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Park YK, Lee JH, Kim KM, Jung JC, Chang HW, Kim DJ, Kim JS, Lim C, Park KH. Acute type A aortic dissection features and outcomes in octogenarians: a propensity score analysis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae038. [PMID: 38507698 PMCID: PMC10980583 DOI: 10.1093/icvts/ivae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 02/18/2024] [Accepted: 03/18/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVES The clinical characteristics and early outcomes of surgical repair in octogenarians with acute type A aortic dissection were compared with those in nonoctogenarians. METHODS All patients who underwent emergency surgical repair for acute type A aortic dissection in our institution between 2003 and 2022 were included in this study. The patients were divided into an octogenarian group and a nonoctogenarian group. The patients in the 2 groups were propensity score matched at a ratio of 1:1. Before matching, the baseline characteristics were compared between 2 groups. The major complication and 30-day mortality rates were compared in the matched population. RESULTS A total of 495 patients were screened, and 471 were included in the analysis, with 48 in the octogenarian group and 423 in the nonoctogenarian group. Before matching, DeBakey type II dissection was significantly more prevalent in the octogenarians (42% vs 14% in the octogenarians and nonoctogenarians, respectively, P < 0.001). Additionally, intramural haematomas (39.6% vs 14.4%, P < 0.001) were more prevalent in the octogenarians. However, severe aortic regurgitation (4.2% vs 15.4%, P = 0.046) and root enlargement (0% vs 13.7%, P = 0.009) were less prevalent in the octogenarians. After matching (36 pairs), the incidence of postoperative delirium was higher in the octogenarians (56% vs 25%, P = 0.027). However, there were no significant differences in 30-day and in-hospital mortality rates, intensive care unit stay or major complications, including stroke, paraplegia, respiratory complications, mediastinitis and haemodialysis. CONCLUSIONS The octogenarians with acute type A aortic dissection had higher incidences of DeBakey type II dissection and intramural haematomas and lower incidences of severe aortic regurgitation and aortic root enlargement than the nonoctogenarians. Being an octogenarian was not associated with an increased risk of early major complications or mortality after surgery for acute type A aortic dissection.
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Affiliation(s)
- You Kyeong Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Hang Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kang Min Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joon Chul Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyoung Woo Chang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jun Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Kageyama S, Ohashi T, Yoshida T, Kobayashi Y, Kojima A, Kobayashi D, Kojima T. Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study. J Thorac Cardiovasc Surg 2024; 167:65-75.e8. [PMID: 35277246 DOI: 10.1016/j.jtcvs.2022.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications. METHODS This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications. RESULTS Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091). CONCLUSIONS The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.
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Affiliation(s)
- Soichiro Kageyama
- Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai-city, Aichi, Japan
| | - Takeki Ohashi
- Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai-city, Aichi, Japan
| | - Takeshi Yoshida
- Department of Cardiovascular Surgery, Matsubara Tokushukai Hospital, Matsubara-city, Osaka, Japan
| | - Yutaka Kobayashi
- Department of Cardiovascular Surgery, Uji Tokushukai Hospital, Makishima-cho, Uji-city, Kyoto, Japan
| | - Akinori Kojima
- Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai-city, Aichi, Japan
| | - Daiki Kobayashi
- Graduate School of Public Health, St Luke's International University, Tokyo, Japan
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu-shi, Aichi, Japan.
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Chang X, Yao J, Xu Y. The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies. BMC Cardiovasc Disord 2022; 22:556. [PMID: 36544083 PMCID: PMC9768940 DOI: 10.1186/s12872-022-02925-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/29/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The research of the sensitivity and specificity point-of-care testing (POCT) of D-dimer as a diagnostic protocol for differential diagnosis of Stanford Type A aortic syndrome (hereafter as TAAS) mimicking ST-elevated myocardial infarction (STEMI) with regular STEMI in the emergency department is limited. METHODS Full medical information of 32 patients confirmed TAAS and 527 patients confirmed STEMI from January 1st, 2016 to October 1st, 2021 were retrospectively analyzed in Shanghai Tenth People's Hospital of Tongji University. RESULTS The baseline characteristics of two groups of patients were well-balanced post propensity score matching (PSM) analysis, and each group had 32 patients enrolled. Patients in the STEMI group had higher positive cardiac troponin I (cTNI) (0.174 ng/ml vs. 0.055 ng/ml, P = 0.008) results but lower D-dimer (0.365μg/ml vs. 31.50μg/ml, P < 0.001) results than the TAAS group. The D-dimer cutoff value of 2.155μg/ml had the best sensitivity of 100% and specificity of 96.9%, and the positive predictive value (PPV) as well as the negative predictive value (NPV) of the cutoff value were 96.9 and 100%, respectively, in total 64 patients, the area under the curve (AUC) values were 0.998 (95% CI:0.992-1.000, P < 0.001) for the D-dimer. No significant correlation between the D-dimer concentration and the time from symptoms onset to first medical contact in both groups (TAAS group: r = - 0.248, P = 0.170; STEMI group: r = - 0.159, P = 0.383) or significant correlation between D-dimer and creatine clearance (TAAS group: r = - 0.065, P = 0.765; STEMI group: r = 0.222, P = 0.221). The total in-hospital mortality for the patients with TAAS presenting as STEMI was 62.5% (20/32). The mortality rate for TAAS patients confirmed by computed tomography angiography (CTA) was significantly lower (40% vs. 82.4%, P = 0.014) than the mortality rate for TAAS patients confirmed by coronary angiography (CAG) and had a longer average survival time (log-rank = 0.015), less peri-surgical complications especially gastrointestinal hemorrhage (0.00% vs. 55.6%, P < 0.001). CTA diagnosis can reduce the mortality rate by 67.5% (95%CI:0.124-0.850, P = 0.16). CONCLUSIONS The POCT D-dimer with cut-off 2.155μg/ml would be useful to rule-out TAAS mimicking STEMI from regular STEMI prior to reperfusion therapy. CTA diagnosis is effective in reducing the probability of perioperative complications and lowering perioperative mortality than CAG diagnosis in TAAS patients.
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Affiliation(s)
- Xiaoxin Chang
- grid.24516.340000000123704535Department of Cardiology, Tongji University, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072 China
| | - Jianhua Yao
- grid.24516.340000000123704535Department of Cardiology, Tongji University, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072 China
| | - Yawei Xu
- grid.24516.340000000123704535Department of Cardiology, Tongji University, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072 China
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Eranki A, Merakis M, Williams ML, Flynn CD, Villanueva C, Wilson-Smith A, Lee Y, Mejia R. Outcomes of surgery for acute type A dissection in octogenarians versus non-octogenarians: a systematic review and meta analysis. J Cardiothorac Surg 2022; 17:222. [PMID: 36050776 PMCID: PMC9434858 DOI: 10.1186/s13019-022-01980-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Acute Type A Aortic Dissection (ATAAD) is a cardiothoracic emergency that requires urgent intervention. Elderly status, particularly age over 80, is an independent risk factor for mortality and morbidity. The mid-term outcomes of this age group are also unknown. This systematic review and meta-analysis of observational studies was therefore performed to analyse short- and mid-term mortality and morbidity in octogenarians following surgery for ATAAD. METHODS A systematic review was conducted for studies published since January 2000. The primary endpoint was short-term mortality, either reported as 30-day mortality or in-hospital mortality and medium-term (five year) survival. Secondary endpoints were rates of postoperative complications, namely stroke, acute renal failure (ARF), re-exploration and intensive care unit (ICU) length of stay (LOS). RESULTS A total of 16 retrospective studies, with a total of 16, 641 patients were included in the systematic review and meta-analysis. Pooled analysis demonstrated that octogenarian cohorts are at significantly higher risk of short-term mortality than non-octogenarians (OR 1.93; 95% CI 1.33-2.81; P < 0.001). Actuarial survival was significantly lower in the octogenarian cohort, with a five-year survival in the octogenarian cohort of 54% compared to 76% in the non-octogenarian cohort (P < 0.001). There were no significant differences between the cohorts in terms of secondary outcomes: stroke, ARF, re-exploration or ICU LOS. CONCLUSION Octogenarians are twice as likely to die in the short-term following surgery for ATAAD and demonstrate a significantly lower five-year actuarial survival. Patients and family members should be well informed of the risks of surgery and suitable octogenarians selected for surgery.
