[HSF] Acute dissection - what now?

[Ani Anyanwu]

But Hal surely no visual inspection of external appearance a type A can be superior to the external and internal imaging one obtains with ultrasound or x-rays? Indeed in Dr Harris case I would argue the visual inspection suggested a need to immediately replace the aorta as there was blood and clots in the pericardium - surely that blood came from somewhere? In taking the patient the OR in the first place surely the intention was to fix the dissection so how/why did that decision change?
 
I am aware of no surgical algorithm for treatment of type A where any part of the decision is based on external inspection of the dissected aorta, so I do not see how Dr Harris seeing the aorta is an improvement on an entirely catheter based strategy to achieve the same thing. We have to have clear rationale and logic when we violate established surgical principles, else the next dissection that comes to your ER will be treated by a few stents and a pigtail...and why not? I am not by any means advocating this approach - it is actually not clear to me the rationale for Dr Harris strategy and it is not one I have seen or been taught or one I would want done on myself - but if we believe that such a strategy has a place then we are marking the beginning of a new era in staged interventions on aortic dissection, and who is to say the first stage cannot be percutaneous?
 
Ani



> From: Hgrmd at aol.com> Date: Sun, 12 Aug 2007 19:47:05 -0400> Subject: Re: [HSF] Acute dissection - what now?> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> There's a big difference in pursuing a staged procedure after visually > inspecting the dissected aorta versus PCI and pericardiocentesis. I don't think > current imaging techniques would be superior to direct inspection in > deciding if staging the procedure was feasible.> However, you're right, maybe we should reassess our management. > Unfortunately, I suspect it's a lot like the management of post infarction VSD's. In > the old days, the recommendation was to wait at least 6 weeks for the margins > of the VSD to mature. However, it was eventually realized (I think by Cooley) > that all this did was allow operation for the few who could survive the > gauntlet of expectant management. I suspect the same would be operant in > expectant management of acute Type I's. Though I'm aware of no randomized trial to > back up my words, I still believe that the maximum number of patients with > acute Type I's are salvaged with immediate surgery.> > Hal> > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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