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J Thorac Cardiovasc Surg 2007;133:1685
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

University of Texas Medical School, Houston, TX

We thank Pocar and colleagues for their interest in our article regarding surgery for acute type A aortic dissection in the setting of stroke.¹ We also acknowledge their recent report about repairing acute type A aortic dissection in patients with coma.² As was pointed out in their report, the use of the Glasgow Coma Scale (GCS) to exclude patients for type A aortic repair was not relevant. Specifically, they noted that all 5 of their patients would have been considered severely brain injured (GCS < 8) based on the GCS alone. We do appreciate and concur with this point and also congratulate them for them for their results in this very difficult subgroup of patients.

Although the GCS, the National Institutes of Health Stroke Scale (NIHSS), and Rankin score for that matter may not be completely applicable in the setting of acute type A aortic dissection, we wanted to analyze these patients with objective criteria. We do believe that the NIHSS and the Rankin score may be helpful, although this study was not powered to demonstrate this. Because we recommended that operative repair was indicated in patients without "neurologic devastation" or coma, we attempted to provide some objective criteria for this condition, hence the use of these scales and scores. Regarding the 1 nonoperated patient who was considered neurologically devastated, we acknowledge that one cannot derive any conclusions in relation to defining neurologic devastation. In fact, it was the appearance of the patient’s computed tomography scan of the head, which showed bilateral massive infarction, that ultimately led to his nonoperative course.

Prior to the results of this study, we maintained that stroke was a relative contraindication to immediate repair for acute type A aortic dissection. We have since modified our approach and have become more aggressive in repairing acute type A aortic dissection in patients with stroke. Our experience in patients with coma, however, has been limited and thus we continue to maintain a selective approach in patients with coma and neurologic devastation. We admit that GCS is not a good measure of coma or neurologic devastation, and radiographic evaluation, in the hemodynamically stable patient, may be more helpful. How coma and neurologic devastation are determined and whether or not surgery is performed, however, should be left ultimately to the neurologist and operating surgeon, respectively.

References

1. Estrera AL, Garami Z, Miller CC, et al. Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?. J Thorac Cardiovasc Surg 2006;132:1404-1408.[Abstract/Free Full Text]
   
2. Pocar M, Passolunghi D, Moneta A, et al. Coma might not preclude emergency operation in acute aortic dissection. Ann Thorac Surg 2006;81:1348-1351.[Abstract/Free Full Text]
   

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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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anthony L. Estrera Hazim J. Safi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Estrera, A. L. Articles by Safi, H. J. Search for Related Content PubMed Articles by Estrera, A. L. Articles by Safi, H. J. Related Collections Great vessels Related Article