Sakakibara Heart Institute Minoru Tabata, MD, MPH, Akihito Matsushita, MD, Toshihiro Fukui, MD, Shigefumi Matsuyama, MD, Tomoki Shimokawa, MD, Shuichiro.

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Sakakibara Heart Institute Minoru Tabata, MD, MPH, Akihito Matsushita, MD, Toshihiro Fukui, MD, Shigefumi Matsuyama, MD, Tomoki Shimokawa, MD, Shuichiro Takanashi, MD Department of Cardiovascular Surgery, Sakakibara Heart Institute Department of Cardiovascular Surgery, Teikyo University Outcomes of emergency open surgery for type A acute aortic dissection in patients of 75 years or older Aortic Symposium 2012

Background Emergency open surgery is the gold standard for type A acute aortic dissection. Surgical outcomes in elderly patients with type A acute aortic dissection have been poorly defined. Thorough operative risk assessment is difficult in emergency situations. We evaluated early and late outcomes of emergency open surgery for type A acute aortic dissection in the elderly and explored predictors of poor surgical outcomes. Sakakibara Heart Institute

Patients Between 01/04 and 06/11, 422 patients underwent emergency open surgery for type A acute aortic dissection at out institution. Of those, we reviewed 124 patients of 75 years or older. We also reviewed 26 patients (≥ 75 years old) who were diagnosed with type A acute aortic dissection during the same period but did not underwent surgery. The diagnosis was made with contrast CT in all patients. Sakakibara Heart Institute

Methods Operative death was defined as death within 30 days after surgery or before discharge. Median follow-up period of operative patients was 560 days (range: 3 to 2,534 days). Late survival rates were calculated by Kaplan-Meier method. We explored predictors of adverse event (operative death, stroke or length of stay > 30 days) using a stepwise multivariate logistic regression model. Sakakibara Heart Institute

Decision-making process for our elderly patients with type A acute aortic dissection 150 elderly patients with type A acute aortic dissection 147 patients with no CPR or successful CPR 136 patients with patent false lumen or dilated ascending aorta (≥ 45mm) 124 patients underwent surgery 12 patients refused surgery 11 patients with fully thrombosed false lumen in the ascending aorta < 45mm 3 patients with unsuccessful CPR Sakakibara Heart Institute

Operative patients’ characteristics VariablesMedian (range) or number (frequency) Age78 (75 to 91) Age ≥ 80 years34 (27%) Woman94 (76%) Cardiac tamponade31 (25%) Preop CPR8 (6.5%) Preoperative neurologic deficit15 (12%) Previous sternotomy3 (2.4%) Preoperative hematocrit (%)33 (13 to 50) Preoperative creatinine (mg/dl) 0.8 (0.3 to 6.0) Sakakibara Heart Institute

Operative data Variables Median (range) or number (frequency) Ascending aortic/hemiarch replacement106 (85.5%) Total arch replacement18 (14.5%) Concomitant procedures Bentall operation AVR CABG Others 27 (21.8%) Cardiopulmonary bypass time (min)114 (73 to 272) Aortic cross-clamp time (min)80 (49 to 247) Sakakibara Heart Institute

Operative outcomes VariablesMedian (range) or number (frequency) Operative death6 (4.8%) Stroke22 (17.7%) Respiratory failure27 (21.8%) Median ICU stay (days)4 (2 to 53) Median length of stay (days)21 (3 to 350) Prolonged hospitalization (> 30 days) 25 (20.1%) Sakakibara Heart Institute

Late survival of surgical patients # at risk Sakakibara Heart Institute 1-year survival: 89.3% 3-year survival: 84.7% 5-year survival: 79.1%

Predictors of adverse event after surgery Odds ratio 95% confidence interval P-value Preop CPR Previous sternotomy – Predictors in the final stepwise model Predictors included in the initial model Age, woman, cardiac tamponade, preoperative CPR, preoperative neurologic deficit, previous sternotomy, preoperative hematocrit and serum creatinine. Sakakibara Heart Institute

Outcomes of elderly patients without surgery Patient group 30-day or inhospital death Actuarial 1-year survival 3 patients with unsuccessful CPR 3 (100%)NA 11 patients with fully thrombosed false lumen in the ascending aorta <45mm 1 (9.1%)90.0% 12 patients who refused surgery 6 (50%)34.7% Sakakibara Heart Institute

Conclusions Emergency open surgery for type A acute aortic dissection in patients of 75 years or older resulted in low mortality but high incidence of stroke. Preoperative cardiopulmonary resuscitation and previous sternotomy were predictors of postoperative adverse event. Our findings may be useful for decision-making in elderly patients with type A acute aortic dissection. Sakakibara Heart Institute