J Thorac Cardiovasc Surg 2002;123:393-394
© 2002 The American Association for Thoracic Surgery
Reply
Eugenio Neri, MD
Istituto di Chirurgia Toracica e Cardiovascolare
Università agli Studi di Siena
Viale Bracci
53100 Siena, Italy
Reply to the Editor:
We read with interest the comments on our article
1 from the group at the Methodist Hospital of Indianapolis, and we applaud their results. They give us the opportunity to underline once again the absolute relativity of our results and offer us the occasion for some comments.
Undoubtedly our series included patients with extremely complicated problems. Nevertheless, the dismal results that we presented facilitated our task of illustrating how difficult it is to refuse an operation when a conscious, although critically ill, patient is referred.
In Italy the choice of treatment is based on informed consent. It is a fundamental procedure to ensure respect for persons through provision of thoughtful consent for a voluntary act. Risks, alternatives, and benefits of the procedures should be illustrated to enable persons to voluntarily decide whether to accept therapy. The physician cannot refuse to operate if the patient chooses to be treated.
Patients with aortic dissection experience the most dramatic sense of dying. Often they have intractable pain, they are desperately seeking a life-saving treatment, and they probably are the most trusting surgical candidates that a physician can meet. Often, inappropriate exhibitions of reanimation outside the hospital reinforce this conviction. Furthermore, the request for maximal life support by the patient and family is independent of age, except in moribund or unconscious subjects.
Starting from these considerations, we wondered whether we really were able to provide adequate information to the patients. The data obtained in our study undoubtedly helped us to illustrate the risks of surgical treatment. Nevertheless, we found ourselves completely unprepared to offer information about the alternatives to surgery in these cases. Our knowledge about the natural history of acute type A aortic dissection is based on historical series published many years ago 2,3 and, with the exception of occasional instances in which patients refused surgery, we had almost no updated experience with alternatives to surgery.
Recently the group at the University of Michigan, Ann Arbor, 4 published an interesting series, partly refuting the dogma of immediate repair of acute type A aortic dissection. Starting from the analysis of their data, which identified organ malperfusion as a high predictor of perioperative mortality in patients with an acute type A dissection, they adopted, for malperfused patients, a "surgical delay" policy associated with percutaneous reperfusion.
This experience represents, to our knowledge, the only recent example of modern medical treatment of acute type A dissection, and the reported results appear fairly satisfactory. We wondered whether we could offer to very old patients a reasonable alternative to immediate surgery with the goal to "chronicize" the acute process of dissection.
Starting in March 2001, 8 patients older than 79 years were admitted to Siena University Hospital with acute type A aortic dissection. We obtained informed consent to proceed with elective medical treatment with the possibility that surgical repair might be attempted later. All patients were admitted to the intensive care unit, where hemodynamic signs were monitored by invasive techniques. ß-Blockers and calcium channel blockers were administered intravenously. Target goals for treatment were a heart rate of less than 80 beats/min, a systemic systolic blood pressure of less than 120 mm Hg, a diastolic pressure of less than 80 mm Hg, and a cardiac index of more than 2.5 L · min–1 · m–2. In patients who had low cardiac output and acute ventricular distention, mainly attributable to volume overload from acute aortic regurgitation, appropriate inotropic and diuretic agents were administered. Simultaneously, all metabolic disturbances were corrected medically.
Three patients had visceral ischemia. Of these, 2 patients also had an acute stroke from innominate artery dissection. Endovascular aortic fenestration was performed in 1 patient, and percutaneous reperfusion with stenting of the true channel of the superior mesenteric artery was performed in 2. Innominate artery dissection was left untreated with good neurologic recovery. Six patients had hemodynamically significant pericardial effusion: all of them were treated with surgical pericardial decompression under local anesthesia. Aortic regurgitation was present in all patients, severe in 3 and moderate to severe in the remaining. In 3 patients chest pain remained severe and necessitated administration of intravenous morphine for 5 days; in the others the pain resolved shortly after the onset. At hospital admission, hypertension was present in all patients but 4, who became hypertensive after pericardial decompression.
Three patients died within the first 15 days, 5, 9, and 15 days after dissection. The causes of death were cardiogenic shock in 1 patient and multiorgan failure in the other 2. Four patients underwent an elective aortic surgical procedure within 32 and 55 days after the onset of dissection. All of them are currently alive. In all 4 patients, surgical procedures included hemiarch aortic replacement with deep hypothermic circulatory arrest. Aortic valve sparing was possible in 2 patients, and a modified Bentall technique was performed in the other 2. One patient refused the operation and is still alive 3 months after dissection.
These encouraging initial results lead us to believe that medical treatment can represent a possible alternative to immediate surgery in selected high-risk patients. Further studies on larger cohorts of patients are needed to fully understand the advantages of "chronicization" and medical stabilization in terms of better operative outcome.
References
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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.
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Anagnostopoulos CE, Prabhakar MJS, Kittle CF. Aortic dissections and dissecting aneurysms. Am J Cardiol. 1972;39:263-73.
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Lindsay J, Hurst JW. Clinical features and prognosis in dissecting aneurysm of the aorta: a re-appraisal. Circulation. 1967;35:880–8.[Abstract/Free Full Text]
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Deeb GM, Williams DM, Bolling SF, Quint LE, Monaghan H, Sievers J, et al. Surgical delay for acute type A dissection with malperfusion. Ann Thorac Surg. 1997;64:1669-75; discussion 1675-7.[Abstract/Free Full Text]
