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Ann Thorac Surg 2000;70:1455-1459
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Early and late surgical outcomes of acute type a aortic dissection in patients aged 75 years and older

^a Department of Cardiovascular Surgery, Omiya Medical Center, Jichi Medical School, Saitama, Japan

Address reprint requests to Dr Kawahito, Omiya Medical Center, Jichi Medical School, 1-847 Amanuma, Omiya, Saitama 330-0834, Japan
e-mail: kawahito{at}omiya.jichi.ac.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. With the general increase in human lifespan, aortic surgeons are faced with an increasing prevalence of acute type A aortic dissection in the elderly. In this study, we reviewed early and late surgical outcomes of acute type A dissection (operation within 48 hours after onset) in patients aged 75 years and older.

Methods. Between 1990 and 1999, 109 patients underwent emergency operation for acute type A dissection at Omiya Medical Center. Twenty-three patients were aged 75 years and older (elderly group, mean age, 79.1 ± 4.7 years) and 86 were younger than 75 years old (younger group, mean age, 58.7 ± 10.8 years). Early and late outcomes of both groups were compared.

Results. The hospital mortality rates were 13.0% (3 of 23) in the elderly group and 10.5% (9 of 86) in the younger group (p = 0.71). In the elderly, actuarial survival rate (including the operative mortality rate) at 1, 3, and 5 years was 78% ± 9% for each point. In the younger group, the rates were 88% ± 4% at 1 year, 83% ± 4% at 3 years, and 81% ± 5% at 5 years (p = 0.57). Actuarial event-free rates were 84% ± 8% at 1 year, 77% ± 11% at 3 years, and 77% ± 11% at 5 years in the elderly group. In the younger group, the rates were 96% ± 2% at 1 year, 88% ± 4% at 3 years, and 81% ± 7% at 5 years (p = 0.27).

Conclusions. No significant differences in the hospital mortality, actuarial survival, or event-free rates were observed between the two groups. Operation for type A acute aortic dissection in patients aged 75 years or older can be performed with acceptable risk of death, and long-term results are satisfactory.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Recent reports have demonstrated substantially improved surgical outcomes in patients with acute type A aortic dissection. Surgical mortality (or hospital mortality) rates have been estimated to range from 9% to 30%, and 5-year survival rates of 51% to 82% have been reported [1–13]. However, older age is an independent determinant of operative death, and surgical mortality and morbidity rates in the elderly are higher than those in younger patients [5, 6, 9, 13].

Life expectancy has been increasing, and this is reflected in the increasing number of elderly patients referred for aortic operations. The reported incidence of aortic dissection is 5 to 27 cases per 100,000 people [14, 15], and the number of elderly patients who undergo operation for aortic dissection has been increasing. Type A dissection creates an extremely deteriorated condition and an increased risk of death in patients who do not receive timely surgical treatment [16]. Emergency operations are necessary even in elderly patients. Thus, it is important to evaluate the early and late surgical outcomes of acute type A dissection in elderly patients.

In this study, we retrospectively reviewed the cases of patients in two age groups, patients aged 75 or older and patients younger than 75, to assess perioperative mortality rates and long-term outcomes of operation for acute type A dissection of the aorta.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
Between March 1990 and November 1999, 23 patients 75 years of age and older (elderly group; mean age, 79.1 ± 4.7 years) underwent operation for acute type A aortic dissection at Omiya Medical Center, Jichi Medical School. The outcome of these patients was compared with that of a group of 86 patients younger than 75 who underwent the same operation (younger group; mean age, 58.7 ± 10.8 years) during the same time interval. Emergency operations within 48 hours of onset were performed in all patients.

Retrosternal chest pain and back pain were the common presenting symptoms. Computed tomography (CT) scanning and echocardiography were the common modality of definitive diagnosis, and transesophageal echocardiography was used as confirmation when possible. At our hospital, angiography is not performed routinely. When the diagnosis was confirmed by CT scan and echocardiography, the patient was transferred to the operating room as soon as possible.

