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Eur J Cardiothorac Surg 2002;22:211-217
© 2002 Elsevier Science NL

Clinical outcome after repair of acute type A dissection in patients over 70 years-old

^a Cardiac Surgery Department, Timone University hospital, Bd Jean Moulin, 13385 Marseilles, France
^b Cardiac Surgery Department, University Hospital Arnaud de Villeneuve, 34000 Montpellier, France
^c Teaching and Research Laboratory of Medical Information (LERTIM), Faculty of Medicine, Bd Jean Moulin, 13385 Marseille, France

Received 15 September 2001; received in revised form 24 April 2002; accepted 29 April 2002.

* Corresponding author. Tel.: +33-4-9138-5717; fax: +33-4-9185-4140
e-mail: tcaus{at}ap-hm.fr

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
Background: Despite current aging of patients proposed for cardiac surgery, published results of type A dissection repair in the elderly are sparse and controversial though an increased operative risk when compared to younger patients is well-documented. Whether any patient of an advanced aged suffering from acute dissection of the proximal aorta should be referred for surgery deserves specific clinical studies. Objective: To define factors of poor outcome after repair of type A dissection in the elderly by focusing on both early and late results. Method: A retrospective study including a consecutive series of 83 patients operated on in two neighboring French university centers between 1988 and 1999 with similar outstanding methods. Complete follow-up was achieved in March 2000. Results were compared according to: (i) the presence or the absence of complications at admission; and (ii) the use of hypothermic circulatory arrest (HCA) for completion of the distal suture. Results: Mean age was 75.2±3.6 years (70–85). Overall operative mortality (OM) was 37.3%. OM was significantly higher (51.2 versus 23.8%, P=0.01) for patients who presented at admission any one of the following complications: tamponade, shock, endotracheal intubation upon arrival or evidence of brain, myocardial, mesenteric, renal or limb malperfusion. OM was not significantly affected by age or by the use of HCA during repair. Overall Kaplan–Meier survival was 50% at 1 year, 30% at 5 years and 13% at 10 years and was significantly lower (P=0.004) for patients who presented at least one complication at admission. Kaplan–Meier survival (excluding OM) was respectively 81, 48 and 21% and was significantly lower in case of prolonged stay in ICU (P=0.014) and for patients operated on without HCA (P=0.02). Conclusions: Results of repair of acute type A dissections in the elderly are acceptable for uncomplicated cases at admission. Using HCA in elderly patients whenever required for appropriate repair does not worsen early or late survival.

Key Words: Aortic dissection • Elderly • Prognosis

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
Indication of emergency surgery for acute type A dissections in the elderly is increasing due to the general aging of the population and to noteworthy improvements in perioperative management, which allow considering complex aortic repair even in patients of an advanced aged. Advanced age is generally recognized as a significant determinant of operative mortality and late survival after surgery for aortic dissections [1–5]. Therefore, whether operations for acute type A dissection repair in elderly patients can be performed with acceptable early risk of death and satisfactory long-term results remains a controversy [6,7]. Generally, the decision to contra-indicate a candidate for this surgery on the sole basis of advanced age would be judged as unethical and purely segregationist if not based on a well-documented clinical experience [8]. Assuming that a large number of patients were necessary to clarify the prognosis of this procedure, we aimed to promote a multicentric evaluation of early and late results after type A dissection emergency repair in the elderly. We therefore conducted a retrospective study including all 83 patients over 70 years-old operated on for acute type A dissection repair in two neighboring French university hospital centers between 1988 and 1999.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
2.1. Patients
From January 1988 to December 1999, 296 consecutive patients suffering from acute type A dissection were operated on at the hospital centers ‘La Timone’, University of Marseilles and ‘Arnaud de Villeneuve’, University of Montpellier by ten different surgeons (see Appendix A). Aiming to study specifically the results of surgery for acute type A dissection in elderly, we limited this study to all patients over 70 years old (n=83). Demographic and medical data were analyzed retrospectively from similar computerized databases filled up prospectively and including summaries of clinical observation at admission, reports of operation and postoperative evolution.