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Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.
| | - Michael Merakis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Campbell D Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia.,The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Claudia Villanueva
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
| | - Ashley Wilson-Smith
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.,The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yangsin Lee
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
| | - Ross Mejia
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
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Catalano MA, Mamdouhi T, Pupovac S, Kennedy KF, Brinster DR, Hartman A, Yu PJ. Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample. JTCVS OPEN 2022; 11:23-36. [PMID: 36172443 PMCID: PMC9510847 DOI: 10.1016/j.xjon.2022.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/29/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022]
Abstract
Objective Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. Methods The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. Results We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups—female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality. Conclusions Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.
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Wang JX, Xue YX, Zhu XY, Chong HS, Chen Z, Zhou Q, Qu JZ, Wang DJ. The impact of age in acute type A aortic dissection: a retrospective study. J Cardiothorac Surg 2022; 17:40. [PMID: 35305695 PMCID: PMC8933992 DOI: 10.1186/s13019-022-01785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute type A aortic dissection (aTAAD) is a lethal disease and age is an important risk factor for outcomes. This retrospective study was to analyze the impact of age stratification in aTAAD, and to provide clues for surgeons when they make choices of therapy strategies.
Methods From January 2011 to December 2019, 1092 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy. Patients were divided into 7 groups according to every ten-year interval (20–80 s). The differences between the groups were analyzed in terms of the baseline preoperative conditions, surgical methods and postoperative outcomes of patients of different age groups. During a median follow-up term of 17 months, the survival rates were compared among 7 groups through Kaplan–Meier analysis.
Results The median age was 52.0 years old in whole cohort. The multiple comorbidities were more common in old age groups (60 s, 70 s, 80 s), while the 20 s group patients had the highest proportion of Marfan syndrome (28.1%). Preoperative hypotension was highest in 80 s (16.7%, P = 0.038). Young age groups (20–60 s) had a higher rate of root replacement and total arch replacement, which led to a longer duration of operation and hypothermic circulation arrest. The overall mortality was 14.1%, the tendency of mortality was increased with age except 20 s group (33.3% in 80 s, P = 0.016). The postoperative morbidity of gastrointestinal bleeding and bowel ischemia were 16.7% and 11.1% in 80 s group. Conclusions Age is a major impact factor for aTAAD surgery. Old patients presented more comorbidities before surgery, the mortality and complications rate were significantly higher even with less invasive and conservative surgical therapy. But the favorable long-term survival indicated that the simple or less extensive arch repair is the preferred surgery for patients over 70 years old. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01785-y.
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Chen JW, Sainbayar N, Hsu RB. Outcome of emergency surgery for acute type A aortic dissection in octogenarians. J Card Surg 2022; 37:610-615. [PMID: 34996133 DOI: 10.1111/jocs.16219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency surgery for acute type A aortic dissection (AAAD) was usually avoided or denied in octogenarians because of high surgical mortality. Refined surgical techniques and improved postoperative care have led to an improved in-hospital outcome. However, a significant number of operative survivors suffered from postoperative complications and had compromised quality of life. We sought to assess the clinical outcome of emergency surgery using a standard conservative approach in octogenarians with AAAD. METHODS From 2004 to 2021, 123 patients underwent emergency surgery for AAAD by one surgeon using a standard conservative approach with right subclavian artery cannulation, no aortic cross-clamp, selective antegrade cerebral perfusion, moderate systemic hypothermia, reinforced sandwich technique, and a strategy of limited aortic resection. Hospital and late outcomes were assessed in patients with age >80 years. RESULTS Eighteen patients (15%) were octogenarians with seven males (39%) and median age of 82 years (range, 80-89). Hypertension was present in six patients (33%). None had diabetes mellitus, Marfan, or bicuspid aortic valve. Dissection was intramural hematoma in six (33%) and DeBakey type I in 15 patients (83%). Cardiac tamponade with shock was present in seven patients (39%). Ascending aortic grafting was performed in 17 patients, and additional hemiarch replacement in one patient. The hospital mortality rate was 17% (3/18). Fourteen patients (82%) were alive and well at discharge. CONCLUSIONS Emergency surgery for AAAD using a standard conservative approach showed an improved outcome in octogenarians. The majority of patients could return home with an acceptable living.
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Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nyamsuren Sainbayar
- Department of Cardiovascular Surgery, Third State Central Hospital, Ulan Bator, Mongolia
| | - Ron-Bin Hsu
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Harky A, Singh VP, Khan D, Sajid MM, Kermali M, Othman A. Factors Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic Review. Heart Lung Circ 2020; 29:1668-1681. [PMID: 32798049 DOI: 10.1016/j.hlc.2020.05.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection is a clinical emergency and is associated with significant morbidity and mortality rates if not managed promptly in specialised and high-volume centres. The mortality rate is increased by 1% for each hour delay in management; however, with advancement in clinical practice, diagnostic imaging and clinician awareness, this has been dramatically reduced to below 30% in most international centres. Not only timing of recognition of the pathology, but also other factors can significantly affect outcomes of such critical pathology. This includes, but is not limited to, age, extent of the pathology, existence of connective tissue disorders, hypertension, diabetes mellitus and surgeon experience. This narrative review will focus on current clinical practice and the evidence behind optimising each factor to minimise adverse outcomes in such high-risk cohort.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
| | | | - Darab Khan
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Muhammed Kermali
- Faculty of Medicine, St. George's, University of London, London, UK
| | - Ahmed Othman
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Masubuchi T, Yoshitani K, Minami K, Yokoyama C, Tsukinaga A, Goto T, Ohnishi Y. Transfusion characteristics and hemostatic conditions in octogenarians undergoing emergency surgery for acute aortic dissection: a retrospective study. JA Clin Rep 2020; 6:52. [PMID: 32648135 PMCID: PMC7347724 DOI: 10.1186/s40981-020-00358-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/03/2020] [Indexed: 12/03/2022] Open
Abstract
Background The number of elderly patients undergoing elective as well as emergent cardiac surgery is increasing. Octogenarian and older patients undergoing surgery for acute type A aortic dissection (AAD) have a significantly higher risk of postoperative mortality than younger patients. Hemostasis is difficult in octogenarians with AAD. However, few studies have investigated perioperative blood transfusion volumes and hemostatic conditions in patients undergoing AAD surgery. We retrospectively investigated whether these factors differed between octogenarians and younger patients with AAD. Methods The records of 207 patients who underwent emergency surgery for AAD were reviewed between 2008 and 2014. We compared the total volumes of transfused blood components (red blood cell concentrate, fresh frozen plasma, platelets concentrate, and cryoprecipitate), perioperative blood coagulation test results (prothrombin time-international normalized ratio, activated partial thrombin time, and activated coagulation time), and intensive care unit and hospital stay durations between octogenarians (n = 33) and patients < 80 years old (n = 170). Results A significantly greater volume of red blood cell concentrates was transfused in octogenarians than in patients < 80 years old. Isolated prolonged activated partial thromboplastin time was observed in octogenarian patients. Duration of hospital stays was significantly longer in octogenarians than in patients < 80 years old. Conclusions Octogenarians required more red blood cells during surgery for AAD and exhibited isolated APTT prolongation.
