. Likewise, it is unclear how the octogenarian population of that region of the world compares with a similarly aged population in this country.
Second, the indications for complex cardiovascular procedures in a particular patient, octogenarian or otherwise, are affected importantly by where the patient happens to be, with respect particularly to the size and resources of the institution and the experience and abilities of the various physicians involved. Anyone who has observed the results of surgical procedures such as those on the thoracic aorta in widely different medical arenas, even in the United States, knows that the results can vary by an order of magnitude.
Having considerable experience with medicine in Great Britain, where rationing of care has been a fact of life for decades, and despite being generally supportive of such rationing, I think we should be slow to adopt such "cookbook medicine" as "We won't operate on any patient of (some arbitrary) age with acute aortic dissection."
Unlike McKneally, I have found that "institutional policy committees" are self-serving, awkward, and generally unhelpful, especially when diluted by the presence of laymen who have no understanding of medical science, epidemiology, or statistics. Such individuals are well-intended and supportive of thoughtful decisions by medical professionals, but their participation in the analysis is counterproductive.
I believe that well-trained, compassionate, and honest physicians have no difficulty in individualizing care for patients with complex problems, including the aged, and in avoiding overtreatment of those in such groups. The call for cookbook policies and institutional protocols suggests a growing dearth of such physicians.
12/8/116551

References

1. Neri E, Toscano T, Massetti M, Capannini G, Carone E, Tucci E, et al. Operation for acute type A aortic dissection in octogenarians: Is it justified? J Thorac Cardiovasc Surg. 2001;121:259-67.
   
2. McKneally MF. "We don't do that here": reflections on the Siena experience with dissecting aneurysms of the thoracic aorta in octogenarians. J Thorac Cardiovasc Surg. 2001;121:202-3.
   

This article has been cited by other articles:

				M. F. McKneally "We didn't expect dementia and diapers": Reflections on the Nihon experience with type A aortic dissection in octogenarians. J. Thorac. Cardiovasc. Surg., May 1, 2008; 135(5): 984 - 985. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William E. Walker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Walker, W. E. Search for Related Content PubMed PubMed Citation Articles by Walker, W. E. Related Collections Great vessels