For all patients, surgery was undertaken within hours following admission with the diagnosis of dissection involving the ascending aorta as assessed by aortography, tomodensitometry or transoesophageal echocardiography. On discharge, patients were prescribed a lifelong computerized tomography (CT) or magnetic resonance imaging (MRI) surveillance with medical follow-up and blood pressure control [9]. To achieve follow-up, survivors, relatives or medical referents were contacted by telephone during a 3-month closing interval ending on June 2000.

2.2. Operative technique
In both teams, the anesthesia was balanced with fentanyl citrate, flunitrazepam and pancuronium bromide during the first time frame (1988–1997), and sufentanyl, midazolam and pancuronium bromide during the second time frame (1998–1999). In both periods, sodium thiopenthal (10 mg/kg) was added just before the circulatory arrest.

The technique of repair of type A acute aortic dissection for elderly patients did not basically differ from the rules currently valid for younger patients. Surgery was comparable in both centers and evolved concurrently according to technical advances observed during the last decade. Briefly, cardiopulmonary bypass (CPB) with deep (bladder temperature 18°C) or moderate (bladder temperature 24–28°C) hypothermia was induced by peripheral canulation. Myocardial protection was assured with antegrade and retrograde blood cardioplegia. In case of hypothermic circulatory arrest (HCA), selective antegrade or retrograde brain perfusion with cooled blood completed the cerebral protection, according to the surgeon's preference.

The aims of the surgery were also similar to those addressed to younger patients: (i) restore the functional anatomy of the aortic root and replace the aortic valve only in case of organic lesions; and (ii) resect or repair any intimal tear situated in the proximal aorta with systematic replacement of the dissected ascending aorta with a precoated Dacron^®-type graft. Generally, in this aged population, the usual inspection of the aortic arch in search for secondary reentry was not performed in case an evident dissecting entry had been found proximally to the aortic clamp. Therefore HCA was not systematically used in the elderly for completion of the distal anastomosis in an attempt to propose a less-invasive surgery. In most cases, Teflon^®-felt strips and biological glue were liberally used for a sandwich-type reinforcement of proximal and distal sutures [10].

2.3. Statistical analysis
As in previously published series [11], we divided the population into two groups according to the presence of complications at admission to analyze the impact of the initial clinical status on early and late operative outcome. Those complications included shock (systolic blood pressure 80 mmHg or need for inotropic support), tamponade, cardiac arrest resuscitated, endotracheal intubation upon arrival and any clinical evidence of brain, myocardial, mesenteric, renal or limb ischemia. Any one of those complications defined a group C (complicated), and none, a group S (simple) of patients (see Table 1).

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
3.1. Patients
Mean age of the study population was 75.2±3.6 years (range 70–85 years). The distribution of age was as follows: 70–75 years old (y-o), 37 patients; 75–80 y-o, 35 patients and 80–85 y-o, 11 patients. Thirty-four patients (41%) were women and 49 (59%) were men. The preoperative clinical status according to the presence of complications at admission and subsequent repartition within group C and S is reported in Table 1. Forty-one patients (49%) presented at least one complication defined above and constituted group C. Group S was made up of the remaining 42 patients (51%) who were not suffering from complication at admission. The clinical presentation of patients from both groups is completed in Table 2. The two groups only differed by a significantly higher proportion of octogenarians in group C (P=0.03).

All patients operated on with the cross-clamp technique benefited from an aortic graft replacement necessarily limited to the ascending aorta. Among patients operated on with HCA, four had a total and 22 a partial replacement of the aortic arch, five had a direct repair of intimal tear located inside the arch with no prosthetic replacement and 16 simply benefited from the so-called ‘open-distal suture’ technique. After completion of the distal anastomosis under HCA, the CPB was restarted in a retrograde fashion through the femoral artery in 19 patients. Since 1994, in 28 patients, restoration of blood flow was switched to antegrade perfusion through the prosthesis or the axillary canula to potentially minimize ischemic complications due to visceral malperfusion during rewarming.

