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Ann Thorac Surg 2005;80:384-385
© 2005 The Society of Thoracic Surgeons

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Correspondence

Acute Type A Dissection and Advanced Age

Department of Surgery, Siena University Hospital, Viale M. Bracci, Siena, 53100 Italy

(Email: nerie{at}unisi.it).

To the Editor:

We read with interest the article by Chiappini and coworkers [1] on acute type A aortic dissection in the elderly, which also interested us in the recent past [2]. The St. Antonius group should be complimented for their brilliant series and outstanding results.

The two studies reached opposite conclusions on two issues: (1) does advanced age negatively affect early and late outcomes after operations for acute type A dissection? and (2) is age a rational criterion for selecting patients for surgical treatment?

In our study we demonstrated that treatment of type A acute dissection in elderly patients does not reverse unfavorable outcomes, despite considerable experience with critical patients and advanced surgical techniques, materials, and management. This introduces the question: what is advanced age?

The series published by Chiappini and coworkers [1] includes a large group of 70 patients, aged 70 years or older. They defined advanced age as 70 years or older. Although the age distribution is not described in detail, we assume that the majority of subjects are clustered between ages 70 and 75 years (mean, 73.8; standard deviation, 3.3 years) and only 21 patients (30% of 70) are between 75 and 82 years. These numbers define a totally different population from the one we described. Therefore, we do not share Chiappini and coworkers’ [1] conclusion that mortality is "still not as prohibitive as suggested by Neri and associates" [2]. Unfortunately the distribution of deaths with respect to patients’ age is not detailed; this makes interpretation of the data difficult. The very small number of octogenarians and the absence of nonagenarians in Chiappini and coworkers [1] series suggests that selection (not necessarily by surgeons) of patients occurred during evaluation and older subjects were not offered operation. Although we do not know the exact referral protocols used in Chiappini and coworkers [1] series, we infer that age was actually used as selection criterion. It is well known that one way to "neutralize" a risk factor is by selection [3]; therefore comparison between the two studies is not useful.

Our analysis of Chiappini and coworkers [1] experience regarding the question "is age a rational criterion to select patients for surgery?" reaches the opposite of his conclusion. In our opinion, his article clearly illustrates how excellent results can be achieved by an access control policy by avoiding inappropriate treatments and reducing treatment failures.

We affirm our conclusion that advanced age in this disease is a risk factor for hospital death. Contrary statements are not supported by data and deceptively encourage favorable expectations of patients and their families.

	References

Top References

 

1. Chiappini B, Tan ME, Morshuis W, Kelder H, Dossche K, Schepens M. Surgery for acute type A aortic dissectionis advanced age a contraindication?. Ann Thorac Surg 2004;78:585-590.[Abstract/Free Full Text]
2. Neri E, Toscano T, Massetti M, et al. Operation for acute type A aortic dissection in octogenariansis it justified?. J Thorac Cardiovasc Surg 2001;121:259-267.[Medline]
3. Kirklin J, Barratt-Boyes B. The generation of knowledge from information, data and analysesIn: Kirklin J, Barratt-Boyes B, editors. Cardiac surgery. 2nd ed. New York: Churchill Livingstone; 1993. pp. 249-282.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eugenio Neri Massimo Massetti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Neri, E. Articles by Massetti, M. Search for Related Content PubMed PubMed Citation Articles by Neri, E. Articles by Massetti, M. Related Collections Great vessels Related Article