In surgery for acute type A aortic dissection, follow the principles and do what you need to do

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1 Accepted Manuscript In surgery for acute type A aortic dissection, follow the principles and do what you need to do Ourania Preventza, MD, Kim I. de la Cruz, MD, Joseph S. Coselli, MD PII: S (19) DOI: Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 7 March 2019 Accepted Date: 7 March 2019 Please cite this article as: Preventza O, de la Cruz KI, Coselli JS, In surgery for acute type A aortic dissection, follow the principles and do what you need to do, The Journal of Thoracic and Cardiovascular Surgery (2019), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 1 2 COMMENTARY In surgery for acute type A aortic dissection, follow the principles and do what you need to do Ourania Preventza, MD, 1,2 Kim I. de la Cruz, MD, 1,2 and Joseph S. Coselli, MD 1,2 From the 1 Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; and the 2 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex. Conflict of interest statement and sources of funding: The authors have nothing to disclose with regard to commercial support. Address for reprints: Ourania Preventza, MD, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, BCM 390, One Baylor Plaza, Houston, TX Phone: ; fax: ; opsmile01@aol.com. Article word count: 488

3 Preventza et al Central Message Whether patients who need surgery for acute type A aortic dissection have a bicuspid or tricuspid aortic valve is irrelevant. The surgical procedure should be tailored to the individual patient. Central Picture Legend A bicuspid or tricuspid aortic valve may be irrelevant in type A aortic dissection surgery.

4 Preventza et al In this issue, Mennander and colleagues, 1 in a cumulative effort among 8 Scandinavian centers, address the significance of bicuspid aortic valve (BAV) in patients who had surgery for type A aortic dissection. A comparison of propensity-score matched patients with BAV versus tricuspid AV (TAV) showed no between-group differences in early or mid-term survival, nor were these outcomes affected by BAV patients greater need for more complex aortic root surgery. The authors should be congratulated for their outstanding effort. In their study, 1,122 patients underwent surgery for acute type A aortic dissection over a 10-year period ( ). Of these, only 65 (5.8%) had BAV (mean follow-up time, 3.2 years). Consequently, the study was underpowered to detect significant differences in major clinical endpoints, due to the small number of BAV patients; further, the follow-up timeframe was too short to permit differentiation between BAV versus TAV patients regarding AV competency in those with root repair or replacement. Thus, major conclusions cannot be drawn. Despite these limitations, this article highlights several important issues. First, and not surprisingly, BAV was more prevalent in patients with acute type A aortic dissection (5.8%) than in the general population (2%). Clinical series and autopsy reports have established that BAV prevalence in patients with acute type A aortic dissection is 7% 15%, and it is much higher in those aged <40 years. 2 Second, although not specifically addressed, the risk for dissection in BAV versus TAV patients remains a topic of debate. The current consensus is that although the relative risk is higher in BAV versus TAV patients with comparable aortic dimensions, the absolute risk is low. 3 This supports the use of similar surgical strategies for ascending aorta replacement in both BAV 29 and TAV patients.

5 Preventza et al Third, whether patients who need surgery for acute type A aortic dissection have a bicuspid or tricuspid aortic valve is irrelevant to their postsurgical outcomes. The usual suspects e.g., increased age, increased cross-clamp time come into play as independent factors for mortality, which is not surprising. The main goals of such surgery are replacing the ascending aorta and restoring/maintaining AV competency. The surgeon should tailor the operation according to intraoperative findings after examining the AV and the aortic root. In patients with a connective tissue disorder, an aortic root operation is warranted. If a Bentall or bioroot procedure is necessary, outcomes will not be affected by BAV versus TAV. An instance in which BAV/TAV status could make a difference is with a David operation. In the current series, only a few (single digits) David operations were performed, and the follow-up was short. Nevertheless, although the David procedure seems ideal for acute type A aortic dissection, it is surgically challenging and requires substantial experience. In surgery for acute type A aortic dissection, as in every surgical procedure, the surgeon should do neither too much nor too little. Surgeons should use sound judgment to offer patients the best possible care under their specific circumstances.

6 Preventza et al References 1. Mennander A, Olsson C, Jeppsson A, Geirsson A, Hjortdal V, Hansson EC, et al. The significance of bicuspid aortic valve after surgery for acute type A aortic dissection (in press). J Thorac Cardiovasc Surg Braverman AC, Guven H, Beardslee MA, Makan M, Kates AM, Moon MR. The bicuspid aortic valve. Curr Probl Cardiol. 2005;30: Kaneko T, Shekar P, Ivkovic V, Longford NT, Huang CC, Sigurdsson MI, et al. Should the dilated ascending aorta be repaired at the time of bicuspid aortic valve replacement? Eur J Cardiothorac Surg. 2018;53:560-8.

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