eComment: does coma state really stop from operating type A aortic dissection patients?

Nomenclature Historical Pages cardiogram, suggesting coronary ostial involvement, were also observed. Echocardiography documented severe aortic regurgitation. Emergency root replacement with a valved conduit was performed with open distal repair at 24 8C, employing selective antegrade cerebral perfusion. Cardiopulmonary bypass, cardioplegic arrest and antegrade cerebral perfu-sion times were 293, 141, and 22 min. The patient was weaned from extracorporeal perfusion with a 0.04 mgykgy min epinephrine infusion. Neurocognitive function improved after a period of coma, and progressively returned to baseline. The only neurological motor deficit was temporary right upper hemiparesis. Computed tomograms documented a right-sided hemispheric stroke, and reperfused arch vessels despite residual arch dissection (Fig. 2). The patient was discharged from the intensive care unit 36 days after surgery. 3. Discussion Medical therapy for type A acute aortic dissection yields unfavourable results. Although successful repair has been reported, preoperative stroke and especially coma are usually considered contraindications for immediate surgery w2–5x, in spite of the absence of criteria to define irreversible brain damage preoperatively. In the first patient, short-term delayed repair was performed after resuscitative measures in the comatose patient, and the timing of the indication was primarily based on the resumption of initially absent brainstem reflexes, whereas the second patient underwent immediate surgery. The postoperative period was temporarily characterized by profound coma, but late recovery was dramatic in apparently hopeless conditions. This suggests the possible benefits of immediate restoration of cerebral blood flow, even in case of altered or absent brainstem reflexes, and outlines the unreliability of the widely adopted Glas-gow coma scale for patient stratification, as previously outlined in a small case series by our group in which, the preservation of brainstem reflexes was considered a criterion to indicate emergent repair w5x. It might also be speculated that, in case of partial compression of the arch vessels, neurological dysfunction may have a higher potential for recovery. Finally, P300 peak latencies recorded with cognitive evoked potentials represent a useful tool to evaluate neurocognitive function, and are normally increased soon after open-heart operations w6x. In our first patient, the P300 latency recorded-2 months after the acute event, was only mildly increased when compared to healthy controls, and was similar to measurements after valve surgery. Our experience stresses the potential for reversibility of dissection-induced neurological injury, and confirms a higher likelihood of a more severe ischaemic insult in right-sided territories. Extensive arch surgery was not performed because of the absence of …