Elective arch repair as a low-risk procedure? We're closer, but not there yet!

For the present article, Urbanski et al. [ 1 ] collected outcome data of aortic arch repair from 11 centres including some from the leading aortic surgery programmes in Europe. They have come up with what represents the largest cohort of patients undergoing arch surgery ever reported. The bias from the overlap with variations in the emergency setting is eliminated by their having excluded acute aortic dissections. The high number of documented patients suggests that some centres carry out this procedure on a routine basis. The high incidence of concomitant relevant surgery on the root, coronaries and mitral valve points in the same direction. Even though the procedures are done at a relatively high volume, the 30-day mortality is still significant, as is the overall follow-up mortality. A closer look at the data reveals a potential volume–outcome relationship. However, this is not supported by any statistical method. It seems obvious that a volume–outcome relationship would exist in conjunction with this type of extensive surgery: at least the manner in which possible complications are addressed could differ according to whether a given centre is low or high volume [ 2 ]. What would be of the greatest interest to the reader is: to what are big differences in the outcome usually attributable—their personnel, or do organizational factors play a role? As a matter of fact, the working conditions of performing extensive surgery have not been well explored: should there not be a specialist team doing these operations? Should there not be two surgeons performing the operation together where both are qualified to do the procedure? Should the perfusionists not be specialized in this topic? The broad variability in the use of perfusion techniques, cannulation sites or other technical considerations among the centres makes fruitful discussion about preferable techniques in aortic arch surgery impossible. There seem to be some take-home messages from the technical perspective: various cannulation sites (axillary, aortic and carotid) produce reliable outcomes, while femoral cannulation might be associated with adverse neurological outcomes as in surgery for acute aortic dissection type A [ 3 ]. Also, the new device for the frozen elephant trunk technique (Thoraflex, Vascutec) might enable excellent results in arch surgery, while more than the arch repair is addressed in the same procedure [ 4 ]. Unfortunately, we learn little about the comparison of perfusion strategies. A large series of patients undergoing the beating heart arch repair technique were recently published. This is an interesting new approach in order to markedly reduce cardiac ischaemic time [ 2 ]. We first applied the beating heart arch surgery method in congenital arch repair. This had been described by the Erlangen group [ 5–7 ]. We have now adopted the beating heart concept with warm, selective myocardial perfusion in all potential patients (e.g. those without aortic insufficiency). These are only few examples of innovative techniques and technology that might account for superior outcomes after arch repair in the future. The most striking fact in this study is still the relatively high early and mid-term mortality that the authors report [ 1 ]. The author groups are from some of the leading European aortic surgery centres. We can assume that the outcome under ‘real world’ conditions might not be better. However, the outcome data from some of the participating centres can already be regarded as coming from elective, routine, low-risk arch repair. This is exactly the goal for our future clinical developments.