Every acute dissection involving the ascending aorta (Stanford type A) must undergo emergency surgical repair. However, the surgical techniques must vary according to the clinical presentation of the patients or the anatomical patterns observed. Furthermore, surgery is generally difficult because of the poor condition of the aortic tissues. To reduce those difficulties many technical artifacts have been described. In 1977, we have proposed the use of Gelatin-Resorcin-Formalin (GRF) biological glue to reinforce the suture areas.
From January 1977 to July 1999, 212 patients (152 males and 60 females) aged from 15 to 80 years (mean age: 54+11 years) underwent an emergency operation for type A aortic dissection. One hundred seventy-eight patients (84%) were operated on within 4h after being referred to the hospital. Twenty-eight patients (13.2%) had Marfan's syndome. In 44 patients (20.7%), the aortic valve was replaced either independently (6 cases: 2.8%) or by means of a composite graft (38 cases: 17.9%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 61 patients (28.7%).
Hospital mortality amounts to 21.6% (46 patients), 25% in patients with arch replacement and 19.4% in patients without arch replacement (n. s). Analysis of hospital mortality demonstrates that the main causes of death were cardiac tamponade, neurologic disorders and visceral malperfusion. One hundred sixty-six patients were discharged and surveyed from 5 months to 22 years postoperatively (Mean follow-up: 85+66 months). During this period of time, 25 patients (15%) had to be reoperated on for a total of 33 reoperations. Seven patients (28%) died at reoperation. At univariate analysis, presence of Marfan's syndrome (p<0.05) and absence of arch replacement (p<0.02) were determinant risk factors for reoperation. Emergency (p<0.01) and thoraco-abdominal replacement (p<0.04) were determinant risk-factors of death at reoperation. The freedom from reoperation (Kaplan-Meier, CI: 95%) is: 96% (90-98), 87% (79-92), 80% (70-88), 66% (51-78) at 1, 5, 10, and 15 years, respectively.
A total of 39 patients (24.3%) died during follow-up. Presence of Marfan's syndrome (p< 0.01), reoperation (p<0.02), stroke (p<0.05), cardiac failure (p<0.05) were determinant risk factors of late mortality. The late survival rate (K-M. C. I.: 95%), including hospital mortality, is 71% (64-77), 66% (58-73), 56% (47-64), 46% (36-56), 37% (28-44) at 1, 10, 15, and 20 years respectively.
During this experience extending over more than 23 years, the GRF glue has proved to be extremely useful, making the procedure much easier and safer. Nevertheless many factors appeared of importance in the pre, intra, and postoperative management of the patients. Cardiac tamponnade and visceral malperfusion must be properly diagnosed and treated. During aortic repair, the main intimal tear must be resected. The transverse arch must be checked and replaced whenever necessary. The aortic valve should be preserved whenever possible. During CPB, perfusing the aorta in the regular antegrade way seems to dramatically reduce the rate of malperfusion. The quality of the first emergency operation seems to have a major influence on the late results, especially concerning the rate of late reoperations and aortic ruptures. However, those late results depend also on the patient's basic condition, particularly in Marfan patients.

  French balneotherapy is highly dependent on public regulations and finance. State and public bodies have a major say on cares delivered, in both nature and number, on required qualifications of therapists, on a fixed 3-week’s duration, on hygiene and safety. At the same time, public financing of cares is by far more important than the contribution of complementary private health insurances and out-of-pocket payments by the patient.   Some 10 years ago, the National Health Insurance Fund openly stated that hypothesized health benefits of spa therapy were no longer good enough to keep the subsidizing of thermal treatments. Clinical research with flawless methodology had to be organized to prove thermalism has a true medical interest.   Years later the challenge has been met and fewer opponents question any longer the virtues of hydrotherapy. The actual medical benefit of spa treatments is now well established in such fields as generalized anxiety disorders, knee osteoarthritis, obesity and overweight, post-breast cancer rehabilitation, healthy ageing, ...   This financial effort of more than 10 million euros proved to be fruitful as the National Health Insurance Fund recently renewed the subsidyzing of thermal treatments.   However, in the wake of spiralling health costs putting a strain on public spending, a new requirement is set on spa center operators. Nowadays, they also have to prove that balneotherapy is cost-efficient in comparison with other therapies. The yet to be proved economic relevance of spa therapy as well as new expectations are set to bring about a dramatic shake-up by which alongside the traditional treatment of chronic diseases, spa companies will have to address new fields of competences, such as prevention, rehabilitation, quitting of addictions, postponing of age-associated loss of autonomy, etc.