Select Articles Published on the Topic of Cardiovascular Surgery in 2013

Summary-Nonaortic cardiac surgery is associated with a low but significant incidence of type A aortic dissection (AAD). Because there are important differences in clinical presentation, surgical management, and prognosis between spontaneous and late AAD following cardiac surgery, this large multicenter study sought to determine the conditions associated with the high surgical mortality of AAD repair as a complication of nonaortic cardiac surgery and to identify management pathways to improve outcome. We found that operative mortality depends on the type of initial surgery, time to AAD, and, importantly, influenceable management factors. AAD occurred mainly in patients with preexisting aortic wall pathology, identifiable with a slightly enlarged aorta, and hypertension at sites of iatrogenic mechanical trauma. This finding emphasizes most careful surgical handling and potentially a low threshold for prophylactic replacement of the ascending aorta that is without additional operative risk in experienced centers. Diagnosis of AAD warrants a mandatory high index of suspicion and depends primarily on imaging. The majority of patients with previous cardiac surgery had no or nonspecific symptoms when AAD was detected. The single most important factor that was associated with a lower operative mortality was implementation of preoperative coronary angiography and appropriate operative management of CAD and graft disease in patients with previous CABG. Because cardiac tamponade and hemodynamic instability are rare (1%), patients with previous cardiac surgery in stable condition should undergo preoperative native coronary and graft status assessment and appropriate operative planning, including aggressive revascularization and the use of deep hypothermic cardiac arrest.