Impact of Hemodynamic Instability and Organ Malperfusion in Elderly Surgical Patients Treated for Acute Type A Aortic Dissection.

OBJECTIVE: Recent studies indicate acceptable survival rates in elderly patients treated surgically for acute type A aortic dissection (aTAAD). However, the impact of preoperative hemodynamic compromise or organ malperfusion on outcomes of such patients is still unclear. METHODS: In a retrospective study of 341 patients, 101 qualified as elderly (≥70 years old). Subjects were further grouped by clinical presentation, using the Penn classification. Univariate and multivariable analyses were conducted to identify variables reflecting in-hospital and long-term mortality. RESULTS: Relative to younger subjects, elderly patients showed significantly higher rates of in-hospital mortality (24.8% vs. 14.6%, p = 0.025) and DeBakey type 2 dissections at presentation (40% vs. 18% p < 0.001), with significantly fewer presenting as Penn class Ab (p = 0.010). Penn class Ac was identified as an independent predictor of in-hospital mortality at all ages. Estimated long-term survival was poorer in the elderly (log rank p < 0.001); but in-hospital mortality, based on Penn classification, was similar for both age groups. Survival rates of Penn class Aa subjects at one, five, and 10 years were lower in elderly (vs. younger) patients (79 ± 5.6% vs. 90 ± 2.7%, 68 ± 6.7% vs. 80 ± 3.9%, and 39 ± 10.3% vs. 75 ± 4.6%, respectively; log rank p < 0.001). CONCLUSION: Overall in-hospital mortality is higher in elderly patients surgically treated for aTAAD. Malperfusion and/or hemodynamic instability at presentation confer a dismal prognosis, independent of patient age.

Generalized ischaemia in type A aortic dissections predicts early surgical outcomes only.

OBJECTIVES: In patients with acute type A aortic dissection (aTAAD), early post-surgical outcomes are largely influenced by preoperative conditions, specifically localized or generalized ischaemia. Such states are reflected in the recent Penn classification. Our aim was to determine the impact of preoperative ischaemia (by Penn class) on in-hospital and long-term mortality. METHODS: All consecutive patients (n = 341) surgically treated for aTAAD between 1998 and 2014 were recruited for a retrospective observational study. Parameters impacting in-hospital and long-term mortality were identified through univariable and multivariable analyses. RESULTS: In-hospital mortality rates by Penn class were as follows: Class Aa, 11%; Class Ab, 14%; Class Ac, 42% and Class Abc, 29%. Both Ac [odds ratio (OR) = 4.4; 95% confidence interval (CI), 1.92-9.80] and Abc (OR = 3.72; 95% CI, 1.26-10.99) classifications independently predicted in-hospital mortality, as did cardiopulmonary bypass time (OR = 1.01; 95% CI, 1.00-1.01). Relative to Class Aa patients, survival did not differ significantly in Class Ac and Abc subsets (log-rank P = 0.365 and P = 0.716, respectively), once 30-day postoperative deaths were excluded. The leading cause of late mortality was cardiac failure or myocardial infarction (29%), followed by aortic rupture (25%). Independent predictors of long-term mortality after aTAAD were age [hazard ratio (HR) = 1.08; 95% CI, 1.05-1.10] and supracoronary replacement graft (HR = 2.27; 95% CI, 1.1-4.75). CONCLUSIONS: Penn classes Ac and Abc were identified as an independent risk factor for in-hospital mortality, whereas neither Penn class nor organ-specific ischaemia significantly impacted long-term survival. Regardless of ischaemic manifestations at presentation, the prognosis of patients surviving both surgery and early postoperative period proved acceptable.