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Affiliation(s)
- Tetsuhito Masubuchi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan.
| | - Kimito Minami
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Chisaki Yokoyama
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshimmachi, Suita, Osaka, 564-8565, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Hospital, 3-9, Fukuura, Yokohama, Kanagawa, 236-0004, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, Yokohama City University Hospital, 3-9, Fukuura, Yokohama, Kanagawa, 236-0004, Japan
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Salem M, Friedrich C, Thiem A, Huenges K, Puehler T, Cremer J, Haneya A. Risk Factors for Mortality in Acute Aortic Dissection Type A: A Centre Experience Over 15 Years. Thorac Cardiovasc Surg 2020; 69:322-328. [PMID: 32559807 DOI: 10.1055/s-0040-1710002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute aortic dissection Type A (AADA) is still associated with a high mortality rate and frequent postoperative complications. This study was designed to evaluate the risk factors for mortality in AADA patients. PATIENTS AND METHODS This retrospective analysis included 344 consecutive patients who underwent surgery for AADA in moderate hypothermic circulatory arrest (20-24°C nasopharyngeal) between 2001 and 2016. RESULTS The 30-day mortality rate was 18%. Nonsurvivors were significantly older (65.7 ± 12.0 years vs. 62.0 ± 12.5 years; p = 0.034) with significantly higher Euro-score II [15.4% (6.6; 23.0) vs. 4.63% (2.78; 9.88); p < 0.001)]. Intraoperatively, survivors had statistically shorter cardiopulmonary bypass times [163 (134; 206) vs. 198 min (150; 245); p = 0.001]. However, the hypothermic circulatory arrest time was similar between both groups. Postoperatively, the incidence of acute kidney injury (AKI) (55.9 vs. 15.2%; p < 0.001), stroke (27.9 vs. 12.1%; p = 0.002) and sepsis (18.0 vs. 2.1%; p < 0.001) were significantly higher among nonsurvivors. The multi-variable logistic regression confirmed that older age, previous cardiac surgery, preoperative cardiopulmonary resuscitation (CPR), blood transfusion and postoperative acute kidney injury (AKI) were independent risk factors for mortality. CONCLUSION Our analysis suggested that the reason for mortality was multifactorial, especially age, previous cardiac surgery, CPR, transfusion, as well as postoperative AKI were considered risk factors for mortality.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Alexander Thiem
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Katharina Huenges
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Thomas Puehler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
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Bojko MM, Suhail M, Bavaria JE, Bueker A, Hu RW, Harmon J, Habertheuer A, Milewski RK, Szeto WY, Vallabhajosyula P. Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians. J Thorac Cardiovasc Surg 2020; 163:2-12.e7. [PMID: 32624307 DOI: 10.1016/j.jtcvs.2020.03.157] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients. METHODS From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively. RESULTS At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories. CONCLUSIONS Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.
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Affiliation(s)
| | - Maham Suhail
- Department of Internal Medicine, Richmond University Medical Center, Staten Island, NY
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Alex Bueker
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Robert W Hu
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Joey Harmon
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Andreas Habertheuer
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Rita K Milewski
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
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12
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Hattori S, Noguchi K, Gunji Y, Nagatsuka M, Katayama I. Acute type A aortic dissection in non-agenarians: to cut or not. Interact Cardiovasc Thorac Surg 2020; 31:102-107. [DOI: 10.1093/icvts/ivaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Surgery for acute type A aortic dissection (type AAD) in non-agenarians is usually contraindicated due to advanced age. The aim of this study was to assess and compare outcomes after surgical or conservative treatment for acute type AAD in non-agenarians by evaluating frailty.
METHODS
Between October 2012 and September 2018, 273 patients underwent open repair for type AAD at the Shonan Kamakura General Hospital and the Shonan Fujisawa Tokushukai Hospital, and here, we retrospectively reviewed the case reports of 10 surgically treated non-agenarians and 15 conservatively treated non-agenarians. Exclusion criteria for surgery were the patient’s refusal of surgery, severe dementia and coma. In patients considered to be at a high risk, our judgements were based on the results of comprehensive evaluation.
RESULTS
Both in-hospital mortality and 30-day mortality in the surgical group were zero, while in-hospital mortality in conservatively treated non-agenarians was 73.3%. Importantly, 1-year survival in the surgical group and conservative group was 90% and 25%, respectively. The 5-year survival in the surgical group and conservative group was 49.2% and 25%, respectively (log-rank test, P = 0.0105). Four of 6 patients with preoperative clinical frailty scores not higher than 4 were still alive at 1 year with the same level of preoperative frailty.
CONCLUSIONS
Surgery for acute type AAD in non-agenarians can be performed with acceptable outcomes in carefully selected patients, particularly in those with preoperative clinical frailty scores not higher than 4.
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Affiliation(s)
- Shigeru Hattori
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Kenichiro Noguchi
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Yusuke Gunji
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Motoki Nagatsuka
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Ikuo Katayama
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, Kanagawa, Japan
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13
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Rahman IA, Kendall S. Cardiac surgery in the very elderly: it isn't all about survival. THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:05. [PMID: 35747424 PMCID: PMC8793928 DOI: 10.5837/bjc.2020.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
| | - Simon Kendall
- Consultant Cardiac Surgeon and President Elect SCTS Department of Cardiothoracic Surgery, James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW
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14
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Chung J, Stevens LM, Chu MWA, Dagenais F, Peterson MD, Boodhwani M, Bozinovski J, El-Hamamsy I, Yamashita MH, Atoui R, Bittira B, Payne D, Ouzounian M. The impact of age on patients undergoing aortic arch surgery: Evidence from a multicenter national registry. J Thorac Cardiovasc Surg 2020; 162:759-766.e1. [PMID: 32178917 DOI: 10.1016/j.jtcvs.2020.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Elderly patients are typically offered aortic surgery at similar diameter thresholds as younger patients, despite limited data quantifying their operative risk. We aim to report the incremental risk experienced by elderly patients undergoing aortic arch surgery. METHODS In total, 2520 patients underwent aortic arch surgery between 2002 and 2018 in 10 centers. Patients were divided into 3 groups: <65 years (n = 1325), 65 to 74 years (n = 737), and ≥75 years (n = 458). Outcomes of interest were in-hospital mortality, stroke, and the modified Society of Thoracic Surgeons composite for mortality or major morbidity (STS-COMP). Multivariable modeling was performed to determine the association of age with these outcomes. RESULTS As age increased, there was an increasing rate of comorbidities, including diabetes (P < .001), renal failure (P < .001), and previous stroke (P = .01). Rates of acute aortic syndrome (P = .50) and total arch repair were similar (P = .59) between groups. Older patients had greater mortality (<65: 6.1% vs 65-74: 9.0% vs ≥75: 14%, P < .001), stroke (6.3% vs 7.7% vs 11%, P = .01) and STS-COMP (25% vs 32% vs 38%, P < .001). After multivariable risk-adjustment, a step-wise increase in complications was observed in the older age groups relative to the youngest in terms of in-hospital mortality (65-74: odds ratio [OR] 1.57, P = .04; ≥75: OR, 2.94, P = .001) and STS-COMP (65-74: OR, 1.57, P < .001; ≥75: OR, 1.96, P < .001). CONCLUSIONS Older patients experienced elevated rates of mortality and morbidity following aortic arch surgery. These results support a more measured approach when evaluating elderly patients. Further research is needed on age-dependent natural history of thoracic aneurysms and size thresholds for intervention.
