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J Thorac Cardiovasc Surg 2001;122:1050-1051
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Acute type A dissection in octogenarians

Department of Cardiothoracic Surgery
Mount Sinai School of Medicine
One Gustave Levy Place
PO Box 1028
New York, NY 10029

To the Editor:

We read with great interest the article by Neri and colleagues ¹ concerning their results in operations for acute type A dissections in octogenarians and the editorial by McKneally. ² We ³ recently examined the results in octogenarians of all operations on the ascending aorta carried out under hypothermic circulatory arrest (HCA) to answer the same question they posed. Although we noted that emergency surgery increased the risk of adverse outcome (death or permanent stroke), our results were not nearly as discouraging as those from Siena.
We agree that the report from Siena is courageous and opens an important ethical debate. But we also concur with McKneally's conclusion that policies are appropriately decided locally rather than generally, given the inevitability of variability in surgical outcome.
To comment more directly on the results from Siena, we reviewed the records of 14 consecutive octogenarians (80-89 years) who were operated on for acute type A aortic dissection from August 1987 to December 2000 at our institution. Of these patients, 4 (28.6%) had preoperative hemodynamic compromise; in 7 (50%) free blood was found in the pericardium, and 1 (7.1%) had new preoperative neurologic symptoms. Only 2 (14.3%) patients died in the hospital, and 1 (7.1%) had a transient stroke but recovered fully before discharge. One (7.1%) patient with preoperative paraparesis became paraplegic postoperatively, and 1 (7.1%) patient had ischemic colitis necessitating abdominal surgery. Thus, an adverse outcome was present in only 3 (21.4%) of 14 patients overall, with a complicated course in another 2 (14.3%) patients.
All patients in our series had an open distal anastomosis. HCA was always used: mean esophageal temperature was 13°C ± 3°C, and median duration was 33 minutes (range 20-50 minutes). A modified Bentall procedure with a biologic valve was done in 10 patients; in 4 the aortic valve was resuspended in a Hemashield graft (Meadox Medicals, Inc, Oakland, NJ). One patient had concomitant mitral valve replacement, and 3 required coronary artery bypass grafting. Postoperative follow-up, including computed tomographic scans, was complete in 11 of 12 hospital survivors. Three patients died during follow-up, including 1 patient who was readmitted because of constrictive pericarditis. The overall 1-year survival including the operative mortality was 69.2% with a median follow-up of 35 months (3-96 months).
In considering the possible reasons for the discrepancy between our results and those from Siena, we noted some differences. The patient cohort in Siena had a staggering amount of comorbidity: pericardial effusions in 91%, hypotension in 66%, cerebral ischemia in 41%, and visceral ischemia in 29%. Our surgical technique was also somewhat different. ⁴ HCA—at more profound levels of hypothermia—was used in all patients; antegrade cerebral perfusion was used liberally and retrograde cerebral perfusion sparingly. Furthermore, a proportion of our patients were cannulated via the axillary or subclavian artery to avoid retrograde femoral arterial perfusion.
On the basis of our own data, therefore, we continue to believe that emergency surgery for acute type A dissections in octogenarians is in fact justified. In our larger series, which included all octogenarians with ascending aorta or aortic arch operations, emergency surgery had a substantial negative impact on outcome. ³ This was especially striking in operations involving the distal arch or proximal descending aorta that necessitated a lateral thoracotomy. Under these circumstances, adverse outcome was 80%, raising the same question posed by the Siena group: whether such a high mortality should deter us in the future from offering emergency surgery to elderly patients in this subgroup. In contrast, elective operations on the ascending aorta or the aortic arch, especially those done via a median sternotomy, were associated with very low risk of adverse outcome (3.6%), even in octogenarians. We suggest, therefore, that willingness to undertake elective operations on the dilated ascending aorta early may reduce the number of elderly patients who require problematic emergency procedures.
12/8/117834
doi:10.1067/mtc.2001.117834

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.
   
3. Hagl C, Galla JD, Spielvogel D, Lansman SL, Squitier R, Bodian CA, et al. Is aortic surgery using hypothermic circulatory arrest in octogenarians justifiable? Eur J Cardiothorac Surg. 2001;19:417-22; discussion 422-3.[Abstract/Free Full Text]
   
4. Hagl C, Ergin MA, Galla JD, McCullough JN, Lansman SL, Spielvogel D, et al. Neurologic outcome after aorta/aortic arch surgery: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg. 2001;121:1107-21.[Abstract/Free Full Text]
   

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				M. Shiono, M. Hata, A. Sezai, M. Iida, S. Yagi, and N. Negishi Emergency Surgery for Acute Type A Aortic Dissection in Octogenarians Ann. Thorac. Surg., August 1, 2006; 82(2): 554 - 559. [Abstract] [Full Text] [PDF]

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This Article 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): Christian Hagl Randall B. Griepp Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hagl, C. Articles by Griepp, R. B. Search for Related Content PubMed PubMed Citation Articles by Hagl, C. Articles by Griepp, R. B.