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.

Background: Although peer-assisted learning is known to be effective for reciprocal learning in medical education, it has been understudied in simulation. We aimed to assess the effectiveness of peer-led compared to instructor-led debriefing for non-technical skill development in simulated crisis scenarios. Methods: Sixty-one undergraduate medical students were randomized into the control group (instructor-led debriefing) or an intervention group (peer debriefer or peer debriefee group). After the pre-test simulation, the participants underwent two more simulation scenarios, each followed by a debriefing session. After the second debriefing session, the participants underwent an immediate post-test simulation on the same day and a retention post-test simulation two months later. Non-technical skills for the pre-test, immediate post-test, and retention tests were assessed by two blinded raters using the Ottawa Global Rating Scale (OGRS). Results: The participants’ non-technical skill performance significantly improved in all groups from the pre-test to the immediate post-test, with changes in the OGRS scores of 15.0 (95% CI [11.4, 18.7]) in the instructor-led group, 15.3 (11.5, 19.0) in the peer-debriefer group, and 17.6 (13.9, 21.4) in the peer-debriefee group. No significant differences in performance were found, after adjusting for the year of medical school training, among debriefing modalities (P = 0.147) or between the immediate post-test and retention test (P = 0.358). Conclusions Peer-led debriefing was as effective as instructor-led debriefing at improving undergraduate medical students’ non-technical skill performance in simulated crisis situations. Peer debriefers also improved their simulated clinical skills. The peer debriefing model is a feasible alternative to the traditional, costlier instructor model.