Surgical procedures
The surgical procedure consisted of median sternotomy with standard cardiopulmonary bypass. A femoral artery or left subclavian artery was used for cannulation, and the right atrium was cannulated with a single atriocaval cannula. Myocardial protection was obtained in all cases with antegrade or retrograde infusion of cold blood cardioplegic solution. A left ventricular drain was inserted through the right upper pulmonary vein. Beginning in 1998, 2 million units of aprotinin was administered before extracorporeal circulation.

Once cardiopulmonary bypass was established, systemic cooling was initiated immediately. After the onset of ventricular fibrillation, the aorta was clamped. Antegrade (selectively) or retrograde blood cardioplegia was carried out after the ascending aorta was opened. The proximal stump was then trimmed and reinforced with a Teflon strip during cooling. Next the arch was explored under circulatory arrest at a rectal temperature of 20°C. If an intimal tear was found in the ascending aorta, replacement of the ascending aorta was performed with the open aorta technique. The replacement technique always included the interposition of woven collagen-impregnated or albumin-sealed grafts with Teflon strip reinforcement of the aortic stumps. If an intimal tear was present or extended to the aortic arch, we partially or totally replaced the arch with a selective cerebral perfusion technique. Gelatin-resorcin-formalin (GRF) adhesive was not routinely used. When the site of the intimal tear could not be identified, we simply replaced the ascending aorta. In 3 patients with conspicuous dilatation of the aortic root, aortic root replacement with composite prosthesis and reimplantation of the coronary arteries by the Bentall or Cabrol technique was performed. From 1990 to 1993, when an intimal tear could be clearly identified in the ascending aorta, we used sutureless ringed intraluminal grafts.

Follow-up
We either examined the patients at our outpatient clinic or contacted patients by letter or telephone. No patients were untraced. Median time of follow-up for surviving patients was 34 months.

Statistical analysis
Statistical analysis was performed with StatView (SAS Institute Inc, Cary, NC). Continuous variables were compared with unpaired two-tailed t test and are expressed as the mean ± SD. Categoric variables were analyzed with an ² test and are expressed as percentages. Actual survival and event-free rates were calculated by the Kaplan–Meier method. The log-rank test (Mantel–Cox test) was used for comparison between the two groups; p values less than 0.05 were considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
Besides age, which was significantly different due to study design, the significant differences in patient characteristics and clinical profiles between our older and young groups were sex ratio (p = 0.0003), smoking (p = 0.03), hyperlipidemia (p = 0.02), and cardiac tanponade (p = 0.04) (Table 1).

View larger version (27K): [in this window] [in a new window]   Fig 1. Long-term survival of patients undergoing operation for acute type A dissection (Kaplan–Meier, confidence interval 95%).

View larger version (30K): [in this window] [in a new window]   Fig 2. Event-free of survivors undergoing operation for acute type A dissection (Kaplan–Meier, confidence interval 95%).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Early results
Overall hospital mortality rate in the present study (11.0%) tended to be lower than those in previous reports (9% to 30%) [1–13], even in the elderly group alone (13.0%). Major causes of death in the younger group were heart failure, visceral ischemia, and bleeding. Most patients in the elderly group died of rupture of the residual false lumen in the aortic arch after ascending aorta replacements (two of three early deaths were caused by rupture). Generally, the tissues of elderly patients, as well as dissected adventitia of the aortic wall, are more fragile than those of younger patients. This explanation may partially account for the high rate of rupture of the false lumen after operation in elderly patients. In both of our rupture cases, the entry was located on the ascending aorta and was resected completely. The fragility of the dissected wall or suture line may have caused the rupture. Although we did not routinely use GRF glue, GRF may be effective in dealing with such fragile adventitia [12, 17].

Some groups reported that extended aortic arch resection benefits patients with entry on the ascending aorta by preventing rupture of the residual false lumen [18–20]. However, such extended operation seems too risky for elderly patients. As we reported above and as other groups have agreed [3, 4, 21], if the intimal tear is located on the ascending aorta, this segment alone should be replaced, and the aortic valve preserved whenever possible. When the intimal tear is located in or extends to the arch, this segment should be partially or totally replaced.

