levels [4]. Although senility is not defined as a disorder, it definitely is an apoptotic process. Although the results of this recent study are satisfactory in terms of mortality, retrograde cerebral perfusion has almost a historical significance nowadays because of the deterioration in cognitive skills. Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Bortecin Eygi, MD Department of Cardiovascular Surgery Izmir Katip Celebi University Ataturk Education and Research Hospital 6436 sok 82/3 35540 Karsiyaka-Izmir, Turkey email: ismoyurekli@yahoo.com References 1. Oda T, Minatoya K, Sasaki H, et al. Is conventional open repair still a good option for aortic arch aneurysm in patients of advanced age? Ann Thorac Surg 2016;101:80–6. 2. Gao H, Zhang N, Lu F, et al. Circulating histones for pre- dicting prognosis after cardiac surgery: a prospective study. Interact Cardiovasc Thorac Surg 2016;23:681–7. 3. Winterhalter M, Brandl K, Rahe-Meyer N, et al. Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infu- sion to intermittent fentanyl. Eur J Anaesthesiol 2008;25: 326–35. 4. Lee KS, Chung JH, Choi TK, Suh SY, Oh BH, Hong CH. Peripheral cytokines and chemokines in Alzheimer’s disease. Dement Geriatr Cogn Disord 2009;28:281–7. Carotid Doppler Assessment in Patients With Severe Aortic Stenosis To the Editor: Condado and colleagues [1] elegantly demonstrated in his retrospective study of almost 1,000 patients that screening for internal carotid artery stenosis (ICAS) with universal Doppler ultrasound, which is commonly used before aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI), is not obligatory. Moreover, ICAS severity was not associated with procedure-related stroke. Nevertheless, an increasing prevalence of patients with valvular heart disease re- quires a dedicated management approach. We agree that patients with severe aortic stenosis (AS) should undergo a Doppler ultra- sound examination of carotid and vertebral arteries as a part of a comprehensive assessment only in limited conditions before AVR or TAVI. In patients scheduled for TAVI there are concerns linked to presence of ICAS and rapid ventricular pacing during balloon aortic valvuloplasty and prosthesis deployment. Performing Doppler ultrasound for screening purposes may be not enough and, in our opinion, should also be extended to orthostatic unload test in AS patients. In a study by our group we emphasized the role of orthostatic stress test in patients with severe AS, in whom we found significant decrease of carotid and vertebral arterial flow velocities and flow volume in upright position [2]. Sato and associates showed that blood flow in the internal carotid artery and medial cerebral artery were reduced during the head-up tilt test [3]. Furthermore, Ogoh and colleagues recently provided data that the effect of graded orthostatic stress on vertebral artery blood flow may be associated with hemodynamic changes in posterior rather than anterior cerebral blood flow [4]. Whether noninvasive estimation of the changes in cerebral blood flow in response to the orthostatic stress test in patients with AS may be helpful before cardiac procedures requires large prospective studies. Pawel Kleczynski, MD, PhD Pawel Petkow Dimitrow, MD, PhD Institute of Cardiology Kopernika 17 St 31-501 Krakow, Poland email: kleczu@interia.pl References 1. Condado JF, Jensen HA, Maini A, et al. Should we perform carotid Doppler screening before surgical or transcatheter aortic valve replacement? Ann Thorac Surg 2017;103:787–94. 2. Kleczy nski P, Petkow Dimitrow P, Dziewierz A, Surdacki A, Dudek D. Decreased carotid and vertebral arterial blood-flow velocity in response to orthostatic unload in patients with severe aortic stenosis. Cardiol J 2016;23:393–401. 3. Sato K, Fisher JP, Seifert T, et al. Blood flow in internal carotid and vertebral arteries during orthostatic stress. Exp Physiol 2012;97:1272–80. 4. Ogoh S, Sato K, Okazaki K, et al. Blood flow in internal carotid and vertebral arteries during graded lower body negative pressure in humans. Exp Physiol 2015;100:259–66. Could Tumor Stage Be Conditioned by Surgical Technique Adopted? To the Editor: We carefully read the paper by Jeon and colleagues [1] about prognostic differences for each T3 descriptor. Their background was that the T3 group is heterogeneous and composed of four very different descriptors (T3-cent, T3-inv, T3-size, T3-sep). Moreover, some authors reported different outcomes depending on individual T3 descriptor, despite the fact that, according to the last TNM classification, prognosis should be homogeneous. Next, the authors supposed that the prognosis for each T3 subgroup could also be influenced by surgical fac- tors; in particular, they investigated whether advanced tech- niques, such as bronchoplastic resection, could improve survival in the T3-cent group. The results are interesting. First, there was a significant pro- pensity to nodal involvement in T3-cent, which was proved by a higher number of clinical N1-N2 cases and a higher number of nodal upstaged cases. Surprisingly, outcomes were significantly in favor of T3-cent compared with the other T3 descriptors. In fact, descriptors (T3-cent versus other groups) were indepen- dent prognostic factors for both DFS and OS. These results were also confirmed in N0 patients. Lastly, surgical technique influ- enced survival in T3-cent group in favor of bronchoplastic procedures versus pneumonectomy, as already reported in the literature [2]. The authors’ data strongly support that the T3-cent subgroup has different and better outcomes than other T3 tumors do, and underlining the need for a T descriptors’ revision in the forth- coming eighth edition of the TNM classification for lung cancer. In our opinion, the different behavior of T3-cent tumors could be explained by clinicopathologic characteristics such as squa- mous cell histotype, early respiratory symptoms, absence of pleural invasion or multifocal disease. All these features could explain earlier diagnosis and minor tumor cell spreading likeli- hood. Instead, the authors supported the hypothesis that better Ó 2017 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc. 1100 CORRESPONDENCE Ann Thorac Surg 2017;104:1095–101 MISCELLANEOUS