eComment. Rationale for operating on the elderly with acute type A dissection

I read with great interest the paper by Kilic et al. [1]. This single centre experience documents 117 patients with type A acute aortic dissection, treated during an 8-year span with excellent results at 30 days and at one year after the surgical intervention. The authors concluded that elderly patients should not be contraindicated to surgical repair. A large body of modern evidence has shown that an age >70 years is an independent preoperative predictor of mortality in patient undergoing surgical intervention for acute type A aortic dissection. The International Registry of Acute Aortic Dissection (IRAD) [2], which includes 18 large referral centres around the world, found in a predictive score to distinguish risk of death that age >70 years is a significant predictor of in-hospital surgical mortality. Other independent preoperative predictors of mortality are shock at presentation, any pulse deficit and myocardial ischaemia. The German Registry for Acute Aortic Dissection Type A (GERAADA) [3], which gathered data from 44 German centres, also identified age as a predictor of increased mortality. In particular, octogenarians patients showed a significantly higher 30-day mortality rate (odds ratio, 3.23; confidence interval, 1.81-5.72). In the last decade, the number of elderly patients suffering from acute type A aortic dissection and undergoing surgery has been steadily increasing. However, without surgical intervention, approximately 75% of those patients die within 2 weeks of the onset of symptoms [4]. So the real question becomes, is it reasonable to perform emergency surgery in elderly patients with acute aortic dissection and is it justified? Age and clinical status at presentation, especially organ malperfusion, should be carefully considered before planning surgical correction. In my opinion, the simple bedside risk prediction tool developed by the International Registry of Acute Aortic Dissection (IRAD) can facilitate the decision-making [2]. Another controversial and more problematic issue is the presence of brain injury at presentation. This question has recently been re-examined [5], the IRAD extracts solely the impact of brain injury on outcomes in this highly lethal condition. On logistic regression analysis, surgical repair was protective against mortality in patients with cerebral injury (odds ratio, 0.058; P= 0.001). Moreover, cerebrovascular accident and coma resolved postoperatively in the majority of cases. According to their findings, the authors stated that patients with acute type A aortic dissection presenting with brain injury should not be contraindicated to surgery. Considering the spontaneous mortality of the disease, I certainly share their conclusion. However, after the age of 80, surgery should be considered on an individual basis, and sophisticated procedures should be meticulously examined. Conflict of interest: none declared.