[HSF] Acute dissection - what now?- Robert Goetz-History of Cardiac Surgery

Wed Aug 15 12:44:24 EDT 2007

Dave,
  Great job from both judgement and technique.  The fact that it was a localized dissection made this case unusual and probably caused it not to have the often swift and terrible natural history.  The lesson for me is not to be so binary in decision making.  Again, congrats.

Hal

-----Original Message-----
From: David Harris <drdharris at yahoo.co.uk>
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 15 Aug 2007 11:26 am
Subject: Re: AW: AW: [HSF] Acute dissection - what now?- Robert Goetz-History of Cardiac Surgery

Another must to read is Vasilii I Kolesov. A surgeon
o remember. Igor E Konstantinov. Tex Heart Inst J
004; 31(4): 349-358.
While we`re on the topic of the aortic dissection:
y patient woke up 2 days ago, I took him back today.
he aorta still looked strong. The brachiocephalic
nterestingly gave origin to both carotids, and was a
ice big vessel to cannulate. I also cannulated
emoral, and could get a clamp between L subclavian,
nd brachiocephalic, and clamped brachiocephalic
roximally. I never clamp aorta in dissections, but
he arch looked OK, and dissection was still localised
o ascending. The entry site was a 1cm tear just
bove, and to left of right coronary. It had tracked
long greater curve, and re-entry was just before
rachiocephalic. The repair was simple.
I think we need to look at each case individually, and
aylor the needs accordingly. I think we would have
iped him out if we had attempted formal repair
nitially......first give the cat a chance to bounce
ack!!
Dave Harris
--- "Dr. Roberto Battellini"
battr at medizin.uni-leipzig.de> wrote:
> For the residents reading HSF,

 Robert Goetz (Bob knows him as Goetz worked in Cape
 Town), performed the
 first successful clinical coronary artery bypass in
 1960.
 Read Ann Thorac Surg 2000;69:1966-72, fascinating
 paper by Igor
 Konstantinov.
 Roberto

 -----Ursprüngliche Nachricht-----
 Von: openheart-l-bounces at lists.hsforum.com
 [mailto:openheart-l-bounces at lists.hsforum.com] Im
 Auftrag von
 Rwmfglycar at aol.com
 Gesendet: Dienstag, 14. August 2007 18:13
 An: OpenHeart-L at lists.hsforum.com
 Betreff: Re: AW: [HSF] Acute dissection - what now?

 In a message dated 8/14/2007 9:54:45 A.M. Eastern
 Daylight Time,  
 Jbflegejr at aol.com writes:

 Myron  Wheat at the University of Florida 30 or 40
 years ago reported on the

 medical treatment of acute aortic dissection, I
 think in the Journal of  
 Thoracic Surgery. He had a fairly large number of
 cases for the time and
 the 
 early 
 mortality was not very high. If I come across the
 reference, I  will post
 it. 
 John Flege

 Myron Wheat's paper was in the context of a very
 high mortality of surgery  
 in acute dissection cases. In 1963 Michael Roman and
 Robert Goetz published
 I  
 think 3 successful cases of urgent surgery done at
 Einstein in the Bronx. 
 There  was quite a flurry of attempts to repeat this
 success with dismal
 results 
 (the initial success was in the nature of a "Black
 Swan").  Wheat then 
 published his unloading therapy the results of which
 were better than
 surgery. A 
 year or two later it was pointed out that the
 natural history of  ascending 
 aortic dissection was worse than descending aortic
 dissection and that
 Wheat's 
 treatment was failing for the ascending cases.The
 reason for this was
 obvious: 
 acute aortic insufficiency, acute coronary
 obstruction and acute  hemorrhage

 into the pericardial cavity were more likely to kill
 the patient than  a 
 hematoma contained by the pleura. At that time the
 idea took hold that
 ascending 
 aortic dissections get emergency surgery and
 descending aortic  dissections
 are 
 started with unloading therapy and closely observed.
       The rule of thumb stated by Ben works. The 
 missing factor in this 
 debate is knowledge that would enable us to predict 
 outcome, to declare
 with any 
 certainty into which third of the three  outcomes 
 the patient will fall. 
 Obviously the presence of one of the  three
 potentially lethal complications
 is 
 likely to put the patient  into one of the first two
 outcomes. Patient 
 anatomical and biological  variability is wide and
 difficult to measure. (I
 notice 
 Roberto thinking of this  when he mentions the
 thinness of the intimal
 layer). All 
 of us have had the  experience of inaccurate
 prediction. 
         I had a case with acute  dissection in a
 severely hypertensive
 little 
 old lady. Although she did not  yet have a
 potentially lethal complication, 
 the dissection had tracked from  mid ascending aorta
 back to just above the 
 sinotubular junction.  She was  not making urine. I
 advised emergency
 surgery 
 which she refused. I thought  she could get worse at
 any moment and decided
 to 
 sit with her through the night  titrating her
 therapy.
 She started making urine and was quite stable by the
 morning. I offered her

 surgery again and once again was turned down flat. I
 kept track of her for a

 year. She remained proud of having refused to let
 the doctors meddle with
 her.
 Bob

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 -----------------------------------------

r. David G. Harris, FCS, MMED,
ardiothoracic Surgeon        
uite 207                                
uils River Private Hospital,        
O Box 1200, Kuils River, 7579, Cape Town, South Africa.            
el +27-21-9006411             
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