Eight (9.6%) proximal extensions of the aortic repair were realized with simple prosthetic aortic valve replacement or Bentall procedure in four (4.8%) patients each. Concomitant coronary artery bypass grafting (CABG) was performed in nine (11%) patients. Limb vascular surgery was performed in four (4.8%) patients. Mean bypass time was 172±58 min (range 72–388 min). Mean aortic cross clamp time was 88±28 min (range 35–160 min). For patients operated on with HCA, mean circulatory arrest time was 33±14 min (range 10–86 min). The comparison of operative data in groups C and S and the procedures concomitant to the replacement of the ascending aorta are reported in Table 3.

The cause of the 21 postoperative deaths was multisystem organ failure (seven), heart failure (five), postoperative bleeding (two), cerebrovascular insult (three), mesenteric infarct (one), and infection (three). The operative mortality rate increased significantly in the case of complications at admission and was 51.2% (21 out of 41 patients) versus 23.8% (ten out of 42 patients) in group C versus S, respectively (P=0.01). The operative mortality rate did not differ significantly according to the surgical technique used. It was 42.6% (20 out of 47 patients) for patients operated on with HCA versus 30.6% (11 out of 36 patients) for patients operated on with the cross-clamp technique (P=0.36). An analysis of risk factors for operative mortality is reported in Table 4. Age was not a significant risk factor for operative mortality in this elderly population, though mortality tended to increase in octogenarians (45 versus 40% for patients between 75 and 80 y-o and 32.4% for patients between 70 and 75 y-o).

Mean length of stay in ICU for early survivors was 20.5±29.7 days (min-max, median: 2–164, 7), and was 19.2±23 versus 21.3±33 days in groups C versus S, respectively (P=0.8). Mean length of stay in ICU for patients who did not survive the operation was 7.9±6 days (min-max, median: 0–26, 1), and was 6.6±8 versus 6.9±7 days in group C versus S, respectively (P=1).

3.5. Late mortality
Of the 52 early survivors, there were 20 late deaths and one patient was lost during follow-up at 64 months after operation. Mean follow-up was 36±24 months, (min-max, median: 1–120, 35) with two patients alive 10 years after surgery. Kaplan–Meier survival rates (including operative mortality) for all patients were 50% at 1 year, 30% at 5 years and 13% at 10 years. Kaplan–Meier survival rates were significantly lower in case of complication at admission (P=0.004) (Fig. 1) but did not differ significantly according to age analyzed as a semi-quantitative variable at the time of surgery (70<age<75 y-o, 75<age<80 y-o and age=80 y-o; P=0.33).

View larger version (14K): [in this window] [in a new window]   Fig. 1. Actuarial survival following repair of type A dissection in elderly patients (including operative mortality) according to the presence (group C, 41 patients) or the absence (group S, 42 patients) of complications at admission. Short lines indicates the follow-up time for censored patients (i.e. follow-up time for patients still alive at the end of the study or at the last news). The numbers of patients at risk are indicated for each group.

View larger version (14K): [in this window] [in a new window]   Fig. 2. Actuarial survival following repair of type A dissection in elderly patients (excluding operative mortality) according to the operative technique used for distal suture: hypothermic circulatory arrest (HCA: 27 patients) or cross-clamp (25 patients). Short lines indicates the follow-up time for censored patients (i.e. follow-up time for patients still alive at the end of the study or at the last news). The numbers of patients at risk are indicated for each group.

View larger version (14K): [in this window] [in a new window]   Fig. 3. Actuarial survival following repair of type A dissection in elderly patients (excluding operative mortality) according to the postoperative length of stay in ICU 8 days (32 patients), and >8 days (20 patients). Short lines indicates the follow-up time for censored patients (i.e. follow-up time for patients still alive at the end of the study or at the last news). The numbers of patients at risk are indicated for each group.

