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• W2912778817 abstract "Author has nothing to disclose with regard to commercial support. Author has nothing to disclose with regard to commercial support. I read with interest the article entitled “Decision-Making Algorithm for Ascending Aortic Aneurysm—Effectiveness in Clinical Application?” by Saeyeldin and colleagues.1Saeyeldin A. Zafar M.A. Li Y. Tanweer M. Abdelbaky M. Gryaznov A. et al.Decision-making algorithm for ascending aortic aneurysm: effectiveness in clinical application?.J Thorac Cardiovasc Surg. 2019; 157: 1733-1745Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar It is, as we have become accustomed from these authors, clearly written and beautifully illustrated. An algorithm is presented, supported by data concerning the fate of those not undergoing surgical intervention, and a claim of clinical effectiveness is made. I am concerned, however, that an algorithm intended to protect from “silent killers” threatens to turn innocent bystanders into victims of mistaken identity. Although the substance of the study focuses on aortic diameter and symptomatic status, the decision tree implies equivalence of an associated bicuspid aortic valve (BAV) with a strong family history, a defined connective tissue disease like Marfan syndrome, or symptomatic status as an indicator for intervention on a 4.0- to 5.0-cm aorta. The accompanying editorialists touch on this issue. Huu and Coselli2Huu A.L. Coselli J.S. Commentary: to be or not to be: the guidelines are the question.J Thorac Cardiovasc Surg. 2018; 157: 1746-1747Google Scholar cite the lack of data to support survival benefit to replacement of aortas less than 4.5 cm associated with BAV, and Schoenhoff and Carrel3Schoenhoff F.S. Carrel T. Decision making in thoracic aortic surgery: one size fits all?.J Thorac Cardiovasc Surg. 2019; 157: 1748-1749Abstract Full Text Full Text PDF Scopus (2) Google Scholar highlight the dilemma of intervention particularly in patients with a normally functioning BAV. I feel compelled to emphasize this point, however, given the frequency of BAV in the population and the common association of moderate aortic dilatation. The potential impact of this controversial recommendation dwarfs that of all the others. The best data to date, summarized in a recent meta-analysis by Guo and colleagues,4Guo M. Appoo J.J. Saczkowski R. Smith H.N. Ouzounian M. Gregory A.J. et al.Association of mortality and acute aortic events with ascending aortic aneurysm: a systematic review and meta-analysis.JAMA Netw Open. 2018; 1: e181281Crossref PubMed Scopus (42) Google Scholar indicate a low risk of rupture or dissection of moderately dilated aortas and no evidence that those associated with BAV behave more badly than others. This low rate of death and dissection is consistent with previous findings reported from the Yale data set.5Davies R.R. Kaple R.K. Mandapati D. Gallo A. Botta Jr., D.M. Elefteriades J.A. et al.Natural history of ascending aortic aneurysms in the setting of an unreplaced bicuspid aortic valve.Ann Thorac Surg. 2007; 83: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar These data and others lead to the roll-back in recommended threshold for intervention by the American College of Cardiology/American Heart Association valve disease guideline committee6Hiratzka L.F. Creager M.A. Isselbacher E.M. Svensson L.G. Nishimura R.A. Bonow R.O. et al.Surgery for aortic dilatation in patients with bicuspid aortic valves: a statement of clarification from the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Thorac Cardiovasc Surg. 2016; 151: 959-966Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar to 5.5 cm absent special conditions. The writers of the subsequent American Association for Thoracic Surgery Consensus Guidelines on BAV-related aortopathy agreed.7Borger M.A. Fedak P.W.M. Stephens E.H. Gleason T.G. Girdauskas E. Ikonomidis J.S. et al.The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: full online-only version.J Thorac Cardiovasc Surg. 2018; 156: e41-e74Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar The authors of this study argue that their algorithm is “effective.” If effectiveness is defined as “successfully producing the desired result” and that result is defined as prevention of dissection, surely it must be such. The counterfactual is not possible, since Dacron does not dissect. Indeed, an even more aggressive algorithm would also prevent dissection. But is it “efficient?” If we define efficiency as being “without waste”—more specifically without unnecessary surgery—perhaps not. We should be careful not to injure the innocent bystander in our zeal to nab the killer. Data demonstrating outcomes of those who declined or were refused surgery are not relevant to the question of whether surgery was necessary among all those who underwent the same. We are at risk of falling intellectual victims of a surgical variant of the “primitive logic fallacy” or “affirming the consequent”: the operated patients did well, so we must have done the right thing. Without knowledge of the actual risk of aortic catastrophe among those with BAV and moderate aortic dilatation, we may be doing more harm than good. Decision-making algorithm for ascending aortic aneurysm: Effectiveness in clinical application?The Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 5PreviewThe risk of rupture and dissection in ascending thoracic aortic aneurysms increases as the aortic diameter exceeds 5 cm. This study evaluates the clinical effectiveness of a specific algorithm based on size and symptoms for preemptive surgery to prevent complications. Full-Text PDF Open ArchiveWitness protection for authors of controversial guidelinesThe Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 5PreviewFor many years, Thoralf M. Sundt has shared his concerns about the premature prophylactic replacement of the aortic root and ascending aorta in patients with a bicuspid aortic valve. In a recent letter to the Editor,1 he shares his perspective on the article by Saeyeldin and colleagues (including Elefteriades),2 which presents their latest thoughts. Elefteriades and colleagues3 have long been at the forefront of enhancing the understanding of the natural history of aortic aneurysm and dissection. Full-Text PDF Open ArchiveRisks and benefits of early aortic repair: “You still cannot unring the bell!”The Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 5PreviewWe welcome the open discussion that the article, “Decision-making algorithm for ascending aortic aneurysm–effectiveness in clinical application?,” by Dr Saeyeldin and colleagues has stimulated.1 Unfortunately, the current system for peer review denies the reader of the sometimes animated discussion between editors, reviewers, and authors before the article gets finally published. The editorialists as well as the authors in their discussion touch on several issues discussed throughout the review process. Full-Text PDF Open ArchiveBicuspid aortic disease: “Marfan light”?The Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 5PreviewWe thank Dr Sundt for his kind comments. We always welcome his insightful perspectives on all aspects of cardiac disease and cardiothoracic surgery. Full-Text PDF Open Archive" @default.
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