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Affiliation(s)
- Jennifer Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Laval University, Quebec City, Quebec, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, University of British Columbia, Victoria, British Columbia, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, University of Montreal, Montreal, Ontario, Canada
| | - Michael H Yamashita
- Division of Cardiac Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rony Atoui
- Division of Cardiac Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Bindu Bittira
- Division of Cardiac Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.
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15
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Tamura K, Chikazawa G, Hiraoka A, Totsugawa T, Yoshitaka H. Characteristics and Surgical Results of Acute Type A Aortic Dissection in Patients Younger Than 50 Years of Age. Ann Vasc Dis 2019; 12:507-513. [PMID: 31942209 PMCID: PMC6957888 DOI: 10.3400/avd.oa.19-00033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives: The aim of this study is to investigate the characteristics and surgical outcomes of acute type A aortic dissection (AAAD) in patients younger than 50 years of age. Methods: We retrospectively evaluated 307 patients who consecutively underwent surgical treatment for AAAD in our institute from January 2007 to June 2017. Patients were classified into two groups: the young group with 31 patients aged younger than 50 and the old group with 276 patients aged 50 years or older. Results: In-hospital mortality was similar in both groups (3.2% vs. 9.4%, p=0.19). Overall survival at 5 years was higher in the young group than that in the old group (97% vs. 71%, p=0.017). No significant differences were observed in freedom from aorta-related death and distal aortic reoperation at 5 years (97% vs. 87%, p=0.26; 86% vs. 92%, p=0.093). The percentage of young patients with postoperative patent false lumen at the descending aorta was significantly higher than that of old patients (76% vs. 30%, p<0.001) in spite of primary entry resection. Conclusion: Early and mid-term outcomes for AAAD in young patients were satisfactory. However, future follow-up is important because postoperative patent false lumen is at a high rate in young patients in spite of entry resection.
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Affiliation(s)
- Kentaro Tamura
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Okayama, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Okayama, Japan
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Okayama, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama, Okayama, Okayama, Japan
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16
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Influence of Age and the Burden of Ischemic Injury on the Outcome of Type A Aortic Dissection Repair. Ann Thorac Surg 2019; 108:1391-1397. [DOI: 10.1016/j.athoracsur.2019.04.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 12/27/2022]
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17
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Bashir M, Harky A, Shaw M, Adams B, Oo A. Type A aortic dissection in patients over the age of seventy in the UK. J Card Surg 2019; 34:1439-1444. [DOI: 10.1111/jocs.14196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Mohamad Bashir
- Department of Emergency Medicine Macclesfield General Hospital Macclesfield UK
| | - Amer Harky
- Cardiothoracic Department Liverpool Heart & Chest Hospital Liverpool UK
| | - Matthew Shaw
- Department of Research & Development Liverpool Heart & Chest Hospital Liverpool UK
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, Barts Heart Centre St Bartholomew's Hospital London UK
| | - Aung Oo
- Department of Cardiothoracic Surgery, Barts Heart Centre St Bartholomew's Hospital London UK
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18
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Mauduit M, Anselmi A, Tomasi J, Belhaj Soulami R, Roisné A, Flecher E, Rouze S, Verhoye JP. Early and late outcomes of aortic surgery under hypothermic circulatory arrest in the elderly: a single center study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:733-741. [PMID: 31599143 DOI: 10.23736/s0021-9509.19.10874-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the progressive aging of the population, aortic surgeons are caring for an increasing number of elderly patients. The objective of this study was to analyze early and late outcomes of aortic surgery with hypothermic circulatory arrest in patients aged 70 and above at our institution. METHODS We performed a retrospective cohort study including every patient aged 70 years or older who underwent aortic surgery with hypothermic circulatory arrest between January 1995 and June 2016 at our institution. Operative results were compared with the contemporary younger counterparts aged <70 years. In-hospital mortality and postoperative stroke were primary outcomes of interest. The main secondary outcomes included acute renal failure, reoperation for bleeding, and spinal cord injury. RESULTS In the study population, the in-hospital mortality was 16.8% (21/125). Ten (8.0%) patients presented postoperative stroke, and 6 had temporary neurologic disturbance (4.8%). Spinal cord injury occurred in 1 (0.8%) patient. For elective interventions and type A aortic dissections, the in-hospital mortality and stroke rates were 4.6% (3/65) and 7.7% (5/65), 26.8% (11/41) and 12.2% (5/41), respectively. The proportion of non-elective interventions, including type A aortic dissection, and the type of neuroprotective strategy were similar in septuagenarians and younger patients. Patients aged ≥70 had significant shorter cardiopulmonary bypass, myocardial ischemia, and circulatory arrest durations, compared to their younger counterparts. The in-hospital mortality of septuagenarians and younger patients were similar for elective surgery (4.6% vs. 4.7%, P=0.900) and aortic dissections (26.8% vs. 15.1%, P=0.107). There was no statistically significant difference between the two age groups regarding postoperative stroke, spinal cord injury, renal failure requiring dialysis or reintervention for bleeding. Estimated 1-, 3-, and 5-year survival was 78.0%, 70.6%, and 65.7%, respectively. The 5-year survival for elective surgery was 74.9% and 56.0% for non-elective procedures. CONCLUSIONS Aortic surgery with circulatory arrest in the elderly demonstrated favorable early and late results when compared with younger individuals, with an acceptable operative risk even under emergency conditions, and should not be denied only because of the chronological age of the patients.
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Affiliation(s)
- Marion Mauduit
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France -
| | - Amedeo Anselmi
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jacques Tomasi
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Reda Belhaj Soulami
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Antoine Roisné
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Simon Rouze
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
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19
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Al-Adhami A, Harky A, Bashir M, Kolvekar S. Replacing the ascending aorta in the elderly: do or do not. Indian J Thorac Cardiovasc Surg 2019; 35:106-111. [PMID: 33061074 DOI: 10.1007/s12055-018-0734-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023] Open
Abstract
Advanced age is a proven independent factor for perioperative morbidity and mortality in all forms of aortic surgery and forms an important variable in most available risk scores. Improvements in selection and perioperative management of high-risk elderly cohorts have reduced the incidence of adverse outcomes. Concerns remain however in the surgical and anesthesiology community that exposing elderly frail patients to ascending aortic surgery is associated with significant risk. As with many clinical scenarios, individualization of care for each patient is of paramount importance. With advances in our understanding of perioperative and intraoperative care, age should no longer be considered in isolation as a contraindication to ascending aortic surgery.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY UK
| | - Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, CH1 2UL UK
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
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20
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Kondo N, Tamura K, Hiraoka A, Totsugawa T, Chikazawa G, Sakaguchi T, Yoshitaka H. Treatment outcomes for acute type A aortic dissection with patent false lumen in patients over the age of 80. Gen Thorac Cardiovasc Surg 2019; 67:765-772. [PMID: 30888589 DOI: 10.1007/s11748-019-01111-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/04/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES While reports which focus on the outcomes of conservative treatments for acute type A aortic dissection in patients over the age of 80 are worth considering, recently many studies have reported improved outcomes of surgical treatment. Accordingly, we analyzed the outcomes of surgical and conservative treatments for acute type A aortic dissection with patent false lumen in patients over the age of 80. METHODS We retrospectively investigated 70 patients over 80 years in age out of 248 consecutive patients with acute type A aortic dissection between January, 2010, and May, 2015. Of the 70 patients, 44 underwent surgical treatments (ascending replacement in 33 and total arch replacement in 11) and 23 patients underwent conservative medical treatments. RESULTS In the surgical treatment, the 30-day mortality rate was 14% (6/44) and the rate of morbidity was 34%. And 17 patients (39%) were discharged home without ambulatory assistance. The actuarial survival rates in the surgical treatment group were 83% and 60% at 1 and 3 years, respectively. The in-hospital death rate of conservative medical treatment was 43% (10/23). Only 26% of the patients having had conservative treatment were discharged home without ambulatory assistance. The actuarial survival rate in the conservative medical group was 8.7% at 1 year. CONCLUSION Surgical outcomes of acute type A aortic dissection with patent false lumen were satisfactory in patients aged over 80 in this study by meticulously determining operative indications, depending on the background of each patient.
