Differences in Outcome of Elderly Patients undergoing Urgent Surgical Repair of Acute Type A Aortic Dissection Complicated by Malperfusion

Background: Acute type A aortic dissection is a possibly lethal event that requires urgent surgical treatment. Preoperative malperfusion as well as advanced age are both well known risk factors for a higher perioperative mortality. Therefore, our aim was to investigate differences in operative outcome of elderly patients with acute type A aortic dissection, using the established Penn-Classification to quantify the severity of malperfusion.

Method: A total of 424 patients with acute type A aortic dissection aged ≥ 70 years who underwent urgent surgical repair between 01/2000 and 12/2020 at our center were analyzed retrospectively. Cases of iatrogenic dissection (n = 67), pain-to-cut time ≥ 48 hours (n = 19) or non-evaluable Penn-Classification (n = 9) were excluded. Patients were divided into four groups according to their specific Penn classification and compared using ANOVA and chi-square test. Primary endpoints were 30-day mortality and cCT-confirmed perioperative stroke.

Results:

Variable	Penn Aa (n = 222)	Penn Ab (n = 112)	Penn Ac (n = 43)	Penn Abc (n = 47)	p-Value
Age, years (±SD)	76.5 (±4.9)	77.4 (±5.2)	78.2 (±5.0)	77.2 (±4.4)	0.083
Preoperative resuscitation, n (%)	0 (0)	0 (0)	9 (21)	8 (17)	<0.001
Acute preoperative neurological deficit, n (%)	9 (4)	60 (54)	5 (12)	31 (66)	<0.001
Cardiopulmonary-bypass time, minutes (±SD)	208.0 (±84.8)	239.9 (±88.6)	255.2 (±96.2)	235.9 (±100.1)	0.001
Cross-clamp time, minutes (±SD)	97.2 (±35.9)	108.2 (±40.9)	111.7 (±40.8)	103.5 (±42.1)	0.042
Intensive care time, days (±SD)	13.4 (±16.3)	14.3 (±15.4)	13.8 (±13.2)	10.9 (±11.4)	0.559
Stroke confirmed by cCT, n (%)	33 (15)	22 (20)	4 (9)	13 (28)	0.076
30-day mortality, n (%)	31 (14)	28 (25)	15 (35)	31 (66)	<0.001

Conclusion: Elderly patients suffering from acute type A aortic dissection complicated by malperfusion are subject to a very high perioperative mortality and morbidity, taking into account the limitation that multiple factors may contribute additionally to the high perioperative mortality and stroke rate. Especially in cases of systemic and multiple-organ malperfusion, mortality increases significantly. Therefore, the decision for surgical treatment of elderly patients with multiple malperfusion syndromes should be well considered and drawn carefully.

Publication History

Article published online:
03 February 2022