Early Outcomes After Total Arch Replacement With Frozen Elephant Trunk in Elderly Patients With Acute Type A Aortic Dissection.

OBJECTIVE

The clinical efficacy and early outcomes of total arch replacement with frozen elephant trunk (TAR+FET) in elderly patients presenting with acute type A aortic dissection (ATAAD) remain incompletely characterized. This study aimed to comprehensively evaluate early clinical outcomes and perioperative risk profiles in elderly patients undergoing TAR+FET for ATAAD, thereby addressing gaps in the literature and providing evidence to guide surgical decision-making in this high-risk population.

METHODS

A multicenter retrospective analysis was conducted involving 1634 patients who underwent TAR+FET for ATAAD between 2015 and 2023 across seven cardiovascular centers. Patients were categorized into elderly (≥ 60 years, n = 258) and non-elderly (< 60 years, n = 1376) groups. Baseline characteristics, operative details, and early outcomes were compared between groups before propensity score matching (PSM). A 1:2 PSM established a balanced cohort of 699 patients (elderly, n = 245; non-elderly, n = 454), in which postoperative complications and survival were compared. To evaluate the independent prognostic impact of age, multivariable Cox proportional hazards models with incremental covariate adjustments were applied.

RESULTS

Before PSM, elderly patients had higher prevalences of coronary artery disease, diabetes, and hyperlipidemia, with significantly longer intensive care unit (ICU) stay, prolonged ventilation time, and lower 30-day survival compared with non-elderly patients. After PSM, baseline covariates were well balanced; however, elderly patients continued to demonstrate worse perioperative outcomes, including longer ICU stay (68 [35-162] vs. 47 [28-113] h, p = 0.001), prolonged ventilation time (49 [21-111] vs. 38 [18-86] h, p < 0.001), and higher incidences of reintubation, tracheostomy, respiratory failure, acute kidney injury (AKI), and dialysis (all p < 0.010). Kaplan-Meier analysis revealed significantly lower 30-day survival in the elderly group (86.5% vs. 93.6%, p = 0.002). Multivariable Cox regression identified age ≥ 60 years as an independent predictor of mortality (hazard ratio = 2.286, 95% confidence interval: 1.361-3.840, p = 0.002). Within the elderly subgroup, non-survivors were older, had longer operative and cardiopulmonary bypass times, and experienced substantially higher rates of severe postoperative complications-particularly neurological injury, dialysis-requiring AKI, arrhythmia, and respiratory failure-than survivors.

CONCLUSION

Even after adjustment for baseline characteristics, elderly patients undergoing TAR+FET have higher risks of perioperative complications and early mortality than non-elderly patients. This unfavorable prognosis likely reflects reduced physiological reserve rather than surgical factors alone. Future strategies should emphasize individualized procedure selection and organ-protective perioperative management to improve outcomes in this population.