Operation for acute type A aortic dissection in octogenarians: Is it justified?

Background: With the progressive aging of Western populations, cardiac surg eons are faced with treating an increasing number of elderly patients. Cont roversy exists as to whether the expenditure of health care resources on th e growing elderly populations represents a cost-effective approach to resou rce management. The potential to avoid surgery in patients with little chan ce of survival and poor quality of life would spare unnecessary suffering, reduce operative mortality, and enhance the use of scarce resources. Methods: We reviewed the records of 24 consecutive patients aged 80 years o r older (mean age 83 years, range 80-93 years) who underwent operations for acute type A dissection from 1985 through 1999. No patient with acute type A dissection was refused surgery because of age or concomitant disease. Se venteen patients were men. Preoperatively, none of the patients was moribun d, although 66% had hemodynamic instability and 41% experienced cerebral is chemia. All patients had one or more associated pathologic conditions. Hosp ital mortality and morbidity models, based on our overall experience with 1 97 patients operated on for acute type A aortic dissection during the perio d of the study, were developed by means of multivariate logistic regression with preoperative and intraoperative variables used as independent predict ors of outcome. Results: Overall hospital mortality was 83%. Intraoperative mortality was 3 3%. All patients who survived the operation had one or more postoperative c omplications. Mean hospital stay was 37 days with a total of 314 days in th e intensive care unit (average 19 days, median 17 days). None of the surviv ors (4 patients) discharged from the hospital was able to function independ ently and their survival at 6 months was 0%. Statistical analysis of the ov erall experience with operations for type A acute aortic dissection confirm ed that age in excess of 80 years is the most important independent patient risk factor associated with 30-day mortality and morbidity. Conclusions: Operations for acute type A dissection performed on octogenari ans involve increased hospital mortality and morbidity. Short-term survival is unfavorable and is associated with a poor quality of life. Without addi tional corroborative studies to endorse the present findings, the use of ag e as a parameter to limit access of patients to expensive medical resources remains an unsubstantiated concept. In the context of acute type A aortic dissection, however, the hypothesis that older patients should be denied su ch a complicated surgical intervention to conserve resources is supported b y the presented data.