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Mortality and Neurologic Injury After Surgical Repair With Hypothermic Circulatory Arrest in Acute and Chronic Proximal Thoracic Aortic Pathology: Effect of Age on Outcome
Study Questions:
What is the effect of advanced age on mortality and incidence of neurological injury in patients undergoing surgical repair with hypothermic circulatory arrest (HCA) in acute and chronic thoracic aortic pathology?
Methods:
A university center audit was done of 523 consecutive patients (median age, 64 years; interquartile range, 56-71 years) between 2005 and 2010. A multivariable logistic model was applied to assess the strongest independent risk factor of overall and neurological outcome after adjustment for possible confounding factors.
Results:
Mortality in acute type A aortic dissection (207 patients) was 9.7%, and in chronic ascending aortic aneurysms (316 patients) was 2.2% (p < 0.001). Neurological injury was observed in 16.9% of patients with acute type A aortic dissection (chronic ascending aortic aneurysms, 7.9%; p = 0.002). Multivariable regression analysis revealed HCA >40 minutes (odds ratio [OR], 4.21; 95% confidence interval [CI], 1.60-11.06; p = 0.004) and redo surgery (OR, 3.44; 95% CI, 1.11-10.64; p = 0.03), but not age (OR, 1.98; 95% CI, 0.73-5.38; p = 0.18) as an independent predictor of mortality. Emergency surgery (OR, 3.27; 95% CI, 1.31-8.15; p = 0.01) and extracardiac arteriopathy (OR, 2.38; 95% CI, 1.26-4.50; p = 0.008), but not age (OR, 1.80; 95% CI, 0.93-3.48; p = 0.08) were independent predictors of neurological injury.
Conclusions:
The authors concluded that age is not associated with increased risk for mortality and neurological injury in patients undergoing surgical repair for acute and chronic thoracic aortic pathology with HCA.
Perspective:
This study suggests that age is not associated with increased risk for mortality and neurological injury in patients undergoing surgical repair for acute and chronic thoracic aortic pathology with HCA. Furthermore, extended HCA times, reflecting the extent of disease, and redo surgery predict mortality; emergency surgery and extracardiac arteriopathy predict neurological injury. Based on these data, it seems reasonable that each patient with aortic disease be evaluated for surgical therapy independent of age. Other novel techniques such as hybrid off-pump therapy of aortic arch aneurysms including aortic arch debranching in high-risk patients, combined with endovascular stent graft placement, may be considered as alternative therapeutic approaches in appropriate patients.
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