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Ann Thorac Surg 2004;78:585-590
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Surgery for acute type a aortic dissection: is advanced age a contraindication?

^a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
^b Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands

Accepted for publication January 22, 2004.

^* Address reprint requests to Dr Chiappini, Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
e-mail: bruno_chiappini{at}hotmail.com

	Abstract

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

 
BACKGROUND: With the general increase in human lifespan, cardiac surgeons are faced with treating an increasing number of elderly patients. The purpose of this study was to demonstrate early and late results of surgery for aortic dissection in patients older than 70 years of age compared with those younger than 70 years and to clarify the clinical problems related to this subset of patients.

METHODS: Between 1976 and 2001, 315 patients underwent emergency operation for acute type A dissection: 245 were younger than 70 years (group 1) and 70 patients were 70 years of age and older (group 2). Early and late outcomes of both groups were compared.

RESULTS: The hospital mortality rates were 20.5% in group 1 and 17.6% in group 2 (p = 0.751). The mean extracorporeal circulation time was 192.6 ± 65.2 minutes and 185.7 ± 58.4 minutes in groups 1 and 2, respectively (p = 0.42). The mean cross-clamp time was 116.3 ± 45.8 minutes and 100 ± 36.7 minutes in groups 1 and 2, respectively (p = 0.009). Actuarial survival rates were 77.1% after a mean follow-up time of 259 ± 9 months for patients of group 1 and 80% after 77 ± 5 months for patients of group 2, without any statistically significant difference (p = 0.619).

CONCLUSIONS: No significant differences were observed in the 30-day mortality and actuarial survival between the two groups. Therefore we believe that surgery for type A acute aortic dissection in patients 70 years of age or older can be performed with acceptable risk of death and satisfactory results.

	Introduction

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

 
With the progressive aging of Western populations, cardiac surgeons are faced with the challenge of the increasing number of elderly patients. Published results about the outcome of the surgery of acute type A dissection in the elderly are controversial, although an increased operative risk is well documented when compared with younger patients. Type A dissection determines an extremely poor condition and increases the risk of death in patients who do not receive an early surgical treatment. Therefore, the decision to contraindicate a candidate for this surgery on the sole basis of advanced age would be judged unethical if it is not based on a well-documented clinical experience. In this study, we retrospectively reviewed the cases of patients in two age groups, patients 70 years of age or older and patients younger than 70 years of age, to evaluate the differences in the clinical presentation, management, and hospital outcomes among patients with acute type A aortic dissection.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

 
We analyzed all patients with acute type A aortic dissection who were admitted for emergency surgery to the St. Antonius Hospital (Nieuwegein, the Netherlands) between November 1976 and March 2002. Patients were identified prospectively at presentation or retrospectively by searching hospital discharge diagnosis records and surgical and echocardiographic databases. Diagnosis was made on the basis of history, imaging study, and visualization at surgery. Acute type A dissection was defined as any dissection that involved the ascending aorta with presentation within 24 hours of symptoms onset [1]. Patients were stratified by less than 70 years of age (group 1) and 70 years of age or more (group 2). A total of 315 consecutive patients form the basis of this study. Patients younger than 70 years of age made up 77.7% (245 of 315) of all acute type A aortic dissections whereas patients 70 years of age and older (70 of 315) made up 22.3% (30% were older than 75 years of age). Table 1 summarizes the demographic and clinical characteristics of the patients. All the patients had anterior chest, back, or abdominal pain at the onset of aortic dissection. Preoperative dissection-related complications, which included cardiac tamponade, hypotension, aortic regurgitations, oliguria, myocardial ischemia, cerebral ischemia, and mesenteric ischemia are summarized in Table 1. Aortography or digital subtraction angiography was performed to confirm the diagnosis of aortic dissection in the early period; later, however the diagnosis was made mainly by transesophageal echocardiography (64.5%, group 1 and 75.7%, group 2), which is our current diagnostic method of choice, and computed tomography (36.3%, group 1 and 42.9%, group 2) or magnetic resonance imaging (1.2%, group 1 and 2.9%, group 2). By preoperative diagnostic measures together with observation during operation, primary intimal tear was detected at the ascending aorta in 188 patients (76.7%) of group 1 and 50 (71.4%) of group 2, between the ascending aorta and the aortic arch in 17 patients (6.9%) of group 1 and 10 (14.3%) of group 2, at the aortic arch in 36 patients (14.7%) of group 1 and 6 (8.6%) of group 2, and at the proximal descending aorta in 4 patients (1.7%) of group 1 and 4 patients (5.7%) of group 2, without any statistically significant difference (p = 0.06; Table 2). Fourteen patients (5.7%) of group 1 and 2 patients (2.9%) of group 2 had an iatrogenic dissection after cardiac surgery with a median interval of 2 days before the onset of the diagnosis of dissection. Preoperative hemodynamic conditions were defined as unstable in 45 patients (9.2%) of group 1 and 22 (32.9%) of group 2 (p = 0.017). Operative mortality was defined as death occurring in the operating theater, during surgery. In-hospital mortality was defined as death occurring within 30 days after the operation or during initial hospitalization. Follow-up was 100% complete: no patients were lost to follow-up during this period. All patient data were obtained by review of hospital records and follow-up by means of written or telephone contact or both.