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Affiliation(s)
- Nobuo Kondo
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan.
| | - Kentaro Tamura
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
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21
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Kornberger A, Petar R, El Beyrouti H, Khalil M, Burck I, Halloum N, Beiras-Fernandez A, Vahl CF. Repair of TEVAR-Associated Type A Dissection in the Elderly Is Possible With Reasonable Morbidity and Mortality. Vasc Endovascular Surg 2018; 52:405-410. [PMID: 29649955 DOI: 10.1177/1538574418767545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Type A aortic dissection (AAD) is a devastating complication of thoracic endovascular repair (TEVAR). In elderly patients, surgery for AAD carries considerable morbidity and mortality. Repair of AAD after previous TEVAR is an even greater challenge as it usually requires the arch to be addressed and a preexisting stent graft to be included into the aortic repair. METHODS A case series of 5 elderly patients who presented with acute AAD after previous TEVAR was reviewed. In 4 cases, there was retrograde AAD with involvement of the arch and stent graft. In 1 patient, intraoperative inspection showed no involvement of the arch. Three underwent ascending and subtotal arch replacement in moderate hypothermic circulatory arrest with selective cerebral perfusion. In 1 case, concomitant tricuspid valve repair was performed. The patient without involvement of the arch underwent emergent replacement of the ascending aorta in deep hypothermic circulatory arrest, and in the oldest, aged 88 years, surgery was limited to wrapping of the ascending aorta as an on-pump beating salvage procedure. RESULTS Four (80%) of 5 patients survived and were discharged after an intensive care unit stay of 17.45 ± 15.98 days and a hospital stay of 26.0 ± 10.98 days. Mortality was 20%. All survivors were discharged with appropriate rehabilitation potential and without lasting neurological disabilities.
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Affiliation(s)
- Angela Kornberger
- 1 Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Risteski Petar
- 2 Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Hazem El Beyrouti
- 1 Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Mahmud Khalil
- 2 Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Iris Burck
- 3 Department of Radiology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Nancy Halloum
- 1 Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Andres Beiras-Fernandez
- 1 Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Christian-Friedrich Vahl
- 1 Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University, Mainz, Germany
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22
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Ozaki N, Yuji D, Sato M, Inoue K, Wakita N. Medical treatment for acute Type A aortic dissection. Interact Cardiovasc Thorac Surg 2018; 26:696-699. [PMID: 29253220 DOI: 10.1093/icvts/ivx404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/26/2017] [Indexed: 11/13/2022] Open
Abstract
Six patients with acute Type A aortic dissection were medically treated due to advanced age, patient refusal and comorbidity despite surgical indication. Computed tomography after onset revealed a thrombosed false lumen in 3 patients and a patent false lumen with flap in 3 patients. All patients were stable during admission except 1 patient who presented with shock. After admission, treatment including strict control of systolic blood pressure was started according to a predetermined treatment strategy. All patients had no significant complications during hospitalization. All patients survived and returned to their usual activities. Medical treatment for stable elderly patients is a possible therapeutic option for acute Type A aortic dissection.
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Affiliation(s)
- Nobuchika Ozaki
- Department of Cardiovascular Surgery, Kobe Rosai Hospital, Hyogo, Japan
| | - Daisuke Yuji
- Department of Cardiovascular Surgery, Kobe Rosai Hospital, Hyogo, Japan
| | - Masanobu Sato
- Department of Cardiovascular Surgery, Kobe Rosai Hospital, Hyogo, Japan
| | - Kyozo Inoue
- Department of Cardiovascular Surgery, Kobe Rosai Hospital, Hyogo, Japan
| | - Noboru Wakita
- Department of Cardiovascular Surgery, Kobe Rosai Hospital, Hyogo, Japan
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23
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Lunstroth R, Ekeoduru R. Reframing "The Patient's Best Interest": The Burden of The Caregiver. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:67-69. [PMID: 29313790 DOI: 10.1080/15265161.2017.1401163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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24
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Castaño M, Gualis J, Martínez-Comendador JM, Martín E, Maiorano P, Castillo L. Emergent aortic surgery in octogenarians: is the advanced age a contraindication? J Thorac Dis 2017; 9:S498-S507. [PMID: 28616346 DOI: 10.21037/jtd.2017.04.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.
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Affiliation(s)
- Mario Castaño
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Javier Gualis
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | | | - Elio Martín
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Pasquale Maiorano
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Laura Castillo
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
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Porizka M, Kunstyr J, Vanek T, Nejedly M, Buckova J, Mokrejs J, Mosna F. Postoperative Outcome of High-Risk Octogenarians Undergoing Cardiac Surgery: A Multicenter Observational Retrospective Study. Ann Thorac Cardiovasc Surg 2017; 23:188-195. [PMID: 28539544 DOI: 10.5761/atcs.oa.16-00280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Cardiac surgery in octogenarians with severely deteriorated functional status is increasingly common, but outcome data are still limited. The aim of this study was to compare postoperative outcome, survival, and quality of life of low-, medium-, and high-risk octogenarians undergoing cardiac surgery. METHODS In all, 285 Czech octogenarians who underwent any cardiac surgical procedure between January 2011 and December 2012 were included in the study. Five out of all twelve national adult cardiac surgical centers participated in the study, representing almost half of all octogenarians operated in our country in that period. Patients' perioperative data were analyzed retrospectively. Follow-up was performed by interviewing patients by telephone. RESULTS There was higher 30-day mortality (20% vs. 6.4% vs. 5.2%, respectively, p <0.001), lower 2-year survival (60% vs. 84.0% vs. 85.4%, respectively, p <0.05), and lower Karnofsky score (44.4 vs. 70.1 vs. 70.6, respectively, p <0.001) in high-risk group compared with medium- and low-risk groups, respectively. Greater improvement in New York Heart Association (NYHA) status was noted in high- and medium-risk groups compared with low-risk group (51% vs. 45% vs. 24%, respectively, p <0.05). CONCLUSION High perioperative mortality, poor 2-year survival, and low postoperative quality of life have been observed in high-risk octogenarians undergoing cardiac surgery.
