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J Thorac Cardiovasc Surg 2001;122:1050
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Operation for acute type A aortic dissection in octogenarians

Assistant Professor of Cardiothoracic Surgery
Medical University of South Carolina
Charleston, SC 29425

To the Editor:

I read with interest the article by Neri and associates ¹ and its associated editorial ² detailing a retrospective review of 197 operations for acute type A aortic dissection between 1985 and 1999. Of these, 12% were older than 80 years, and the authors found that in this subset of patients, intraoperative mortality was 33% and hospital (30-day) mortality was 83%. These figures compared with a hospital mortality of 16% for those patients aged less than 80 years. In addition, 100% of those patients aged greater than 80 had one or more complications in comparison with 32% in the group younger than 80 years. Results of univariate analysis showed that age treated as a categorical variable was strongly predictive for operative mortality but only weakly predictive when treated as a continuous variable. In addition, multivariable analysis showed that age treated as a continuous variable was a weak independent predictor of operative mortality (odds ratio 1.05, 95% confidence intervals 1.03-1.08) and morbidity (odds ratio 1.07, 95% confidence intervals 1.05-1.11) in comparison with other factors such as preoperative visceral ischemia, requirement for cardiopulmonary resuscitation, preoperative myocardial ischemia, aortic rupture, and a primary tear in the aortic arch. The authors state within the body of the article that age taken as a continuous variable is by far the most important risk variable in both mortality and morbidity models based on multivariate logistic regression analysis. I would argue that this is not so if one takes the magnitude of the odds ratio as an index of risk. Hence, I question the conclusion that the authors made on the basis of their data that surgeons should consider withholding surgery for type A aortic dissection in octogenarians. The authors, in my opinion, have not adequately stressed the importance of the fact that before the operation, 66% of these patients had hemodynamic instability, 10 patients had a preoperative stroke, renal and respiratory insufficiency were present before the dissection in 29% and 70% of patients, respectively, and renal function was impaired preoperatively in a total of 62% of patients, largely attributable to hemodynamic instability. Further, the authors found that 50% of the patients had myocardial ischemia at the time of surgery, with moderate to severe chronic cardiac failure present before dissection in 37% of subjects.
These clinical data, combined with the results of the multivariable analysis, which show the strong relationship between these comorbidities and negative outcome, suggest far more emphatically that patients with preoperative complications of their dissection or significant comorbidities are most likely not to fare well with surgery. The multivariable analysis suggests much less strongly that age as an independent variable is an important predictor.
In this study, high risk was incurred though complications of the primary disease process, not through advanced age. The authors state that these data support the concept that age can be used as a parameter to limit access of patients to expensive medical treatment. I would submit that this conclusion is not substantiated by the statistical analysis provided.
12/8/116553
doi:10.1067/mtc.2001.116553

References

1. Neri E, Toscano T, Massetti M, Capannini G, Carone E, Tucci E, et al. Operation for acute type A aortic dissection in octogenarians: Is it justified? J Thorac Cardiovasc Surg. 2001;121:259-67.
   
2. McKneally MF. "We don't do that here": reflections on the Siena experience with dissecting aneurysms of the thoracic aorta in octogenarians. J Thorac Cardiovasc Surg. 2001;121:202-3.
   

This article has been cited by other articles:

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				S. Ohtsubo, T. Itoh, K. Takarabe, K. Rikitake, K. Furukawa, H. Suda, and Y. Okazaki Surgical results of hemiarch replacement for acute type A dissection Ann. Thorac. Surg., November 1, 2002; 74(5): S1853 - 1856. [Abstract] [Full Text] [PDF]

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): John S. Ikonomidis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ikonomidis, J. S. Search for Related Content PubMed PubMed Citation Articles by Ikonomidis, J. S. Related Collections Great vessels