Acute type A aortic dissection repair in octogenarians: Where are the "turn-down" data?

To the Editor:

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With recent improvements in clinical practice, outcomes in acute type A aortic dissection (ATAAD) have improved significantly over the last 2 decades, with mortality rates falling significantly. Several studies emerged trying to focus on outcomes in the elderly cohort, in particular, octogenarians; however, most of these studies are of small size cohorts with a probability of selection bias., The recent study by Bojko and colleagues reports on outcomes in 70 octogenarians who underwent surgery for ATAAD over the course of 15 years compared with 165 septuagenarians. The octogenarians underwent a more conservative approach of only 1 total arch replacement (1.4%) compared with 14 patients (8.4%) in the septuagenarians. Although the 30-day mortality rate was greater in octogenarians (28.6% vs 21.2%) this was not statistically significant P = .29).

While the authors should be commended on these reported outcomes, careful consideration should be given in selecting patients for surgical intervention among the octogenarian cohorts to achieve satisfactory postoperative outcomes. Furthermore, Bojko and colleagues did not report on the number of patients who were turned down for surgery, which forms a key element in comparing outcomes between both cohorts. Clearly, those who were operated on are those who were deemed fit for surgery and as such, included in the analysis. In our experience, over the course of 13 years, we have reported a 33.3% versus 15.8% mortality rate in octogenarians and septuagenarians who underwent nonelective complex aortic surgeries, respectively. Specifically, between 2018 and 2022, we operated on 115 patients with ATAAD, of whom only 3 patients were octogenarians (Figure 1). In this period, we turned down 23 patients with ATAAD (15 patients >80 years old), as they were deemed not fit for surgery due to either significant medical comorbidities that could halt a satisfactory postoperative recovery or debilitating presentation such as extensive neurologic symptoms (Figure 1).

Figure 1

Summary of turned-down cases and their causes.

The authors rightfully measured the quality of life of this cohort, yet only 11% of the octogenarians were followed up, which questions the mid-term impact in operating on such an elderly cohort. Furthermore, could a more conservative approach be a relevant contributing factor for this equal improvement in quality of life among septuagenarians and octogenarians, this remains to be clarified.

Frailty assessment, medical comorbidities, age, cognitive impairment, and careful patient selection should be given serious consideration before operating on patients who are 80 years old or older. Large aortic centers may consider publishing outcomes for those with ATAAD that are not offered surgery to provide a deeper understanding of outcomes and when deciding not to operate.