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Affiliation(s)
- Michal Porizka
- General University Hospital, Department of Anaesthesiology, Resuscitation and Intensive Medicine, The First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jan Kunstyr
- General University Hospital, Department of Anaesthesiology, Resuscitation and Intensive Medicine, The First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Tomas Vanek
- University Hospital Kralovske Vinohrady, Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Michal Nejedly
- University Hospital Kralovske Vinohrady, Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jana Buckova
- Na Homolce Hospital, Department of Cardiology, Prague, Czech Republic
| | - Jiri Mokrejs
- Faculty Hospital Pilsen, Department of Cardiac Surgery, Charles University in Prague, Pilsen-Bory, Czech Republic
| | - Frantisek Mosna
- Motol University Hospital, Department of Anaesthesiology and Intensive Care Medicine, The Second Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Chiu P, Miller DC. Evolution of surgical therapy for Stanford acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5:275-95. [PMID: 27563541 DOI: 10.21037/acs.2016.05.05] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
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Yaffee DW, Williams MR. Cardiovascular Surgery in the Elderly. Semin Thorac Cardiovasc Surg 2016; 28:741-747. [PMID: 28417859 DOI: 10.1053/j.semtcvs.2016.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2016] [Indexed: 11/11/2022]
Abstract
The elderly population is the fastest growing demographic in Western countries. As the population ages, the incidence of age-related comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, renal disease, cerebrovascular disease, and cardiovascular disease increases. With cardiovascular disease occurring in approximately one-quarter of the population over the age of 75 years and more than half of all cardiac procedures performed on this age group, the number of potential elderly surgical candidates is increasing. However, data suggest that old age is associated with increased morbidity and mortality following cardiac surgery. Over the past 2 decades, improvements in myocardial protection, extracorporeal circulation, anesthesia, and surgical techniques have significantly reduced the morbidity and mortality associated with cardiac surgery. Although most prospective studies exclude elderly patients, data from large retrospective studies and subgroup analyses suggest that cardiac surgery is a viable option for many elderly patients with cardiovascular disease, with good outcomes observed in reasonable-risk candidates; moreover, there are a growing number of available less-invasive options for them when surgical risk becomes prohibitive. In this article, we discuss the current state of cardiovascular surgery in the elderly as well as emerging technologies on the horizon.
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Affiliation(s)
- David W Yaffee
- Department of Cardiothoracic Surgery, NYU School of Medicine, New York, New York
| | - Mathew R Williams
- Department of Cardiothoracic Surgery, NYU School of Medicine, New York, New York.
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Ohnuma T, Shinjo D, Fushimi K. Hospital mortality of patients aged 80 and older after surgical repair for type A acute aortic dissection in Japan. Medicine (Baltimore) 2016; 95:e4408. [PMID: 27495057 PMCID: PMC4979811 DOI: 10.1097/md.0000000000004408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
To evaluate whether patients aged 80 and older have higher risk of hospital mortality after repair of type A acute aortic dissection (TAAAD).Emergency surgery for TAAAD in patients aged 80 and older remains a controversial issue because of its high surgical risk.Data from patients who underwent surgical repair of TAAAD between April 2011 and March 2013 were retrospectively extracted from the Japanese Diagnosis Procedure Combination database. The effect of age on hospital mortality was evaluated using multivariate logistic regression analysis.A total of 5175 patients were enrolled. The mean age of patients was 67.1 ± 13.0 years, and the male:female ratio was 51:49. Patients aged 80 and older more frequently received tracheostomy than their younger counterparts (9.5% vs 5.4%, P <0.001). Intensive care unit and hospital stays were significantly longer in the elderly cohort versus the younger cohort (7.6 vs 6.7 days, P <0.001, and 42.2 vs 35.8 days, P <0.001, respectively). Logistic regression analysis showed that age ≥80 years was significantly associated with a higher risk of hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 1.28-2.06; P <0.001). In linear regression analysis, age ≥80 years was also significantly associated with longer hospital stay (P = 0.007).In a large, nationwide, Japanese database, patients aged 80 and older were at increased risk of hospital mortality and length of hospital stay.
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Affiliation(s)
| | | | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
- Correspondence: Kiyohide Fushimi, Department of Health Policy and Informatics Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138519, Japan (e-mail: )
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Kondoh H, Satoh H, Daimon T, Tauchi Y, Yamamoto J, Abe K, Matsuda H. Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians. J Thorac Cardiovasc Surg 2016; 152:439-46. [DOI: 10.1016/j.jtcvs.2016.03.093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/23/2016] [Accepted: 03/12/2016] [Indexed: 01/16/2023]
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Karimi A, McCord MR, Beaver TM, Martin TD, Hess PJ, Beck AW, Feezor RJ, Klodell CT. Operative and Mid-Term Outcomes of Thoracic Aortic Operation in Octogenarians and Beyond. J Card Surg 2016; 31:334-40. [DOI: 10.1111/jocs.12722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ashkan Karimi
- Division of Cardiovascular Medicine; University of Florida; Gainesville Florida
| | | | - Thomas M. Beaver
- Department of Surgery; University of Florida; Gainesville Florida
| | - Tomas D. Martin
- Department of Surgery; University of Florida; Gainesville Florida
| | - Philip J. Hess
- Department of Surgery; University of Florida; Gainesville Florida
| | - Adam W. Beck
- Department of Surgery; University of Florida; Gainesville Florida
| | - Robert J. Feezor
- Department of Surgery; University of Florida; Gainesville Florida
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State-of-the-Art Surgical Management of Acute Type A Aortic Dissection. Can J Cardiol 2016; 32:100-9. [DOI: 10.1016/j.cjca.2015.07.736] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 01/16/2023] Open
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Afifi RO, Sandhu HK, Leake SS, Rice RD, Azizzadeh A, Charlton-Ouw KM, Nguyen TC, Miller CC, Estrera AL, Safi HJ. Determinants of Operative Mortality in Patients With Ruptured Acute Type A Aortic Dissection. Ann Thorac Surg 2016; 101:64-71. [DOI: 10.1016/j.athoracsur.2015.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/26/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
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Colli A, Carrozzini M, Galuppo M, Comisso M, Toto F, Gregori D, Gerosa G. Analysis of early and long-term outcomes of acute type A aortic dissection according to the new international aortic arch surgery study group recommendations. Heart Vessels 2015; 31:1616-24. [PMID: 26577993 DOI: 10.1007/s00380-015-0770-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/30/2015] [Indexed: 01/16/2023]
Abstract
To evaluate predictors of early and long-term outcomes of surgical repair of acute Type A aortic dissection. Retrospective single-centre study evaluating patients surgically treated between 1998 and 2013. Clinical follow-up was performed. Complications were classified according to the International Aortic Arch Surgery Study Group recommendations. Statistical analysis included univariate and multivariate analysis of preoperative and operative data. One hundred eighty-five patients were evaluated. The follow-up was complete for 180 patients (97 %). Mean age was 63 years, 82 % had a DeBakey type I aortic dissection, 18 % a type II. Eleven patients (6 %) died intraoperatively, 119 of the remaining (68 %) had postoperative complications. Thirty-day mortality was 21 % (38 patients). Average ICU and hospital stay were 6 and 14 days, respectively. During a mean follow-up time of 6 ± 4 years we observed 44 deaths (31 %). Twenty patients (14 %) needed late thoracic aorta reoperation. Results from the multivariate analysis are as follows. Thirty-day mortality was associated with abdominal pain at presentation (p < 0.01). The incidence of postoperative complications was related to older age at intervention (p < 0.01) and longer cross-clamp time (p < 0.01). Mortality at follow-up was significantly increased by older age at intervention (p < 0.01), with a logarithmic growth after 60 years, female sex (p < 0.01), preoperative limb ischemia (p = 0.02) and DHCA (p < 0.01). The surgical results of type A aortic dissection are affected by age at intervention with a logarithmic increase of late mortality in patients older than 60 years.