Late survival was established with the Kaplan-Meier method, and comparison between groups was made using the log-rank test. A p value of less than 0.05 was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

 
Besides age, which was significantly different as a result of the study aim, the most significant differences in patient characteristics between the two groups were the presence of Marfan syndrome (p = 0.014), preoperative aortic valve regurgitation (p = 0.014), preoperative cardiac tamponade (p = 0.008), preoperative unstable hemodynamic conditions (p = 0.017), and rupture of the ascending aorta (p = 0.011). There were also statistically significant differences in the cross-clamp time (p = 0.009). There were no significant differences in operative mortality (2.4%, group 1 and 2.8%, group 2; p = 0.848) and hospital mortality (20.5%, group 1 and 17.6%, group 2; p = 0.751). Using multivariate analysis, preoperative chronic cardiac disease (p = 0.03; odds ratio [OR], 1.1), cardiopulmonary resuscitation (p = 0.01; OR, 2.6), and new neurologic deficits (p < 0.01; OR, 9.1) were indicated as independent determinants for hospital mortality (Table 4). By univariate analysis, age older than 70 is not a risk factor for in-hospital mortality (OR, 0.943; 95% confidence interval, 0.495 to 1.798; p = 0.8595). Adding the propensity score did not change this (OR, 1.035; 95% confidence interval, 0.512 to 2.093; p = 0.9244); the propensity score also was not a risk factor. Adding the three most significant predictors also did not change the older than 70 years of age risk factor (OR, 1.080; 95% confidence interval, 0.513 to 2.270; p = 0.8398). The three statistically most powerful predictors were year of operation, with early years as risk; central nervous system involvement before surgery; and the need for changing venous cannulation during surgery because of malperfusion. Fourteen patients (5.8%) of group 1 and 7 patients (10.3%) of group 2 had renal failure in the early postoperative period (p = 0.208), and the multivariate analysis showed that the predictors were age older than 70 years of age (0.03) and preoperative renal failure (p = 0.01); 18 patients (7.5%) of group 1 and 11 (16.1%) of group 2 underwent tracheostomy postoperatively as a result of a severe prolonged respiratory failure (p = 0.033). There were no significant differences in reoperation for bleeding (p = 0.09) and neurologic complications rates: the incidence of new neurologic events was 28.5% and 34.1% (p = 0.910) in group 1 and group 2, respectively. Left ventricle (p = 0.02) and extracorporeal circulation (p = 0.02) were identified as the predictors for new neurologic deficits. Two patients (0.8%) in group 1 and 3 patients (4.4%) in group 2 underwent reoperation for mediastinitis (p = 0.04), and female sex was identified as a predictor for it (p = 0.03). Mean length of stay in intensive care unit was 9.1 days for patients of group 1 and 12.1 days for those of group 2 (p = 0.06). At follow-up late events included stroke in 11 patients (5.8%) of group 1 and 1 patient (1.8%) of group 2 (p = 0.222), transient ischemic attack in 6 patients (3.1%) of group 1 and 1 patient (1.8%) of group 2 (p = 0.599), and myocardial infarction in 2 patients (1.1%) of group 1 and 1 patient (1.8%) of group 2 (p = 0.649). At the multivariate analysis the predictors for late postoperative morbidities were not identified. Kaplan-Meier survival rates (including 30-day mortality) were 77.1% after a mean follow-up time of 259 ± 9 months (95% confidence interval, 241 to 277) for patients of group 1 and 80% after 77 ± 5 months (95% confidence interval, 67 to 86) for patients of group 2, without any statistically significant difference (p = 0.619; Fig 1). There was no difference in cardiac reoperation rate between the two groups (26.3% and 16.1% in groups 1 and 2, respectively; p = 0.11) during follow-up.

