Bringing down mortality to single digits in type A aortic dissection: Japan can

Type A aortic dissection still is a feared disease and patients with a type A dissection require immediate surgical treatment to survive. Depending on the age of the patients and the burden of ischaemic injury caused by the acute dissection, the in-hospital mortality may be close to zero or dismally high [1]. In this issue of the journal, Abe et al. [2] present data from a nationwide Japanese database including 11 843 patients with type A aortic dissection who were surgically managed. Two major conclusions can be drawn from this extremely interesting analysis: (i) the mortality after surgery decreased significantly during the observational period to below 8% despite a significant increase in preoperative risk factors and (ii) the number of patients with type A aortic dissection who were treated surgically in Japan increased by 45% within 8 years. It seems very plausible that the increase in surgeries performed is due to better diagnostic modalities for type A aortic dissections and the willingness of surgeons to perform surgery even in older or sicker patients [2]. In fact, the authors describe a significant increase in the number of patients over 80 years during the study period and it has been shown that the mortality in older patients can still be very low depending on the burden of preoperative ischaemic injury [1, 2]. Hence, this study underlines the fact that it is implausible to deny surgery to patients with a type A dissection solely because of a high age—particularly in ageing societies. While the excellent single-digit survival in this nationwide database deserves recognition, it has to be stressed that no information on preoperative malperfusion has been provided. Hence, the comparability of this data to other regions or hospitals is not possible and we cannot draw conclusions on the optimal surgical management of these patients. Low, single-digit mortality rates are already a reality in patients with acute type A aortic dissection without shock or malperfusion [1]. The key question is how to lower mortality in patients with malperfusion, shock or both. The Penn Classification or new classification systems for acute type A aortic dissection like the recently published TEM classification are very helpful tools to realistically compare different surgical management strategies [1, 3]. While the value of large databases is undeniable relatively small series are being published on the management of patients with selected organ malperfusion even though these patients have the highest mortality [4, 5]. With immediate surgical treatment [6], improving surgical technique [7], individualized cannulation and organ protection strategies [8], and evolving endovascular treatment options for the ascending aorta [9], we can continue to bring down the mortality to single digits in patients with malperfusion as well. Institutional funding from the Heart Centre Freiburg University.