Commentary: The enemy of good is perfect, but please define good and perfect.

Berhane Worku, MD, and Mario Gaudino, MD

In the setting of a type A dissection with an aorto-right atrial fistula, a double patch repair of the fistula by an experienced surgeon allows for valve preservation and a positive outcome.

See Article page 1.

In the current manuscript, the authors describe the repair of an acute type A dissection complicated by aorto-right atrial fistula using a “2-patch” technique. It addresses a complicated version of an already-complicated, high-risk, urgent operation with a combination of novelty and simplicity that allows the young patient a valve-sparing approach with resolution of the fistula and an overall positive outcome. Or is it that simple?

The goal of type A repair is to resect the portion of the ascending aorta with the primary tear and to reestablish blood through the true lumen. However, a variety of long-term complications may still result from such a strategy. Although many argue that the goal of the operation is “to end up with a live patient,” others extend the operation either proximally into the root or distally into the arch and descending aorta to treat the longer-term sequelae such as aortic root dilation, aortic regurgitation, and a persistent type B dissection, thereby violating the principle of “the enemy of good is perfect.”

In this case report, the authors obey this principle with regards to the management of the aortic root and fistula. A somewhat more conservative approach is taken with the theoretical risk of long-term fistula recurrence, aortic root dilation, and aortic regurgitation, while disobeying it at the same time with regards to the arch and descending aorta, where an aggressive approach is taken. Is a more aggressive (“perfect”) approach more warranted in one part of the aorta than the other? Is the eloquent double-patch technique described here more expeditious than an aortic root replacement? Would this alternative plan have been an acceptable approach to all surgeons, or would a valve-sparing approach be “mandatory,” given the patient's young age and normal aortic valve?

One must take into account individual patient characteristics, institutional capabilities, and surgeon experience in tailoring an approach to each patient with type A dissection. That medicine is an art, not a science, is rarely better demonstrated than in the management of this feared disease. The art is in defining where to be good, and where to be perfect.