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Is Conventional Aortic Arch Surgery in Octogenarians Justifiable?
K. Minatoya, H. Ogino, H. Matsuda, H. Sasaki, H. Tanaka, J. Kobayashi, T. Yagihara, S. Kitamura. National Cardiovascular Center, Osaka, Japan,
BACKGROUND: Although 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 with aortic diseases, however, is steadily increasing. The aim of this study is to analyze the outcomes of aortic arch surgery in octogenarians.
METHODS: Since 1995, 114 octogenarians have undergone aortic arch replacement (mean age 83.0±2.5, 60 male). All patients underwent surgery under hypothermic circulatory arrest (HCA). The lowest body temperature during HCA was below 22 degree until 2001, however, the temperature was gradually raised up to 28 degree after 2002. Antegrade selective cerebral perfusion or retrograde cerebral perfusion was applied as an adjunctive technique for brain protection. Emergent operations were 37 (32.5%) cases and 28 (24.6%) were for acute aortic dissections. Seventy-four patients (64.9%) had total arch aortic replacement, 40 (35.1%) had hemiarch aortic replacement. Concomitant operations were aortic root replacement in 1 patient, aortic valve replacement in 4, and CABG in 25.
RESULTS: The average duration of circulatory arrest was 57±21 min, the average duration of myocardial ischemic time was 123±45 min, and the average duration of pump time was 224±80 min. The hospital mortality was 7.9% (9 out of 114) in total, 5.2% (4 out of 77) in elective operations, and 13.5% (5 out of 37) in emergent operations (P=0.12). The hospital mortality was 19.2% (5 out of 26) until 2001, however, it was improved down to 4.5% (4 out of 88) after 2002 (P=0.015). Eleven patients (9.6%) had perioperative stroke in total, and 8 patients (7.0%) had transient neurological dysfunction. Other complications were respiratory failure in 17 patients (14.9%), bleeding in 6 (5.3%), problems of GI tract in 3 (2.6%), and mediastinitis in 1 (8.8%). Multivariate predictor (P<0.05) of hospital death was COPD and that of perioperative stroke was emergency operation. Postoperative 1-year survival rate was 84.8%, 3-year survival rate was 68.5%, and 5-year survival rate was 58.1%. CONCLUSIONS: The result of conventional aortic arch surgery in octogenarians is improving. The operations could be performed with an acceptable operative risk even in emergent situation including acute aortic dissection. The conventional surgical option for aortic arch diseases in octogenarians should not be abandoned because of the high chronological age only.
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