| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2007;133:1684-1685
© 2007 The American Association for Thoracic Surgery
Letter to the Editor |
Cattedra di Cardiochirurgia, Università degli Studi di Milano, IRCCS MultiMedica, Milano, Italy
To the Editor:
We congratulate Estrera and colleagues1
and Urbanski and coworkers2 on their impressive results with immediate aortic surgery for acute type A dissection with cerebral malperfusion. However, we would like to add specific observations, according to our experience with this complex issue.3
Estrera and associates1 report a case series of 16 patients with acute aortic dissection and stroke, outlining a correlation between the time interval before aortic repair and outcome. Specifically, neurologic status never worsened, whereas recovery or improvement was observed in 80% of patients operated on within 10 hours. Surgery was denied in 1 patient with "neurologic devastation," defined as coma with a Glasgow score of 5 or less. This definition appears somewhat arbitrary and refers to a single patient in this series, which is insufficient to draw specific recommendations. We previously reported on 5 comatose patients selected for immediate repair on the basis of hemodynamic stability, preserved pupillary reactivity, and coma duration of 12 hours or less, with encouraging results.3 Median Glasgow coma score was 5.5, whereas all patients showed an eye response score of 1. Similarly, all documented strokes in our series were right-sided, which likely indicates the same underlying pathophysiology, namely, malperfusion with dynamic flow patterns and prevalent compression of the innominate artery true lumen. In this respect, we pointed out the unsuitability of the Glasgow coma score, originally developed for the evaluation of neurologic trauma, to stratify these patients. Importantly, prompt aortic repair has been successfully reported with a score of 3,4 whereas neurologic recovery has been reported with extra-anatomic revascularization and delayed aortic repair more than 2 decades ago.5 Furthermore, the Rankin score also failed to correlate with outcome in this series, suggesting that pathophysiologic mechanisms are different than those involved in acute occlusion causing traditional stroke.
Urbanski and colleagues2 introduced the left common carotid as a systemic perfusion route for arterial return, with excellent results in 100 patients, including 27 with acute dissection, 4 of whom had cerebral malperfusion. In view of the prevalence of right-sided arch vessel malperfusion in the case of an acutely dissected aorta and cerebral injury, this approach seems particularly appealing in this context, especially if cannulation via a prosthetic vascular graft is established distant from the arch, thus avoiding dissected segments. Furthermore, this strategy reduces embolic hazards and greatly simplifies the implementation of selective antegrade brain perfusion. However, there is also a rationale for additional innominate artery perfusion after intraluminal arch inspection, which requires only an insignificant period of total circulatory arrest. In our opinion, we would hesitate to not provide selective antegrade perfusion to the most severely ischemic territory.
In summary, available reports indicate the importance of a nondelayed attitude for a satisfactory outcome in selected patients with acute type A aortic dissection and cerebral malperfusion. Current scores appear unsuitable to stratify the severity of neurologic injury in this specific context and should be viewed cautiously when the intent is to define irreversible "neurologic devastation," particularly in stable patients with preserved brain stem reflexes.
References
Related Article
This article has been cited by other articles:
|
|
 |
|
  R. S. Bonser, A. M. Ranasinghe, M. Loubani, J. D. Evans, N. M. A. Thalji, J. E. Bachet, T. P. Carrel, M. Czerny, R. Di Bartolomeo, M. Grabenwoger, et al. Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection J. Am. Coll. Cardiol., December 6, 2011; 58(24): 2455 - 2474. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