Two patients only (3.8%) were reoperated on during follow-up at 1 and 49 months after the initial operation, due to, respectively, a progressive aneurysm of the descending aorta and a false aneurysm on the proximal suture line after Bentall procedure. The two other patients who declared a false aneurysm during follow-up, and who had been denied redo surgery, presented sudden death. Those two patients had been initially operated on with the cross-clamp technique and the secondary false aneurysms appeared to be located on the distal anastomoses.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
4.1. Can every elderly patient benefit from repair of acute type A aortic dissection?
Due to age-related alteration of physiological reserves, any complication during early outcome after cardiac surgery may compromise survival in the elderly. As a result, though early survival can sometimes be preserved due to effective postoperative management, need for prolonged ventilation after surgery has been shown to affect long-term survival [12]. On the basis of this knowledge, the results of challenging procedures in the elderly, especially when proposed on an emergency basis like a type A acute dissection repair, require attentive evaluation in order to achieve an appropriate use of care resources. However, the results and conclusions of the two series that have already been published on this topic are diametrically opposed because of the reported operative mortality rate ranging from 13 to 83% [6,7].

Our results clearly show that acceptable results can be obtained after emergency repair of acute type A aortic dissection in an elderly population provided that complications are absent at admission. As one would expect, early mortality was related in this series to the preoperative conditions of patients and increased more than twofold to reach 51% in the case of severe hemodynamic compromise, resuscitation maneuvers or malperfusion syndrome before surgery (P=0.008). This relationship confirms, for an elderly population, the results described in numerous published papers [1–3,5,11,13–15]. Late outcome was also influenced in this series by the preoperative patient's status and by the length of stay in ICU postoperatively. Those two predictors, which both significantly impaired late survival, appear however independent, since length of stay in ICU did not significantly differed between groups C and S.

The fact that advanced age was not, per se, a sufficient contraindication for surgery of acute type A dissection supported our common regional policy, which allowed us to present a large series of non-selected cases in the elderly. As a consequence, nearly half of our patients, though presenting complications at admission, were not denied surgery since, had they had been younger, they would have been operated on with no hesitation. A switch from the current attitude to a ‘do not resuscitate’ attitude towards complicated cases on the basis of the results presented here would, however, be excessive. Rather, operating on nearly all the cases to give a chance and increased hope of survival but not resuscitating hopeless cases after surgery seems an attitude in line with our results since prolonged stay in ICU clearly affects late outcome in our elderly population. This attitude is more likely to be in keeping with a rational use of the health care resources and with the wishes of families who generally agree to surgery but are frequently opposed to a prolonged use of intensive medication for their elderly relatives.

4.2. Is limited aortic resection more justified in the elderly?
The controversy that still exists regarding the extent of proximal or distal aortic resection for repair for acute type A dissection in the general population [16] is even more pertinent in elderly patients. Besides, reserving extended resection for younger patients is still advocated by highly experienced centers [14]. On the one hand, it remains to be proven that early survival in the elderly would not be influenced by the extent of the aortic resection. On the other hand, the potential benefit of an extended resection on late survival [17] has to be related to the limited life expectancy of patients at an advanced age. The cross-clamp technique avoids HCA and therefore reduces by-pass time, which correlates with early mortality in this series, a result in line with some previously published studies [5]. Therefore, in this study, the cross-clamp technique was often considered, at the time of surgery, to be a ‘less-invasive’ alternative to HCA for repair of acute type A dissection in the elderly. However, the realization of the distal suture may become hazardous with the cross-clamp technique when the aortic arch is calcified, as frequently observed in the elderly, or in case associated intimal tears are present beyond the aortic clamp (Table 5). Though the use of HCA tended to increase early mortality as well as respiratory, digestive and infectious complications, the difference was not clearly significant when compared to results obtained with the cross-clamp technique. It is interesting to note that the rate of postoperative stroke was similar with both techniques, probably due to a short mean time of circulatory arrest and to the cerebral protection techniques used in addition to HCA [18,19].

