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Memis F, Thijssen CGE, Gökalp AL, Notenboom ML, Meccanici F, Mokhles MM, van Kimmenade RRJ, Veen KM, Geuzebroek GSC, Sjatskig J, ter Woorst FJ, Bekkers JA, Takkenberg JJM, Roos-Hesselink JW. Elective Ascending Aortic Aneurysm Surgery in the Elderly. J Clin Med 2023; 12:jcm12052015. [PMID: 36902802 PMCID: PMC10004422 DOI: 10.3390/jcm12052015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND No clear guidelines exist for performing preventive surgery for ascending aortic (AA) aneurysm in elderly patients. This study aims to provide insights by: (1) evaluating patient and procedural characteristics and (2) comparing early outcomes and long-term mortality after surgery between elderly and non-elderly patients. METHODS A multicenter retrospective observational cohort-study was performed. Data was collected on patients who underwent elective AA surgery in three institutions (2006-2017). Clinical presentation, outcomes, and mortality were compared between elderly (≥70 years) and non-elderly patients. RESULTS In total, 724 non-elderly and 231 elderly patients were operated upon. Elderly patients had larger aortic diameters (57.0 mm (IQR 53-63) vs. 53.0 mm (IQR 49-58), p < 0.001) and more cardiovascular risk factors at the time of surgery than non-elderly patients. Elderly females had significantly larger aortic diameters than elderly males (59.5 mm (55-65) vs. 56.0 mm (51-60), p < 0.001). Short-term mortality was comparable between elderly and non-elderly patients (3.0% vs. 1.5%, p = 0.16). Five-year survival was 93.9% in non-elderly patients and 81.4% in elderly patients (p < 0.001), which are both lower than that of the age-matched general Dutch population. CONCLUSION This study showed that in elderly patients, a higher threshold exists to undergo surgery, especially in elderly females. Despite these differences, short-term outcomes were comparable between 'relatively healthy' elderly and non-elderly patients.
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Affiliation(s)
- Feyza Memis
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - Carlijn G. E. Thijssen
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Arjen L. Gökalp
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Maximiliaan L. Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Frederike Meccanici
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - Mohammad Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | | | - Kevin M. Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Guillaume S. C. Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Jelena Sjatskig
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | | | - Jos A. Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Johanna J. M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jolien W. Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
- Correspondence: ; Tel.: +31-10-70-32-432
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Guo MH, Appoo JJ, Hendry P, Masters R, Chu MWA, Ouzounian M, Dagenais F, Boodhwani M. Knowledge, attitudes, and practice preferences in the surgical threshold for ascending aortic aneurysm among Canadian cardiac surgeons. J Thorac Cardiovasc Surg 2023; 165:17-25.e2. [PMID: 33714570 DOI: 10.1016/j.jtcvs.2021.01.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The survey aimed to assess the practice patterns of Canadian cardiac surgeons on the size threshold at which patients with ascending aortic aneurysm would be offered surgery. METHODS A 18-question electronic survey was electronically distributed to 148 practicing cardiac surgeons in Canada via email from January to August 2020. Questions presented clinical scenarios focusing on modifying a single variable, and respondents were asked to identify their surgical size threshold for each of the clinical scenarios. RESULTS The individual response rate was 62.0% (91/148) and institutional response rate was 89.3% (25/29). For an incidental asymptomatic ascending aortic aneurysm in a 60-year-old otherwise-healthy male patient with a tricuspid aortic valve and bicuspid aortic valve of 1.9 m2, 20.2% of the respondents would recommend surgery when the aneurysm was <5.5 cm. A significant number of surgeons modified their surgical threshold in response to changes to BSA, bicuspid aortic valve, growth rate, age, occupation, symptom, and family history (P < .01). Notably, if the patient had a bicuspid aortic valve, 41.0% of respondents lowered their threshold for surgery, with only 43.0% recommending surgery at ≥5.5 cm (P < .01). CONCLUSIONS Practice variations exist in the current size threshold for surgery of ascending aortic aneurysms in Canada. These differences between surgeons are further accentuated in the context of bicuspid aortic valve, smaller body stature, younger age, low growth rate, family history, and for the performance of isometric exercise. These represent important areas where future prospective studies are required to inform best practice.
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Affiliation(s)
- Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Paul Hendry
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Roy Masters
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Beckmann E, Martens A, Kaufeld T, Natanov R, Krueger H, Haverich A, Shrestha M. Is total aortic arch replacement with the frozen elephant trunk procedure reasonable in elderly patients? Eur J Cardiothorac Surg 2021; 60:131-137. [PMID: 33582774 DOI: 10.1093/ejcts/ezab063] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Total aortic arch replacement is an invasive procedure with significant risks for complications. These risks are even higher in older, multimorbid patients. The current trends in demographic changes in western countries with an ageing population will aggravate this issue. In this study, we present our experience with total aortic arch replacement using the frozen elephant trunk (FET) technique in septuagenarians. We compared the results of septuagenarians with those of younger patients and analysed if there was an improvement in outcome over time. METHODS Between August 2001 and March 2020, 225 patients underwent non-urgent FET procedure at our institution. There were 75 patients aged ≥70 years (mean age 74 ± 4) who were assigned to group A, and 150 patients aged <70 years (mean age of 57 ± 11) who were assigned to group B. In groups A and B, the indications for surgery were chronic dissection (21% vs 53%), aortic aneurysm (78% vs 45%) and penetrating atherosclerotic ulcer (1% vs 2%). RESULTS The rate for temporary dialysis was significantly higher in group A than in group B (29% vs 13%, P = 0.003), although the majority recovered kidney function. Rates for re-exploration for bleeding and stroke were comparable in both groups. In-hospital mortality was significantly higher in group A than in group B (24% vs 13%, P = 0.037). Logistic regression analysis showed that age >70 years was an independent statistically significant risk factor for in-hospital mortality (odds ratio = 2.513, 95% confidence interval = 1.197-5.278, P-value = 0.015). Follow-up was complete for 100% of patients and comprised a total of 1073 patient-years with a mean follow-up time of 4.8 ± 4.5 years. The 1- and 5-year survival rates were 68% and 49% in group A, and 85% and 71% in group B, respectively (log rank, P < 0.001). Survival did not significantly improve over time. DISCUSSION Total aortic arch replacement using the FET technique has a significantly higher risk for perioperative morbidity and mortality in septuagenarians than in younger patients. Long-term survival is significantly impaired in older patients. We recommend thorough patient selection of those who require total aortic arch replacement, and optimization of perioperative management to improve outcomes.
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Affiliation(s)
- Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krueger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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DeRoo S, Takayama H. Commentary: How Old Is Too old? Semin Thorac Cardiovasc Surg 2020; 32:653-654. [PMID: 32416128 DOI: 10.1053/j.semtcvs.2020.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/26/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Scott DeRoo
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
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