View larger version (19K): [in this window] [in a new window]   Fig 1. Kaplan-Meier survival curves for groups 1 and 2.

	Comment

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

We reviewed the early and late outcome for 70 elderly and 245 younger patients in this study. Our results indicate no significant differences in the hospital and follow-up mortality rates between the two groups. The critical influence of older age on the postoperative outcome was analyzed in our study. In this era of diminishing economic resources for health care, the question of whether such expensive surgical therapy should be offered to these patients is very relevant. Without the aid of specific studies to address this point in the context of acute type A aortic dissection, using age as a factor to limit the access of patients to resources remains an unsubstantiated concept, rather than a scientifically proven cost-saving measure. In our study the frequency of postoperative complications was similar in the two groups; in addition the mortality in patients 70 years of age or older was not higher than that in younger patients, and it was still not as prohibitive as suggested by Neri and associates [5]. In our experience we reported an exceptional achievement in terms of operative mortality and hospital mortality; these results are outstanding, especially over so long a time period. The operative mortality rates were 2.4% in group 1 and 2.8% in group 2 (p = 0.848); the hospital mortality rates were 20.5% in group 1 and 17.6% in group 2 (p = 0.751). We believe that the key factors of our results are the prompt preoperative management and surgery, the postoperative intensive care unit approach of our anesthesiologists, and the selection criteria of the patients. Thus, our study supports the findings of others [6, 7] that indicated an aggressive surgical approach is not unreasonable in selected elderly patients with acute type A aortic dissection for improving survival.

Postoperative neurologic damage has been a challenging problem for acute type A aortic dissection [8–10]. Pansini and colleagues [9] reported that neurologic damage occurred frequently in their series. Goossens and coworkers [8] also reported neurologic deficits in 31.7% of their patients, and these problems influenced hospital mortality rate. However, we did not find any significant difference in the neurologic complications rate between the two groups. As for brain protection during surgery, we use the open aorta technique with deep hypothermic circulatory arrest at the descending aorta replacement. When intimal tears were found in the arch, we replaced the aortic arch during antegrade selective cerebral perfusion. Many surgeons use hypothermic circulatory arrest during arch replacement; we believe that this technique gives the surgeon only a limited time to perform the aortic repair, and neurologic complications have been correlated with the use of deep hypothermia and circulatory arrest. The technique also requires that cardiopulmonary bypass be prolonged to rewarm the patient, which can cause some complications. Elderly patients are a 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.

In our hospital echocardiography became the method of choice for diagnosis of type A aortic dissection because it is accurate, fast, and a relatively noninvasive bedside examination; in effect, we believe that a rapid noninvasive diagnosis and immediate operation might improve survival rate and decrease the risk of adverse events before surgery. Reports on long-term survival and complications have included follow-up data for up to 20 years. According to these reports, 5-year survival rates are between 50% and 80% [11–15].

Although it is difficult to compare these previous reports with ours, the long-term outcome of our elderly patients seems to be quite good. The study gives remarkable results in that it is one of the very few, if not the first, to indicate that older patients can well be operated on with an acceptable risk. This has important implications on risk-benefit considerations, particularly in an upcoming era of "militant" health-care restrictions. In conclusion, surgical repair for acute type A dissection should not be denied on the sole consideration of advanced age: in our experience, surgery can be performed in elderly patients with an acceptable hospital mortality rate and gratifying long-term survival results, providing both early and late benefits.

	Appendix. Preoperative and perioperative patient related data considered in the univariate and multivariate analysis of hospital mortality

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

 
Age

Sex

Previous cardiac catheterization

Preoperative chronic cardiac disease

Iatrogenic dissection

Neurologic dysfunction

Diabetes

Marfan syndrome

Oliguria or anuria

Cardiac tamponade

Cardiogenic shock

Cardiopulmonary resuscitation

Left ventricular function

Ruptured ascending aorta

Dissection left coronary artery

Dissection right coronary artery

Deep hypothermic circulatory arrest

Antegrade selective cerebral perfusion

Additional surgical procedure

Surgical technique

	References

Top Abstract Introduction Material and methods Results Comment Appendix. Preoperative and... References

 

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