Operation for acute type A aortic dissection in octogenarians: is it justified?
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.
Neri
E
E
Istituto di Chirurgia Cardiovascolare, Universita' agli Studi di Siena, Unita' Operativa di Chirurgia dell' Aorta Toracica, 53100 Siena, Italy. euxneri@tin.it.nerie@unisi.it
Toscano
T
T
Massetti
M
M
Capannini
G
G
Carone
E
E
Tucci
E
E
Diciolla
F
F
Scolletta
S
S
Morello
R
R
Sassi
C
C
D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D011183:Postoperative Complications; D012044:Regression Analysis; D012189:Retrospective Studies