Is conventional aortic arch surgery justifiable in octogenarians?

Abstract

Objective: Although the surgical result of conventional aortic arch replacement has been improved with sophisticated techniques, it is still a deeply invasive procedure. On the other hand, advanced age has been reported as a factor of increased morbidity and mortality in patients undergoing cardiovascular surgery. The number of octogenarians, however, is steadily increasing. The aim of this study is to analyze the outcome of aortic arch surgery in octogenarians.

Methods: From January 1995 to September 2007, 113 octogenarians and 1 nonagenarian underwent aortic arch replacement (mean age, 83.0 +/- 2.5; 60 men) in our institute. All patients underwent surgery under hypothermic circulatory arrest. The lowest body temperature during circulatory arrest was below 22 degrees C until 2001 and 28 degrees C after 2002. Antegrade selective cerebral perfusion or retrograde cerebral perfusion was used as an additional brain protection technique. Emergency operations were performed in 37 (32.5%) patients; of them, 28 (75.7%) were for acute aortic dissection. Seventy-four (64.9%) patients underwent total arch aortic replacement and the other 40 (35.1%), hemiarch aortic replacement. Concomitant operations consisted of aortic root replacement in 1 patient, aortic valve replacement in 4, and coronary artery bypass grafting in 25.

Results: The average duration of circulatory arrest, myocardial ischemic time, and pump time was 57 +/- 21, 123 +/- 45, and 224 +/- 80 minutes, respectively. The total hospital mortality was 7.9% (9/114), 5.2% (4/77) for elective operations and 13.5% (5/37) for emergency operations (P = .12). The hospital mortality was 19.2% (5/26) until 2001 and decreased to 4.5% (4/88) after 2002 (P = .015). Eleven (9.6%) of the 114 patients had a perioperative stroke, and 8 (7.0%) had transient neurologic dysfunction. Other complications were respiratory failure in 17 (14.9%) patients, bleeding in 6 (5.3%), gastrointestinal tract problems in 3 (2.6%), and mediastinitis in 1 (8.8%) patient. Chronic obstructive pulmonary disease was a multivariate predictor (P < .05) of hospital death and emergency operation was a predictor of perioperative stroke. The postoperative 1-year survival was 84.8%, the 3-year survival was 68.5%, and the 5-year survival was 58.1%.

Conclusions: The outcome of conventional aortic arch surgery in octogenarians is improving. The operations were performed with an acceptable operative risk even under emergency situations, including acute aortic dissection. The conventional surgical option for aortic arch diseases should not be abandoned only because of the high chronologic age of the patient.