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• W2912770042 abstract "Central MessageThe use of a modified Cabrol shunt in all patients may completely eliminate postoperative bleeding complications and improve outcomes in patients undergoing repair of type A aortic dissections.See Article page 1307. The use of a modified Cabrol shunt in all patients may completely eliminate postoperative bleeding complications and improve outcomes in patients undergoing repair of type A aortic dissections. See Article page 1307. Aortic dissection: The term strikes terror into the hearts of many outside our specialty, with whispered mortalities of 1% to 2%/hour or 15% to 18% mortality at surgery. The development of surgical approaches to the management of aortic dissection has in many ways closely followed that of surgery of the aortic root: Early efforts were plagued with excessive bleeding, and not until the inclusion technique reported by Bentall and DeBono1Bentall H. DeBono A. A technique for complete replacement of the ascending aorta.Thorax. 1968; 23: 338-339Crossref PubMed Scopus (1128) Google Scholar were outcomes more universally successful. The “button” described by Kouchoukos and colleagues2Kouchoukos N.T. Karp R.B. Blackstone E.H. Kirklin J.W. Pacifico A.D. Zorn G.L. Replacement of the ascending aorta and aortic valve with a composite graft. Results in 86 patients.Ann Surg. 1980; 192: 403-413Crossref PubMed Scopus (89) Google Scholar alleviated the major complication associated with the inclusion technique (pseudoaneurysm formation), allowed complete replacement of the root and ascending aorta, and made treating these patients more routine with acceptable outcomes. Nonetheless, complications of the repairs remain confounding. Among the most humbling of these complications is bleeding, which has been reported in as many as 28% of selected patient subsets. In this issue of the Journal, Zhang and colleagues3Zhang H. Wu X. Fang G. Qui Z. Chen L-w Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?.J Thorac Cardiovasc Surg. 2019; 158: 1307-1314.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar report on their experience with a modified Cabrol fistula that reduces this figure to 0%. The Cabrol fistula (or shunt) is a periaorta–to–right atrial fistula created to direct any bleeding from the repair into the right atrium, thereby both preventing tamponade and diminishing the operative duration. First described in 1986,4Cabrol C. Pavie A. Mesnildrey P. Gandjbakhch I. Laughlin L. Bors V. et al.Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries.J Thorac Cardovasc Surg. 1986; 91: 17-25Abstract Full Text PDF PubMed Google Scholar the technique has undergone many modifications, all of which require obliteration of any egress points (eg, transverse sinus) from which free blood might escape into the pericardium. Creation of this closed space is difficult in the virgin pericardium once the aortic repair has been effected, but Zhang and colleagues3Zhang H. Wu X. Fang G. Qui Z. Chen L-w Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?.J Thorac Cardiovasc Surg. 2019; 158: 1307-1314.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar avoid this difficulty by creating the posterior closure before undertaking the aortic repair, whether primarily or with a piece of bovine pericardium. After completion of the aortic repair and control of any major (spurting) bleeding, the periaortic “sac” is completed by suturing another piece of bovine pericardium over the anterior structures. Before completion of the repair, a small defect is created in the right atrium or medial superior vena cava, and the anterior baffle is completed. Direct comparison of shunt and nonshunt groups was undertaken: Group sizes and characteristics were essentially identical, and all surgeries were performed by the same surgeon. Interestingly, the decision to shunt or not to shunt was made by a second surgeon; Zhang and colleagues3Zhang H. Wu X. Fang G. Qui Z. Chen L-w Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?.J Thorac Cardiovasc Surg. 2019; 158: 1307-1314.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar do not elaborate as to why. Comparison of the 2 groups' outcomes demonstrated statistically significant improvements in chest tube drainage, reexploration for bleeding, blood transfusions, intensive care unit stay, and dialysis need. A trend toward decreased length of ventilator support was seen but did not reach significance. A metric labeled “chest closure time” was also significantly decreased, although the term is not defined. Zhang and colleagues3Zhang H. Wu X. Fang G. Qui Z. Chen L-w Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?.J Thorac Cardiovasc Surg. 2019; 158: 1307-1314.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar note that closure of the transverse sinus only requires 1 to 2 minutes, although time to create the completed fistula was not studied. In addition, no episodes of postoperative heart failure from shunt flow were seen, and all fistulas spontaneously closed although the methods used to determine this are not specified. The potential to offer a type A dissection repair without any risk of reexploration for bleeding is enticing, although one questions whether the need to add a supplemental procedure for all patients is justified. Despite the historical reports of high “take-back” rates,5Conway B.D. Stamou S.C. Kouchoukos N.T. Lobdell K.W. Khabbaz K.R. Murphy E. et al.Improved clinical outcomes and survival following repair of acute type A aortic dissection in the current era.Interactive Cardiovasc Thorac Surg. 2014; 19: 971-977Crossref PubMed Scopus (27) Google Scholar, 6Zindovic I. Gudbjartsson T. Ahlsson A. Fuglsang S. Gunn J. Hansson E.C. et al.Malperfusion in acute type A aortic dissection: an update from the Nordic consortium for acute type A aortic dissection.J Thorac Cardiovasc Surg. 2019; 157: 1324-1333.e6Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 7Kreibich M. Bavaria J.E. Branchetti E. Brown C.R. Chen Z. Khurshan F. et al.Management of patients with coronary artery malperfusion secondary to type A aortic dissection.Ann Thorac Surg. November 13, 2018; ([Epub ahead of print])Google Scholar with meticulous care and precise technique, reoperative rates of 2% to 4% are increasingly reported.8Etz C.D. Bischoff M.S. Bodian C. Roder F. Brenner R. Griepp R.B. et al.The Bentall procedure: is it the gold standard? A series of 597 consecutive cases.J Thorac Cardiovasc Surg. 2010; 140 (discussion S86-91): S64-S70Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 9Andersen N.D. Ganapathi A.M. Hanna J.M. Williams J.B. Gaca J.G. Hughes G.C. Outcomes of acute type A dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program.J Am Coll Cardiol. 2014; 63: 1796-1803Crossref PubMed Scopus (113) Google Scholar Although accurate assessments of postoperative reexploration rates are difficult to ascertain (most type A series do not report bleeding rates), and the present series results remain to be replicated (or even extended), one is compelled to question whether the placing of an additional piece of foreign material in every patient is justified and what, if any, long term sequelae of fistula formation exist. Indeed, one may also reasonably question whether the shunt actually functions as such or spontaneously closes after heparin reversal. Zhang and colleagues3Zhang H. Wu X. Fang G. Qui Z. Chen L-w Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?.J Thorac Cardiovasc Surg. 2019; 158: 1307-1314.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar have presented an intriguing solution to a frustrating problem associated with dissection repairs. Further evaluation of their results seems to be ongoing, and studies by others may confirm these findings. It may ultimately be that wrapping the repair, albeit in a larger baggie than originally described, may return us to the early days of dissection and root repairs. Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?The Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 5PreviewOpen repair of acute type A aortic dissection frequently results in oozing from the suture lines. A modified fistula technique was developed to rapidly control oozing and allow closing the chest immediately and safely. The efficiency of this modified fistula technique in surgical repair of acute type A aortic dissection was evaluated. Full-Text PDF Open Access" @default.
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• W2912770042 title "Commentary: To wrap or not to wrap—Have we now come full circle?" @default.
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