JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 65, NO. 24, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jacc.2015.05.006

EDITORIAL COMMENT

Thinking Beyond the Tube Graft Using Malperfusion as a Guide to Define Treatment of Type A Dissection* Allan Stewart, MD, Joanna Chikwe, MD

A

cute type A aortic dissection is a catastrophic

90% of these patients will still have flow in the false

disease, with mortality traditionally esti-

lumen distal to the ascending aortic replacement af-

mated at 80% in the first 48 h of symptoms

ter surgical repair. Consequently, the potential still

and operative mortality approaching 20%. In this

exists for post-operative end-organ malperfusion: the

issue of the Journal, Czerny et al. (1) analyze one of

most common malperfusions seen post-operatively in

the largest multicenter registries of aortic dissection

this registry were renal and cerebral ischemia, which

patients with the aim of quantifying the effect of

each occurred in 6.8% of patients. The authors

pre-operative end-organ malperfusion syndromes on

identify several risk factors for post-operative mal-

early post-operative mortality and major morbidity.

perfusion beyond the pre-operative presence of

SEE PAGE 2628

malperfusion, including the extent of the dissection. Perhaps more importantly, Czerny et al. (1) add to

Malperfusion syndromes were reported in more

single-center data, quantifying the incremental mor-

than one-third of the 2,137 patients in the registry that

tality associated with pre-operative malperfusion

underwent operative intervention. This probably

syndromes (2,3). In this registry, operative mortality

under-represents the prevalence of malperfusion and

for emergency type A dissection repair was only

ischemia in patients presenting with type A dissec-

12.6%

tions, because such patients are less likely to be

increasing by approximately 10% with each addi-

considered appropriate candidates for surgical inter-

tional system affected by malperfusion or ischemia,

vention. The mechanism of ischemia is compression

to more than 40% in patients with 3 or more systems

or complete occlusion of the true lumen of branch

affected. Although this model does not claim to pre-

vessels by the dissection flap. Czerny et al. (1) report

dict the futility of care, it may help frame a discussion

that cerebral, coronary, renal, and peripheral ex-

with patients and families about the operative risks

tremity ischemia were the most common types of pre-

and likely quality of post-operative life. When 3 or

operative malperfusion, each of which were seen in

more organ systems are involved, palliation may be

slightly more than 10% of patients, whereas mesen-

more appropriate than surgery. The authors have

teric and spinal ischemia were less common. In most

taken an important step toward creating an indivi-

cases, replacement of the ascending aorta corrects

dual treatment strategy not only focusing on treat-

malperfusion by restoring the normal pathway of

ment of the primary tear, but also addressing each

blood flow. Surgery often converts an acute type A to

malperfused organ. In this setting, a hybrid approach

a chronic type B dissection, and between 80% and

may be most appropriate (4). For instance, patients

in

patients

without

any

malperfusion,

presenting with malperfusion may benefit from a concurrent peripheral bypass at the time of aortic surgery; simultaneous catheter-based intervention *Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the Department of Cardiovascular Surgery, Mount Sinai Health

on visceral ischemia at the time of aortic surgery; or even a 2-team approach, where a renal artery stent is placed during the core cooling period for aortic

System, New York, New York. Both authors have reported that they have

replacement. For patients presenting with a retro-

no relationships relevant to the contents of this paper to disclose.

grade

dissection

from

a

primary

tear

in

the

Stewart and Chikwe

JACC VOL. 65, NO. 24, 2015 JUNE 23, 2015:2636–7

Malperfusion and Type A Dissection

descending aorta, operative therapy should include a

aortic cannulation), were less likely to undergo

total arch replacement and perhaps frozen elephant

hemiarch replacement (potentially leaving residual

trunk for complete treatment of the diseased aorta to

ascending aorta dissection), and had worse operative

reduce the increased risk of adverse outcomes seen

outcomes (6). In this series reported by Czerny et al.

by these patients in this registry.

(1), the incidence of axillary cannulation was only

The authors elected not to include 2 very different

42%, and a hemiarch replacement was performed in

variables that have each been shown to indepen-

only 62% of patients. These data may provide further

dently predict operative outcomes of aortic dissec-

support for the creation of regional centers of excel-

tion. First, the severity of malperfusion syndromes,

lence where high volume and focused expertise

which can range from an asymptomatic finding on

consistently improve surgical outcomes.

computed tomographic angiography to circulatory

In this regard, as well as in their primary aim, the

collapse, is an obvious risk factor for worse clinical

authors should be congratulated for quantifying the

outcomes that was not evaluated in this analysis (2,3).

well-recognized effect of malperfusion on patient

The clinical value of their predictive model is weak-

outcomes. Instead of applying an optimism that “it

ened as a result. The second key determinant of

ought to get better” after surgery, end-organ salvage

outcome is the experience of the surgical team (5).

may improve with aggressive strategies by experi-

The registry data suggest an average operative vol-

enced teams to address ischemia pre-operatively,

ume of only 11 cases/center per year. In a recent

intra-operatively, or with hybrid therapy.

comparison of outcomes of type A dissection by specialist versus nonspecialist teams, patients who

REPRINT

were operated on by nonspecialist cardiac surgeons

Dr. Allan Stewart, Mount Sinai Health System, 1190

REQUESTS

AND

CORRESPONDENCE:

were less likely to undergo axillary cannulation

Fifth Avenue, Box 1028, New York, New York 10029.

(which is associated with a lower stroke risk than

E-mail: [email protected].

REFERENCES 1. Czerny M, Schoenhoff F, Etz C, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: results from the GERAADA

ischemic presentation in patients with acute type A aortic dissection: the Penn classification. Nat Clin Pract Cardiovasc Med 2009;6:140–6.

registry. J Am Coll Cardiol 2015;65:2628–35. 2. Kimura N, Ohnuma T, Itoh S, et al. Utility of the

4. Tsagakis K, Konorza T, Dohle DS, et al. Hybrid operating room concept for combined diag-

Penn Classification in predicting outcomes of surgery for acute type A aortic dissection. Am J Cardiol 2014;113:724–30.

nostics, intervention and surgery in acute type A dissection. Eur J Cardiothorac Surg 2013;43: 397–404.

Surg 2014 Dec 11 [E-pub ahead of print].

3. Agoustides JG, Geirsson A, Szeto WY, et al. Observational study of risk stratification by

5. Chikwe J, Cavallaro P, Itagaki S, et al. National outcomes in acute aortic dissection: influence of

KEY WORDS early outcome, independent

surgeon and institutional volume on operative mortality. Ann Thorac Surg 2013;95:1563–9. 6. Lenos A, Bougioukakis P, Irimie V, et al. Impact of surgical experience on outcome in surgery of acute type A aortic dissection. Eur J Cardiothoracic

predictor, supra-aortic

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