ObjectiveTo examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Summary Background DataAcute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. MethodsFrom January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). ResultsMean age was 59 Ϯ 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 Ϯ 50 minutes. Mean HCA with RCP time was 42 Ϯ 12 minutes (range 19 -84). Mean cardiac ischemic time was 140 Ϯ 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n ϭ 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. ConclusionThe authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.Aortic dissection is the most common acute aortic catastrophe requiring emergent surgical therapy.1 Urgent surgical treatment of acute type A dissection is mandated because medical treatment is associated with a 60% in-hospital death rate.2 Since the first description of the successful repair of an aortic arch aneurysm by DeBakey et al 3 in 1955, numerous advances have been described in the diagnosis and management of thoracic aortic diseases. 4,5 Despite these advances, acute aortic dissection remains one of the most challenging operations to the cardiovascular surgeon. During the past decade, there have b...

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Abstract-Suppression of prostacyclin (PGI 2 ) biosynthesis may explain the increased incidence of myocardial infarction and stroke which has been observed in placebo controlled trials of cyclooxygenase (COX)-2 inhibitors. Herein, we examine if COX-2-derived PGI 2 might condition the response of the vasculature to sustained physiologic stress in experimental models that retain endothelial integrity. Deletion of the PGI 2 receptor (

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