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Operation for acute type A aortic dissection in octogenarians: is it justified?
E Neri1, T Toscano, M Massetti
1Istituto di Chirurgia Cardiovascolare, Universita' agli Studi di Siena, Unita' Operativa di Chirurgia dell' Aorta Toracica, 53100 Siena, Italy. euxneri@tin.it.nerie@unisi.it
Insights
Surgery for acute type A aortic dissection in octogenarians has extremely high mortality and poor outcomes. These findings suggest that age is a significant risk factor, questioning the benefit of such interventions in this population.
Area of Science:
- Cardiovascular Surgery
- Geriatric Medicine
- Surgical Outcomes Research
Background:
- Increasing elderly populations present challenges in cardiac surgery resource allocation.
- Ethical considerations arise regarding the cost-effectiveness of treating older patients.
- Optimizing resource use by avoiding futile interventions is crucial.
Purpose of the Study:
- To evaluate the outcomes of surgical intervention for acute type A aortic dissection in patients aged 80 years and older.
- To determine if age is an independent risk factor for mortality and morbidity in this patient group.
- To assess the quality of life and survival of octogenarian survivors.
Main Methods:
- Retrospective review of 24 consecutive patients aged 80+ undergoing surgery for acute type A aortic dissection (1985-1999).
- Development of hospital mortality and morbidity models using multivariate logistic regression on a larger cohort (197 patients).
- Analysis included preoperative and intraoperative variables, focusing on age as a predictor.
Main Results:
- Overall hospital mortality was 83%, with 33% intraoperative mortality.
- All survivors experienced postoperative complications; none were independent at discharge.
- Six-month survival for survivors was 0%; age over 80 was the strongest predictor of 30-day mortality/morbidity.
Conclusions:
- Octogenarian surgery for acute type A aortic dissection is associated with high mortality and morbidity.
- Short-term survival is poor, with a low quality of life for survivors.
- Data support the hypothesis that denying complex surgical interventions to older patients may conserve resources, though further studies are needed.
Background:
With the progressive aging of Western populations, cardiac surgeons are faced with treating an increasing number of elderly patients. Controversy exists as to whether the expenditure of health care resources on the growing elderly populations represents a cost-effective approach to resource management. The potential to avoid surgery in patients with little chance of survival and poor quality of life would spare unnecessary suffering, reduce operative mortality, and enhance the use of scarce resources.
Methods:
We reviewed the records of 24 consecutive patients aged 80 years or older (mean age 83 years, range 80-93 years) who underwent operations for acute type A dissection from 1985 through 1999. No patient with acute type A dissection was refused surgery because of age or concomitant disease. Seventeen patients were men. Preoperatively, none of the patients was moribund, although 66% had hemodynamic instability and 41% experienced cerebral ischemia. All patients had one or more associated pathologic conditions. Hospital mortality and morbidity models, based on our overall experience with 197 patients operated on for acute type A aortic dissection during the period of the study, were developed by means of multivariate logistic regression with preoperative and intraoperative variables used as independent predictors of outcome.
Results:
Overall hospital mortality was 83%. Intraoperative mortality was 33%. All patients who survived the operation had one or more postoperative complications. Mean hospital stay was 37 days with a total of 314 days in the intensive care unit (average 19 days, median 17 days). None of the survivors (4 patients) discharged from the hospital was able to function independently and their survival at 6 months was 0%. Statistical analysis of the overall experience with operations for type A acute aortic dissection confirmed that age in excess of 80 years is the most important independent patient risk factor associated with 30-day mortality and morbidity.
Conclusions:
Operations for acute type A dissection performed on octogenarians involve increased hospital mortality and morbidity. Short-term survival is unfavorable and is associated with a poor quality of life. Without additional corroborative studies to endorse the present findings, the use of age as a parameter to limit access of patients to expensive medical resources remains an unsubstantiated concept. In the context of acute type A aortic dissection, however, the hypothesis that older patients should be denied such a complicated surgical intervention to conserve resources is supported by the presented data.