Defining the Futility Point: Early and Late Outcomes of Surgical Repair of Type A Aortic Dissection in Octogenarians
Rohan S. Menon, Wilson Szeto, Y. Joseph Woo, Patrick Moeller, William Moser, Prashanth Vallabhajosyula, Joseph Bavaria, Nimesh Desai, University of Pennsylvania, Philadelphia, PA
OBJECTIVE: Octogenarians are frequently denied surgery for Stanford Type A Aortic Dissections due to high mortality and morbidity. We reviewed surgical outcomes of 52 octogenarians undergoing Type A dissection repair.
METHODS: Between 1995 and 2010, acute Type A aortic dissection repair was performed in 500 patients (52>80years: (17>85, 2>90). All patients underwent sternotomy, aortic valve resuspension and open distal hemiarch under circulatory arrest. Patients were cooled to 18C core temperature and had retrograde cerebral perfusion. Five underwent full root replacement and two underwent total arch replacement. Standard univariate, survival, logistic regression and Cox proportional hazards modeling methods were employed.
RESULTS: 30day mortality among all octogenarians was 17.3% (9/52): <85(11.4%(4/35), >85(29.1%(5/17)) [p=0.1]. Perioperative mortality among patients <80years was 10.7%(48/448), [p=0.16 for <80years vs >80years]. Complicated presentations (malperfusion, shock, arrest and/or hemopericardium/tamponade ) were similar in both groups(51% vs 54%[p=0.7]). Mortality within this group was: <85(16%(3/19)) and >85 (57%(4/7))[p=0.57]. Five year survival among all octogenarians was 44.8%: <85(60.4%) and >85(18.1%)[log rank p=0.04]. Patients <80 years: Five year survival was 71.5%[log rank p=0.001 for <80 years vs >80years comparison}. Median survival in patients >85 years was 20+/-12 months.
CONCLUSIONS: Octogenarians have favorable outcomes following repair for Type A aortic dissection. Patients <85 years have similar outcomes to the younger cohort. Patients >85 years with complicated presentations have poor outcomes and open aortic surgery may not be superior to medical therapy. These patients may be more suited to emerging therapies.