Abstract
Thoracic aortic surgery is a source of extreme pride in quaternary care cardiac centers. While lesser mortals cower their heads, department chiefs wear their successful thoracic aortic programs like a badge of courage. Creation of these programs is not for the weak-willed or resource-stretched. Failure of a program could have devastating consequences in a competitive environment, particularly with the transparency that is demanded of most healthcare delivery systems.
Successful teams are just that; they are teams first and foremost. Success is based on the integration of best clinical practice and hard work, but effective communication amongst the team is a key element to success in order to develop over-arching strategies to manage these challenging cases.
Having said that, it is very tempting to stick rigidly to a strategy that almost works 90% of the time in 90% of the patients. But, can we identify persistent clinical problems that challenge this fall-back position, aiming to bring that remaining 10% into the realm of successful outcomes? For example, are we using the best techniques for cerebral protection? What about myocardial protection – is bad myocardial protection not infrequently the precipitant or harbinger of disaster?
If our current strategies had no limitations, everyone would do the same thing and there would be tremendous outcomes all around. In the thoracic aortic literature, studies abound supporting that this is not the case. We are encouraged by the litany of published attempts, some of them failures, but, thankfully, all are justified by good science and we are obligated to test and support these respective hypotheses.
The manuscript of Salah et al. 1 describes a retrospective review of two cohorts of patients, reflecting a period of the uniform integration and deployment of antegrade cerebral perfusion and moderate hypothermia. In the earlier cohort, deep hypothermic circulatory arrest (DHCA) was routinely used with alternative means of cerebral protection (DHCA alone, retrograde cerebral perfusion or DHCA with antegrade cerebral perfusion). This is a very useful review as the authors were able to tease out the innovation of this relatively bold approach (i.e. don’t go so low!) as the sole factor that could be examined. Indeed, their data convincingly support the hypothesis that this alternative approach improves short-term outcomes, possibly related to avoiding the catastrophic consequences of bleeding from those few additional, but potentially lethal, degrees.
The case report of White et al. 2 provides an ingenious approach to a tough surgical dilemma, notably that of achieving excellent myocardial protection through a left thoracotomy. The rather clever use of the vent in the left atrial appendage to fill antegradely and de-air the heart and arch while venting in the thoracic aorta is also an extremely useful potential adjunct to the surgical team’s armamentarium
How can we, as a journal, support innovation going forward? First off, we should endeavor to acknowledge, through editorials such as this, the work of surgical teams to use systematic approaches with databases and reproducible protocols so they can turn their hard work into academic rewards. We are encouraged by the integration of perfusionists as equal partners in the planning and implementation of innovation and we must elicit contributions from their know-how and expertise to provide technical pearls in perfusion skills. Perhaps our other role will be to help document and catalogue these issues for easy retrieval in real-time to teams with access to computers and, thus, to our journal, in the OR.
If thoracic aortic surgery was risk-free we’d feel more comfortable offering intervention for smaller sizes of thoracic aortic aneurysm pathology or, perhaps, we’d take on sicker patients with greater co-morbidity. Developing improved skills in the delivery of cardiopulmonary bypass can, and will, optimize our operative experiences and the outcomes of our patients and we applaud those who take the dissemination of these skills as their mandate.