Steroids in aortic dissection surgery

Dear Editor, We read with interest the article by Luo et al. [1]. In a prospective randomized trial involving patients with acute aortic dissection, they demonstrated that the administration of methylprednisolone in the immediate postoperative period reduces organ injury measured as a significant reduction in SOFA score. Of note is the numerical decline in mortality and acute renal failure, although not statistically significant. Neither the SIRS trial [2] nor the DECS trial [3], with adequate sample size, demonstrated clinical benefits of this magnitude; this large discrepancy warrants discussion. It is likely that neither in SIRS nor in DECS treatment with steroids was specifically assigned to patients who could benefit from it, i.e. patients who produced an excessive inflammatory response to cardiac surgery with cardiopulmonary bypass (CPB). We have recently shown that after cardiac surgery, inflammation detected with clinical parameters occurs in ∼25% of subjects and that in these patients, the incidence of 30-day mortality and postoperative complications is significantly higher than in non-inflamed patients, with postoperative inflammation being an independent predictor of 30-day mortality [4]. Factors such as preoperative neutrophils, preoperative C-reactive protein, intraoperative haemoglobin and lactate levels and duration on CPB were associated with postoperative inflammation. Many of these factors are altered in patients with aortic dissection undergoing a complex and prolonged intervention often performed in deep hypothermic circulatory arrest. Studies have shown that (and Luo et al. have partially confirmed this) aortic dissection patients arrive at the operation with a very activated inflammatory state [5] as well as with an intense activation of coagulation and fibrinolysis [6]. This is probably determined by the flow in the false lumen and by possible ischaemic phenomena induced by malperfusion. The operation then accentuates these reactions to a degree much higher than that normally observed in elective interventions with CPB.