在 80 岁以上的老年人中，进行传统的主动脉弓手术是否合理？
Is conventional aortic arch surgery justifiable in octogenarians?
机构信息
Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 5658565, Japan.
出版信息
J Thorac Cardiovasc Surg. 2010 Mar;139(3):641-5. doi: 10.1016/j.jtcvs.2009.11.008.
OBJECTIVE
Although the surgical result of conventional aortic arch replacement has been improved with sophisticated techniques, it is still a deeply invasive procedure. On the other hand, advanced age has been reported as a factor of increased morbidity and mortality in patients undergoing cardiovascular surgery. The number of octogenarians, however, is steadily increasing. The aim of this study is to analyze the outcome of aortic arch surgery in octogenarians.
METHODS
From January 1995 to September 2007, 113 octogenarians and 1 nonagenarian underwent aortic arch replacement (mean age, 83.0 +/- 2.5; 60 men) in our institute. All patients underwent surgery under hypothermic circulatory arrest. The lowest body temperature during circulatory arrest was below 22 degrees C until 2001 and 28 degrees C after 2002. Antegrade selective cerebral perfusion or retrograde cerebral perfusion was used as an additional brain protection technique. Emergency operations were performed in 37 (32.5%) patients; of them, 28 (75.7%) were for acute aortic dissection. Seventy-four (64.9%) patients underwent total arch aortic replacement and the other 40 (35.1%), hemiarch aortic replacement. Concomitant operations consisted of aortic root replacement in 1 patient, aortic valve replacement in 4, and coronary artery bypass grafting in 25.
RESULTS
The average duration of circulatory arrest, myocardial ischemic time, and pump time was 57 +/- 21, 123 +/- 45, and 224 +/- 80 minutes, respectively. The total hospital mortality was 7.9% (9/114), 5.2% (4/77) for elective operations and 13.5% (5/37) for emergency operations (P = .12). The hospital mortality was 19.2% (5/26) until 2001 and decreased to 4.5% (4/88) after 2002 (P = .015). Eleven (9.6%) of the 114 patients had a perioperative stroke, and 8 (7.0%) had transient neurologic dysfunction. Other complications were respiratory failure in 17 (14.9%) patients, bleeding in 6 (5.3%), gastrointestinal tract problems in 3 (2.6%), and mediastinitis in 1 (8.8%) patient. Chronic obstructive pulmonary disease was a multivariate predictor (P < .05) of hospital death and emergency operation was a predictor of perioperative stroke. The postoperative 1-year survival was 84.8%, the 3-year survival was 68.5%, and the 5-year survival was 58.1%.
CONCLUSIONS
The outcome of conventional aortic arch surgery in octogenarians is improving. The operations were performed with an acceptable operative risk even under emergency situations, including acute aortic dissection. The conventional surgical option for aortic arch diseases should not be abandoned only because of the high chronologic age of the patient.
目的
尽管传统主动脉弓置换术的手术效果已经通过复杂的技术得到了改善，但它仍然是一种深度侵袭性的手术。另一方面，高龄已被报道为心血管手术患者发病率和死亡率增加的一个因素。然而，80 岁以上的老年人的数量正在稳步增加。本研究旨在分析 80 岁以上患者主动脉弓手术的结果。
方法
1995 年 1 月至 2007 年 9 月，我院 113 例 80 岁以上患者（平均年龄 83.0+/-2.5；60 例男性）和 1 例 90 岁以上患者接受了主动脉弓置换术。所有患者均在低温体外循环下进行手术。体外循环期间，最低体温在 2001 年之前低于 22°C，之后低于 28°C。顺行选择性脑灌注或逆行脑灌注作为附加的脑保护技术。37 例（32.5%）患者行急诊手术，其中 28 例（75.7%）为急性主动脉夹层。74 例（64.9%）患者行全主动脉弓置换术，40 例（35.1%）行半主动脉弓置换术。同期手术包括主动脉根部置换 1 例，主动脉瓣置换 4 例，冠状动脉旁路移植术 25 例。
结果
体外循环时间、心肌缺血时间和泵时间的平均值分别为 57+/-21、123+/-45 和 224+/-80 分钟。总的院内死亡率为 7.9%（9/114），择期手术为 5.2%（4/77），急诊手术为 13.5%（5/37）（P=0.12）。2001 年之前，院内死亡率为 19.2%（5/26），2002 年之后降至 4.5%（4/88）（P=0.015）。114 例患者中有 11 例（9.6%）发生围手术期卒中，8 例（7.0%）发生短暂性神经功能障碍。其他并发症包括 17 例（14.9%）呼吸衰竭、6 例（5.3%）出血、3 例（2.6%）胃肠道问题和 1 例（8.8%）纵隔炎。慢性阻塞性肺疾病是院内死亡的多变量预测因素（P<0.05），急诊手术是围手术期卒中的预测因素。术后 1 年生存率为 84.8%，3 年生存率为 68.5%，5 年生存率为 58.1%。
结论
传统主动脉弓手术在 80 岁以上患者中的结果正在改善。即使在急性主动脉夹层等紧急情况下，手术也可以在可接受的手术风险下进行。对于主动脉弓疾病，不应仅仅因为患者的高龄而放弃传统的手术选择。
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