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Affiliation(s)
- Andrea Colli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy.
| | - Massimiliano Carrozzini
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Marco Galuppo
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Marina Comisso
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesca Toto
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Dario Gregori
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Zindovic I, Sjögren J, Bjursten H, Danielsson E, Ingemansson R, Nozohoor S. Impact of Hemodynamic Instability and Organ Malperfusion in Elderly Surgical Patients Treated for Acute Type A Aortic Dissection. J Card Surg 2015; 30:822-9. [DOI: 10.1111/jocs.12633] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Igor Zindovic
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Eric Danielsson
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
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Goldfinger JZ, Halperin JL, Marin ML, Stewart AS, Eagle KA, Fuster V. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol 2015; 64:1725-39. [PMID: 25323262 DOI: 10.1016/j.jacc.2014.08.025] [Citation(s) in RCA: 229] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 11/27/2022]
Abstract
Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.
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Affiliation(s)
- Judith Z Goldfinger
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan L Halperin
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Marin
- Department of Surgery, Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Allan S Stewart
- Department of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kim A Eagle
- Department of Medicine, Samuel and Jean A. Frankel Cardiovascular Center, University of Michigan Health System and Medical School, Ann Arbor, Michigan
| | - Valentin Fuster
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
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Malvindi PG, Modi A, Miskolczi S, Kaarne M, Barlow C, Ohri SK, Livesey S, Tsang G, Velissaris T. Acute type A aortic dissection repair in elderly patients. Eur J Cardiothorac Surg 2015; 48:664-70; discussion 671. [DOI: 10.1093/ejcts/ezu543] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 11/26/2014] [Indexed: 11/12/2022] Open
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Yuan Q, Yu H, Karmacharya U, Bai X, Sun H, Huang Y, Ma YT, Ma X. Comparison of chronic type A aortic dissection with acute type A dissection of short-term and long-term survival rate. Int J Cardiol 2014; 175:363-5. [PMID: 24935889 DOI: 10.1016/j.ijcard.2014.04.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/04/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Qinghua Yuan
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Hui Yu
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Ujit Karmacharya
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xue Bai
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Huipin Sun
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Ying Huang
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yi-tong Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
| | - Xiang Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
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Ansari E, Blehm A, Boeken U, Lichtenberg A. Successful acute type A aortic dissection repair in a nonagenarian. Heart Surg Forum 2014; 17:E178-9. [PMID: 25002397 DOI: 10.1532/hsf98.2014329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Surgical repair in older patients with acute type A aortic dissection (ATAAD) evokes a higher peri- and postoperative mortality, it therefore remains controversial in nonagenarians. The authors present a case of a surgically managed ATAAD in a nonagenerian, a 94-year-old man presented with an uncomplicated ATAAD, necessitating emergency surgical repair. The subsequent postoperative course was uneventful, and the patient was discharged after uncomplicated recovery. Aggressive surgical approach should be feasable in select nonagenarian patients with ATAAD, depending on the clinical presention and prior patient history.
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Affiliation(s)
- Edward Ansari
- Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Moorenstrasse 5, 40225 Dusseldorf, Germany, Europe
| | - Alexander Blehm
- Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Moorenstrasse 5, 40225 Dusseldorf, Germany, Europe
| | - Udo Boeken
- Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Moorenstrasse 5, 40225 Dusseldorf, Germany, Europe
| | - Arthur Lichtenberg
- Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Moorenstrasse 5, 40225 Dusseldorf, Germany, Europe
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The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes. BIOMED RESEARCH INTERNATIONAL 2014; 2014:736298. [PMID: 24812629 PMCID: PMC4000933 DOI: 10.1155/2014/736298] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 03/25/2014] [Indexed: 01/22/2023]
Abstract
Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.
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Piccardo A, Le Guyader A, Regesta T, Gariboldi V, Zannis K, Tapia M, Collart F, Kirsch M, Caus T, Cornu E, Laskar M. Octogenarians with uncomplicated acute type a aortic dissection benefit from emergency operation. Ann Thorac Surg 2013; 96:851-6. [PMID: 23916804 DOI: 10.1016/j.athoracsur.2013.04.066] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 04/06/2013] [Accepted: 04/22/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6±2.8 years). RESULTS The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p<0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p<0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years. CONCLUSIONS Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed.
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria JE, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reardon M, Reece TB, Reiss GR, Roselli EE, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures. Ann Thorac Surg 2013; 95:S1-66. [DOI: 10.1016/j.athoracsur.2013.01.083] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 12/24/2012] [Accepted: 01/15/2013] [Indexed: 12/31/2022]
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Zheng J, Lu S, Sun X, Hong T, Yang S, Lai H, Wang C. Surgical management for acute type A aortic dissection in patients over 70 years-old. J Cardiothorac Surg 2013; 8:78. [PMID: 23577777 PMCID: PMC3639068 DOI: 10.1186/1749-8090-8-78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/09/2013] [Indexed: 01/23/2023] Open
Abstract
Background This study aimed to retrospectively investigate our experience of surgical treatment for acute type A aortic dissection in patients older than 70 years. Methods From September 2005 to January 2012, eleven patients who were older than 70 years underwent surgical treatment for type A aortic dissection at our center and were included in this study. Total arch replacement was performed in three patients, seven patients underwent subtotal arch replacement and one with single-branched stent graft implantation. One patient underwent a valve-sparing (David) procedure while another underwent a concomitant aortic valve replacement (Wheat procedure). One patient required coronary artery bypass grafting. All operations were performed under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Results There was one in-hospital death (9.1%) and no operative mortality within 30 days. Cardiopulmonary bypass time, myocardial ischemic time and antegrade cerebral perfusion time accounted for 151.4±33.5 minutes, 68.5±41.4 minutes and 30.3±12.9 minutes, respectively. Overall in-hospital duration, intensive care unit (ICU) time and mean ventilation time were 40.9±40.3 days, 16.5±22.5 days and 90.5±139.4 hours, respectively. New postoperative permanent neurological dysfunction and temporary neurological dysfunction were observed in one patient (9.1%) and in three patients (27.3%), respectively. Mean follow-up was 49.0±19.9 months and nine patients are still alive, one patient died of cancer after 24 months postoperation. Conclusions Surgical management for acute type A dissection in patients older than 70 years is a safe alternative with acceptable risk of death and the early and late results are satisfactory.
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Affiliation(s)
- Jiayu Zheng
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
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Kilic A, Tang R, Whitson BA, Sirak JH, Sai-Sudhakar CB, Crestanello J, Higgins RSD. Outcomes in the current surgical era following operative repair of acute Type A aortic dissection in the elderly: a single-institutional experience. Interact Cardiovasc Thorac Surg 2013; 17:104-9. [PMID: 23563053 DOI: 10.1093/icvts/ivt155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We reviewed our single-centre experience with emergent operative repair of Stanford Type A aortic dissections, with particular attention to outcomes in the elderly. METHODS Consecutive adult patients undergoing emergent operative repair of acute Type A aortic dissections between February 2004 and December 2011 at a single institution were identified. Patients were stratified into elderly (≥ 70 years) and control cohorts (<70 years). Kaplan-Meier analysis was used to evaluate survival. RESULTS A total of 117 patients undergoing emergent repair of Type A aortic dissection were identified during the study period, including 31 (26.5%) elderly and 86 (73.5%) control patients. The mean age in the elderly cohort was 78.0 ± 4.7 years, with 41.9% (13 of 31) being 80 years or older. The elderly and control groups were well matched with regard to preoperative comorbidities (each P>0.05) and the presence of malperfusion at presentation (elderly: 19.4 vs controls: 27.9%, P = 0.35). The most common site of tear involved the proximal ascending aorta (elderly: 83.9 vs controls: 84.9%), with fewer cases affecting the aortic arch (12.9 vs 14.0%; P = 0.75). Operative data, including cardiopulmonary bypass and aortic cross-clamp time, concomitant aortic valve procedures and arch replacement were also similar between cohorts. Fewer elderly patients underwent hypothermic circulatory arrest (67.7 vs 90.7%, P = 0.002). Overall survival to discharge was 87.2% (n = 102), with no difference in the elderly (83.9%; n = 26) vs controls (88.4%; n = 76; P = 0.52). The 30-day (elderly: 82.8 vs controls: 86.2%), 90-day (elderly: 79.0 vs controls: 84.8%) and 1-year (elderly: 75.4 vs controls: 84.8%) survivals were also comparable. CONCLUSIONS Excellent operative outcomes can be achieved in elderly patients undergoing emergent repair of Type A aortic dissections. Advanced patient age should therefore not serve as an absolute contraindication to operative repair in this high-risk cohort.