4.3. Limitations of the study
We are aware that this study is retrospective and is subjected to potential bias due to the fact that ten different surgeons from two different institutions using necessarily different, though not fundamentally so, surgical, anesthetic and intensive care techniques operated on the population of patients. However, a large majority of patients were operated on by a minority of surgeons (*) with extensive training in emergency procedures. We therefore could not find any risk factor of operative mortality related to the surgeon or the institution in charge for the patient (data not shown). We believe that this emphasizes the weight of the patient's preoperative status in the outcome after surgery, early (not surprisingly) but also late survival being worse for complicated cases at admission. Concerning late outcome, the relatively low long-term survival rates which remain sobering and may induce statistical bias, together with the absence of systematic necropsies to verify the exact cause of late deaths, preclude any definitive conclusion about the apparent influence of HCA on occurrence of complications or death during follow-up.

	5. Conclusions

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
Surgical repair for acute type A dissection should not be denied on the sole consideration of advanced age. Early and late results are acceptable for uncomplicated cases at admission. Complicated cases present the highest mortality and, once having been operated on, and complete information having been given to the family, they should be resuscitated according to the objective hope for survival based on the center's experience. Whenever surgery is addressed to an elderly patient, using HCA when required by operative findings does not seem to affect early survival, and may even have a beneficial impact on late results in this series. However, due to the limitations of this study, definitive conclusions should not be drawn on this last factor before further studies have been completed.

	Footnotes

 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.

¹ Present address: Ottawa Heart Institute, Ottawa, Ont., Canada.

	Appendix A. Operative surgeons

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
Bernard Albat*, Dominique Blin, Thierry Caus*, Paul-André Chaptal, Frédéric Collart, Jean-Marc Frapier*, Alain Goudard, Alberto Riberi, Thierry Mesana*, Jean-Raoul Montiès.

	Appendix B. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 
Dr J. Bachet (Paris, France): I am surprised that the only option that you consider for brain protection in those patients is deep hypothermic circulatory arrest. We know that deep hypothermic circulatory arrest is dangerous in all patients, and is very dangerous in elderly patients. Why don't you switch to antegrade cerebral protection? You will get much better results, especially in this setting of patients.

Dr Frapier: Well, 65% of the patients were operated by deep hypothermic circulatory arrest but only one had simple circulatory arrest. The other have had antegrade cerebral protection and retrograde cerebral protection. But I think you mean to perform the procedure with antegrade at 25 degrees, that's correct?

Dr Bachet: I mean to perfuse the brain antegradely with no deep hypothermia. If you perfuse the brain antegradely, deep hypothermia is absolutely unnecessary, and hypothermia is a very dangerous situation in any patient.

Dr Frapier: We turned more recently to this technique, but those patients were not included. Now we systematically perform subclavian cannulation and cannulation of the aortic arch by retrograde cannulation in the arch and try to make temperature at 23–24°C. But this is too recent. And recently we tried also to treat those malperfusion syndromes by beginning to implant stents in the renal arteries and in the celiac arteries before the procedure.

Dr A. Haverich (Hannover, Germany): As a take-home message for us from what you experience in the elderly population, do you consider any upper age limit at this point an absolute age where you say I do not operate on for age reasons only?

Dr Frapier: I think that now we won't operate on patients aged 82 or 83 if they have any of those complications.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Operative surgeons Appendix B. Conference... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Thierry Caus Alberto Riberi Bernard Albat Thierry Mesana Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Caus, T. Articles by Mesana, T. Search for Related Content PubMed PubMed Citation Articles by Caus, T. Articles by Mesana, T. Related Collections Great vessels