Recent Advances in the Management of Acute Aortic Syndrome

Type A acute aortic dissection is one of the most serious cardiovascular conditions and is associated with significant morbidity and mortality. A half century ago, Hirst et al published a milestone article describing the linearized mortality rate of one percent per hour after the onset of an ascending aortic dissection [1]. Hence, the importance of accurate, quick and reliable diagnosis, as the timing of procedure is vital for optimal management of this highly lethal condition. Despite improvements in the diagnostic modalities, surgical techniques and perioperative care, the overall mortality remains high, between 10% and 30% [2]. Due to its major role in systemic perfusion, the aorta and its main branches after dissection are often challenging when trying to prevent surgical morbidity and mortality. The complexity of aortic dissection presents not only a pure cardiovascular surgical task, but also consideration must be given to protection of the myocardium, cerebrum, peripheral tissues and organs. An early fatal result of aortic dissection is due to ischaemic injury to the brain or heart, although longer peripheral ischaemia can cause multiorgan failure resulting in extended hospital stay, increased morbidity and mortality. Alexis Carrel highlighted the risks of surgery in 1910 with the following short summary on aortic interventions: “The main danger of the aortic operation does not come from the heart or from the aorta itself, but from the central nervous system.” Even a century later, we are still trying to optimize cerebral protection, despite having significantly wider range of diagnostic and therapeutic modalities. Advances in our understanding of varying pathologies of aortic dissections have improved as have the technological developments in the modes of detection. These advances together with improved therapeutic options have raised expectations for better outcomes.