Should octogenarians be denied access to surgery for acute type A aortic dissection?

AIM: Outcomes after surgery for acute type A aortic dissection in the octogenarian are controversial. To analyze this issue further, the authors reviewed their experience in the hope of finding ways to improve results in these high-risk patients. METHODS: Between April 1990 and November 2006, 319 consecutive patients underwent emergency surgery for acute type A aortic dissection at the San Martino University Hospital of Genoa (Italy). Among them, 23 (7%) patients were aged 80 years or older (mean age 82 years, range 80 to 86 years) and represent the study population. On admission 7 patients (30%) had preoperative shock, 1 needed cardiopulmonary resuscitation, 7 (30%) had a neurological deficit, 2 (9%) had acute renal failure. Deep hypothermic circulatory arrest was performed in 19 patients (83%). Surgical procedures included isolated replacement of the ascending aorta in all patients associated with root replacement in 2 (9%) and total aortic arch replacement in 5 (22%). Median follow up was 4.1 years (range 3 to 83 months). RESULTS: Hospital mortality was 61% (14 of 23 patients). Late mortality was 11% (1 of 9 survivors). Stepwise logistic regression identified the extension of surgery to the arch as independent risk factors for hospital death. Fourteen patients (61%) had 1 or more postoperative complications. Overall survival was 39+/-10% and 33+/-10% after 1 and 5 years respectively. CONCLUSIONS: Surgery for acute type A aortic dissection in the octogenarian shows high hospital mortality but satisfactory long-term survival among discharged patients. A less aggressive approach should increase the outcomes of surgically managed patients.

Quadricuspid aortic valve, parossistyc supraventricular tachycardia and double right kidney: an uncommon association.

Fourteen years after surgery for replacement of the aortic valve, an interesting case previously unreported was brought to our attention. The female patient came to our OP Dept for a routine follow-up: she had been found at surgery to have a quadricuspid aortic valve. Operation dated October 1985. At a careful appraisal of the world-wide literature, we noticed that such an association of pathologies had never been reported before: quadricuspid aortic valve, paroxystical supraventricular tachycardia and right double kidney with double renal pelvis and double proximal ureter. Other anomalies associated with the quadricuspid valve, available in the literature are: patent duct, subvalvular fixed aortic stenosis, ventricular septal defect, hypoplastic anterior mitral leaflet and pulmonary stenosis. The pathologic findings at autopsy of this congenital malformation vary between 0.008% and 0.033%; attention must be turned to the fact that the incidence can be underestimated if not expressly searched for. The first quadricuspid aortic valve was described in 1862 by Balington in an autoptic report and sixty other cases have been reported since. In rare cases this pathology has been diagnosed at angiography. At follow up our patient remains in SR with rare transitory episodes of supraventricular tachycardia.