Postoperative neurologic damage has been a major problem for acute type A aortic dissection [7, 8, 10]. Pansini and coworkers [8] reported that neurologic damage occurred frequently in their series. Goossens and colleagues [7] also reported neurologic deficits in 31.7% of the patients, and these problems significantly influenced hospital mortality rate. However, no patients in our study died of neurologic complications. As for brain protection during operation, we use an open aorta technique with deep hypothermic circulatory arrest at the ascending aorta replacement. When intimal tears are found on the aortic arch, we replace the aortic arch during selective cerebral perfusion. Many aortic surgeons favor hypothermic circulatory arrest during arch replacements. However, this technique gives the surgeon only a limited time to carry out the aortic repair, and neurologic complications have been correlated with the use of deep hypothermia and circulatory arrest [8]. The technique also requires that cardiopulmonary bypass be prolonged to rewarm the patient, which can cause some complications. Ueda and coworkers [22] reported the effectiveness of retrograde cerebral perfusion; this technique has gained wide acceptance rapidly and is presently used routinely in many centers. However, the physiologic advantage of retrograde cerebral perfusion has not been clarified [23, 24]. Elderly patients are a potentially high-risk group for neurologic complications because they often have episodes of cerebral infarction and other neurologic problems. For such patients, selective cerebral perfusion may bring added protection [13, 23].

Enhanced CT scan and echocardiography are the methods of choice for diagnosis of the type A aortic dissection because they are accurate, relatively noninvasive bedside examinations. After confirming diagnosis, we start operation as soon as possible. Rizzo and coworkers [6] reported that routine angiography was an independent predictor of hospital mortality and that it is an additional risk for patients already at high risk of hospital death. We agree that a rapid noninvasive diagnosis and immediate operation might improve survival rate and decrease the risk of catastrophic events before operation.

Long-term outcomes
Reports on long-term survival and complications related to type A acute dissection have included follow-up data for up to 20 years. According to these prior reports, 5-year survival rates are approximately 50% to 80% [2, 4, 5, 8, 11, 12]. Although it is difficult to compare these results with ours because the patient characteristics are not comparable, the long-term results of our elderly patients seem acceptable.

The main cause of late death in our elderly group was respiratory complications. The high prevalence of chronic obstructive pulmonary disease and the fragility of most elderly patients contribute heavily to the development of these complications; thus, careful long-term management of these patients is mandatory. Only one operation-related death occurred in our younger group, that of a patient who died of rupture of the residual false lumen after a ringed intraluminal graft insertion. (Although we recommended a reoperation for enlargement of aortic arch, the patient rejected the recommendation.) The 8 patients who underwent reoperation included 1 patient who underwent a ringed graft insertion. Two of the 18 (11%) patients who underwent intraluminal graft insertions had long-term events (1 death and 1 reoperation). One group reported the effectiveness of the intraluminal ringed graft [25]. However, another group reported that their use increases the risk of reoperation [26]. We have abandoned this method because its long-term safety has been questioned based on occasional postoperative complications.

One limitation of this study is that we did not explore the postoperative quality of life (QOL) for elderly patients after discharge. Ogino and coworkers [27] reported that postoperative QOL after major cardiac and thoracic aortic operation in patients more than 75 years old is satisfactory except for emergency cases. Kirsch and coworkers [28] reported that despite the high incidence of postoperative complications, cardiac surgical procedures can be performed in octogenarians with gratifying long-term survival results and that most long-term survivors are satisfied with their QOL. Almost two thirds of the patients in their series remained fully autonomous. Among our patients, although survivors did not always maintain full autonomy, all survivors returned to their homes.

Another limitation of this study is the significant sex ratio difference between the groups. Generally, acute type A aortic dissection occurs more frequently in men [1–13]. However, female patients were dominant in our elderly group (male:female = 6:17). According to the 1995 Japanese census of the population, the female population aged 75 and older is approximately two times larger than the male population. These sex-based differences of the total population may partially explain the different male:female ratios in this study.

In conclusion, surgical procedures can be performed in patients aged 75 and older with an acceptable hospital mortality rate and gratifying long-term survival results. We believe surgical treatment, even for elderly type A aortic dissection patients, provides both short- and long-term benefits.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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