Complex Aortic Arch Repair Can Be Performed with Good Outcome in Septuagenarians

Objectives: The prevalence of significant thoracic aortic disease rises with age. Complex aortic arch repair carries considerable risks. It may be especially hazardous for elder patients. We reviewed our data on patients older than 70 years that received complex aortic arch repair in our institution.

Methods: Between 04/2010 and 12/2014, a total of 168 patients underwent complex aortic arch repair (>= 2 supra-aortic vessels involved) in our institution. 45 patients were aged >= 70 years. 22 patients (49%) presented with aneurysms, 8 patients (18%) had chronic dissections, 15 patients (33%) received emergency operations for acute aortic dissection and 12 cases (27%) were re-operations. Patients were operated on using prefabricated branched aortic arch grafts. Body temperature was kept at 25°C during circulatory arrest. 13 patients (29%) underwent aortic arch repair on a ́beating heart́ that was continuously perfused with noncardioplegic blood after finishing cardiac procedures to reduce cardiac ischemia.

Results: Patients were aged 73 (71–77) years, 20 (44%) were male. 14 patients (31%) showed reduced renal function preoperatively. 18 patients (40%) received concomitant cardiac procedures including 13 (29%) aortic root replacements. 37 patients (82%) received a classical or frozen elephant trunk. Cardiopulmonary bypass time, cardiac ischemic time, hypothermic circulatory arrest time and selective antegrade cerebral perfusion times were 242 ± 67 minutes, 100 ± 65 minutes, 52 ± 18 minutes, and 92 ± 35 minutes, respectively. With the ́beating heart́ technique, cardiac ischemia could be reduced to 54 ± 28 minute. Postoperative ventilation time was 1.6 (0.6–3.8) days. Rethoracotomy for bleeding, stroke, temporary paraparesis and temporary dialysis occurred in 11%, 9%, 4% and 24% of patients. In hospital mortality was 24% (n = 11; 6 after emergent operations, 3 after re-operations; Cause of death: low cardiac output syndrome n = 7, stroke n = 1, pulmonary embolism n = 1, sepsis n = 1, bleeding n = 1). Mortality was lower in patients undergoing “beating heart” aortic arch repair (1/13 = 7%, p = 0.14).

Conclusion: Complex aortic arch repair can be performed with good results in septuagenarians. Cardiac protection (e.g., by “beating heart” technique) is key to reduce mortality. Preoperative kidney function should be evaluated carefully. We recently introduced lower body perfusion to reduce the risk of renal failure in these patients. Evaluation of a larger patient cohort is mandatory.