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Affiliation(s)
- Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA.
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Orihashi K. Acute type a aortic dissection: for further improvement of outcomes. Ann Vasc Dis 2013; 5:310-20. [PMID: 23555530 DOI: 10.3400/avd.ra.12.00051] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/07/2012] [Indexed: 12/20/2022] Open
Abstract
Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.
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Affiliation(s)
- Kazumasa Orihashi
- Department of Surgery II, Kochi Medical School, Nankoku, Kochi, Japan
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Surgery for acute type A aortic dissection in octogenarians is justified. J Thorac Cardiovasc Surg 2013; 145:S186-90. [DOI: 10.1016/j.jtcvs.2012.11.060] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/06/2012] [Accepted: 11/28/2012] [Indexed: 11/22/2022]
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Chien TM, Li WY, Wen H, Huang JW, Hsieh CC, Chen HM, Chiu CC, Chen YF. Stable haemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg 2012; 16:158-65. [PMID: 23166202 DOI: 10.1093/icvts/ivs463] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Acute type A aortic dissection (AAD) is a medical emergency with high mortality even with emergency repair. We explored the prognostic factors of in-hospital mortality for AAD repair. METHODS One hundred and thirty-three consecutive patients operated on for AAD between 1997 and 2011 were enrolled in our study. They were assigned to the in-hospital mortality or the survival group. We evaluated 101 variables to predict in-hospital mortality. All data were collected retrospectively. RESULTS The 30-day mortality, including intraoperative deaths, was 12.8% (17/133 patients) and in-hospital mortality was 18.0% (24/133). Univariate analysis disclosed 10 significant prognostic factors. Multivariate analysis confirmed that preoperative shock or hypotension (odds ratio (OR) = 4.71; P = 0.004), an initial 24 h of bleeding >1500 ml (OR = 5.17; P = 0.01) and age ≥ 75 years (OR = 3.70; P = 0.019) were independent prognostic factors of in-hospital mortality. On the contrary, an electrocardiogram (ECG) showing no abnormalities (OR = 0.22; P = 0.008) is a good prognostic factor for survival. Interestingly, patients with stable haemodynamics without abnormal ECG findings had an excellent result of 1.6% (1/63) in-hospital mortality. CONCLUSIONS Stable haemodynamics and no significant abnormal ECG findings predicted excellent in-hospital survival. Cardiac surgeons and cardiologists should be aware of these positive predictors when treating patients diagnosed with AAD.
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Affiliation(s)
- Tsu-Ming Chien
- School of Post-baccalaureate Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Legras A, Bruzzi M, Nakashima K, Hillion ML, Loisance D, Kirsch M. Risk factors for hospital death after surgery for type A aortic dissection. Asian Cardiovasc Thorac Ann 2012; 20:269-74. [PMID: 22718714 DOI: 10.1177/0218492311435423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was undertaken to identify perioperative risk factors for hospital death in patients undergoing surgery for acute type A aortic dissection. Between 2000 and 2009, 101 consecutive patients underwent emergency surgery for acute type A aortic dissection. Four patients died before institution of cardiopulmonary bypass or completion of the procedure. In the remaining 97 (68 men; mean age, 63.4±16.7 years), proximal repair was performed using ascending aortic replacement with valve re-suspension in 52 (53.6%) and composite valve graft replacement in 44 (45.4%). Distal repair required hemi- or total arch replacement in 42 (43.3%) patients. Overall hospital mortality reached 25.8% (25/97 patients). Logistic regression analysis revealed that advanced age, location of an intimal tear in the arch or more distally, and preoperative coronary malperfusion were significant independent risk factors for hospital death. No procedure-related variables were significant risk factors. Current hospital mortality in patients undergoing emergency surgery for acute type A aortic dissection remains high, but seems to be mainly determined by preoperative variables. More aggressive proximal or distal repairs were not associated with increased mortality.
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Affiliation(s)
- Antoine Legras
- Cardiovascular and Thoracic Surgery Service, Hospital Henri Mondor, 51 Avenue du Mare´chal de Lattre de Tassigny, 94010 Cre´teil Cedex, France
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Wrapping Procedure for Stanford Type A Acute Aortic Dissection: Is There an Indication for Surgery Without a Cardiopulmonary Bypass? Ann Thorac Surg 2012; 94:990-1. [DOI: 10.1016/j.athoracsur.2011.12.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 12/13/2011] [Accepted: 12/19/2011] [Indexed: 11/23/2022]
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Vautrin E, Thony F, Chavanon O, Hannachi I, Barone-Rochette G, Pierre H, Baguet JP. [Aortic dissection spread to the renal arteries: role of renal volumetry after angioplasty]. Ann Cardiol Angeiol (Paris) 2012; 61:203-8. [PMID: 22621849 DOI: 10.1016/j.ancard.2012.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/15/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Type A or B aortic dissection can extend to renal arteries, causing a renal ischemia which treatment is usually endovascular. The aim of our study is to show the interest of the renal volumetry in the follow-up of these patients. PATIENTS AND METHODS Twenty-two patients (16 men, mean age 63.4±11.8years, BMI 25.2±3.4kg/m(2)) with a type A or B aortic dissection spread to one or to both renal arteries and followed at Grenoble university hospital were consecutively included. All patients underwent renal angiography with aorto-renal pressure gradients measurements and follow-up by renal volumetry (scanner Siemens(®)). A renal ischemia was defined by a decrease of 20% or more of the volumetry. RESULTS Sixteen patients (73%) were hypertensive before the aortic dissection among which ten (62%) were treated. Eight patients (36%) have a significant renal pressure gradient among which five (62%) underwent renal endovascular therapy. The renal volumetry of these five patients remained unchanged while six of 17 patients (36%) without angioplasty have a decreasing volumetry. CONCLUSION Renal volumetry appeared an effective and attractive option for the follow-up of the patients with aortic dissection spread to the renal arteries. These results should be taken into account to put the indication of an endovascular treatment.
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Affiliation(s)
- E Vautrin
- Clinique de cardiologie, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France.
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Klodell CT, Karimi A, Beaver TM, Hess PJ, Martin TD. Outcomes for Acute Type A Aortic Dissection: Effects of Previous Cardiac Surgery. Ann Thorac Surg 2012; 93:1206-12; discussion 1212-4. [DOI: 10.1016/j.athoracsur.2011.12.076] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 12/27/2011] [Accepted: 12/30/2011] [Indexed: 11/27/2022]
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