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Methodological quality of a meta‐analysis precedes its clinical significance

Dear Editor, We read the recent publication entitled “Hypothermic circulatory arrest time affects neurological outcomes of frozen elephant trunk for acute type A aortic dissection: A systematic review and meta‐analysis” by Dr. Mousavizadeh et al. with great interest. In this study, they aimed to assess the efficacy of frozen elephant trunk (FET) in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on postoperative neurologic outcomes. A total of 35 studies (quite large) were included with 3211 patients undergoing total arch replacement (TAR) with FET. They found that the pooled estimate for in‐hospital mortality, postoperative stroke, and spinal cord injury (SCI) were 7% (95% confidence interval [CI]: 5–9; I = 68.65%), 5% (95% CI: 4–7; I = 63.93%), and 3% (95% CI: 2–4; I = 19.56%), respectively. More importantly, they found an increased duration of hypothermic circulatory arrest time confer an escalated risk of postoperative stroke and SCI. Therefore, they concluded that employing the FET procedure for ATAAD is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET. We believe that these findings are of great clinical importance. However, several important issues remained unsolved, challenging the credibility of conclusions.