A perfect storm: type A aortic dissection and previous cardiac surgery.

A cute type A aortic dissection (AAD) is a lethal disease. The overall mortality rate—even when diagnosed and treated in a timely fashion with emergent surgical interven-tion—exceeds 20%. 1 This fact alone serves as a constant reminder that this disease represents a formidable challenge to all cardiovascular professionals who encounter AAD. Cardiovascular surgeons maintain great respect for operations to deal with AAD, because achieving a successful outcome is based on executing a perfect technical operation and solving a myriad of management decisions during the procedure. In this issue of Circulation, Stanger and colleagues 2 report on the infrequent, but extraordinarily complex situation of AAD occurring after nonaortic surgery. The incidence of AAD during or following nonaortic surgery in the present report is 0.15%, which is consistent with other reports, although the true incidence of this entity is difficult to determine. Although this incidence is low—the development of AAD following nonaortic surgery is analogous to an airliner crash in today's era, infrequent, but catastrophic. Indeed, deserving of emphasis , AAD following nonaortic surgery instantly converts a low-risk elective operation into a high-risk salvage situation. Thus, the entity of AAD after nonaortic surgery is a highly complex and dangerous situation that demands skillful judgments to successfully navigate a good outcome. Two recent single-center experiences with AAD illustrate that even experienced aortic surgical centers find this operation challenging. The highlights and important messages of Stanger's report include the fact that 100% of the operative reports for the procedure to address the AAD were available. Nearly three-fourths of the index procedure operative notes were available, and many of these reports (>50%) had a surgeon's description of the ascending aorta. These details are critical, because nearly all the aortas that ultimately dissected were reported to have a diameter of >40 mm at the index operation. All but 1 aorta were noted to appear qualitatively abnormal to the surgeons at the primary operation. A recommendation to replace a thinned, enlarged aorta cannot be made based on this report; however, this strategy of presumptive ascending aortic replacement cannot be dismissed outright, either. Special consideration should be given to the group with aortic regurgitation, hypertension, and a thinned aorta measuring >40 mm. Perhaps patients meeting these 3 criteria should be considered candidates for ascending aortic replacement at the time of the index procedure. The overall operative mortality observed in this report is 27%. The centers and surgeons who …