Original Cardiovascular

113

Outcome after Surgery for Acute Aortic Dissection Type A in the Elderly: A Single-Center Experience Assad Haneya1 Jill Jussli-Melchers1 Felix Schoeneich1

1 Department of Cardiovascular Surgery, University of Schleswig-

Holstein, Campus Kiel, Germany Thorac Cardiovasc Surg 2015;63:113–119.

Abstract

Keywords

► aorta/aortic ► cardiac ► geriatric (includes elderly) ► postoperative care

Kirstin Schmidt1

Aziz Rahimi1

Address for correspondence Rouven Berndt, MD, Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105 Kiel, Germany (e-mail: [email protected]).

Objectives Despite improvements in surgical and perfusion techniques, surgery for acute aortic dissection type A (AADA) remains associated with high mortality rates. The aim of this study was to evaluate outcome after surgery for AADA in elderly in comparison with the outcome in younger patients. Methods Between January 2004 and December 2012, 204 patients underwent operation for AADA. Of these, 65 patients were aged 70 years and older (elderly group; range, 70–85 years) and 139 were younger than 70 years (younger group; range, 18–69 years). Results No significant differences were detected between the groups with regard to preoperative risk factors on admission. Significantly more number of elderly patients than younger underwent supracoronary replacement of the ascending aorta (93.8% versus 80.6%, p ¼ 0.013). In comparison to the elderly patients, younger patients more frequently received complex surgery (Bentall and David operation). The mean extracorporeal circulation time (183  62 minutes versus 158  3 minutes; p ¼ 0.003) and the mean aortic cross-clamp time (100  45 minute versus 82  30 minute; p ¼ 0.006) were significantly higher for younger patients. No significant differences in postoperative complications and major morbidity were observed. The operative mortality (elderly group 4.6% versus younger group 1.4%; p ¼ 0.33) and 30-day mortality (elderly group 18.5% versus younger group 8.6%; p ¼ 0.06) were without statistical significance between the groups. Conclusion Surgery for AADA in the elderly resulted in acceptable mortality. Satisfactory outcomes should encourage the offering of surgery in these patients.

Introduction Acute aortic dissection type A (AADA) is a life-threatening emergency, which, without surgical treatment, is associated with adverse outcomes.1 Despite relevant improvements in surgical techniques and perioperative management, surgery for AADA remains associated with high mortality rates.2,3

received August 7, 2014 accepted after revision October 2, 2014 published online January 8, 2015

Insa Tautorat1

With the general increase in human lifespan, cardiac surgeons are faced with treating an increasing number of elderly patients. According to the International Registry of Acute Aortic Dissection (IRAD) and the German Registry for Acute Aortic Dissection Type A (GERAADA), the number of elderly patients undergoing emergency surgery for AADA has been steadily increasing.2,4 Previous reports about the

© 2015 Georg Thieme Verlag KG Stuttgart · New York

DOI http://dx.doi.org/ 10.1055/s-0034-1395985. ISSN 0171-6425.

Downloaded by: National University of Singapore. Copyrighted material.

Rouven Berndt1 Jochen Cremer1

Surgery for Acute Aortic Dissection Type A

Berndt et al.

outcome following surgery of AADA in the elderly are controversial. Several studies have shown age to be an independent predictor of mortality in patients with AADA.5–7 Moreover, advanced age has been shown to be associated with neurologic complications after surgical treatment.4,6 However, recent studies have demonstrated satisfactory outcomes in elderly patients after emergency surgery for AADA.7,8 In this study, we analyzed differences in demographics, clinical characteristics, surgical approach, and outcomes of a large cohort of patients with AADA. To identify patients at risk and evaluate the influence of advanced age, we divided the cohort into elderly (70 years) and younger patients (48 h)

114 (55.9%)

75 (54.0%)

39 (60.0%)

0.45

Temporary dialysis

43 (21.1%)

32 (23.0%)

11 (16.9%)

0.36

Sternal wound infection

9 (4.4%)

8 (5.8%)

1 (1.5%)

0.28

Intensive care unit stay, d

5 [3–12]

6 [2–15]

5 [3–8]

0.18

Hospital stay, d

11 [8–12]

12 [9–22]

9 [7–12]

0.06

Operative mortality

5 (2.4%)

2 (1.4%)

3 (4.6%)

0.33

30-d mortality

24 (11.8%)

12 (8.6%)

12 (18.5%)

0.06

Cause of death Low cardiac output

3 (1.5%)

1 (0.7%)

2 (3.1%)

0.24

Hemorrhage

5 (2.4%)

2 (1.4%)

3 (4.6%)

0.33

Severe neurologic damage

7 (3.4%)

2 (1.4%)

5 (7.7%)

0.035

Multiple organ failure

8 (3.9%)

6 (4.3%)

2 (3.1%)

0.99

Sepsis

1 (0.5%)

1 (0.7%)

0 (0%)

0.99

ischemia or acute renal failure compared with 17% in stable patients.15 Stamou et al demonstrated a higher mortality in patients with hemodynamic instability and evidence of myocardial infarction or ischemia.16 Moreover, Matsushita et al had shown that preoperative CPR was a significant predictor of neurological complications in elderly surgical patients with AADA.13 Hence, quick diagnosis is necessary to minimize a chance of preoperative hemodynamic compromise. However, it is often difficult to make a diagnosis of AADA in elderly patients because characteristic symptoms and signs are less common compared with younger patients.1 Furthermore,

elderly patients seem to suffer more preoperative complications,4,17 thus significantly increasing mortality among them. In our study, only limb ischemia occurred more frequently in the younger group. As previously reported, the etiology of AADA varied between the two age groups. Connective-tissue disorders such as Marfan or Ehlers-Danlos syndrome were presented exclusively in the younger group, whereas the incidence of hypertension, atherosclerosis, and prior aortic aneurysm was similar in the groups. Owing to the different etiology, the surgical operative data varied between the elderly and younger cohorts,

Table 4 Comparisons between survivors and nonsurvivors All patients (n ¼ 204)

Survival (n ¼ 180)

Nonsurvival (n ¼ 24)

p Value

Age, y (range)

64 (18–85)

62 (18–85)

70 (47–84)

0.15

Age > 80 y

12 (5.9%)

10 (5.6%)

2 (8.3%)

0.64

Sex male

135 (66.2%)

119 (66.1%)

16 (66.7%)

1.0

Intubated

29 (14.2%)

20 (11.1%)

9 (37.5%)

0.002

98 (48.0%)

86 (47.8%)

12 (50.0%)

0.99

Clinical presentation Cardiac tamponade Cardiopulmonary resuscitation

13 (6.4%)

8 (4.4%)

5 (20.8%)

0.01

Free rupture

5 (2.4%)

0 (0%)

5 (20.8%)

Outcome after surgery for acute aortic dissection type A in the elderly: a single-center experience.

Despite improvements in surgical and perfusion techniques, surgery for acute aortic dissection type A (AADA) remains associated with high mortality ra...
114KB Sizes 3 Downloads 10 Views