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\begin{document}

\title{Physical activities and surgical outcomes in elderly patients with acute
type A aortic dissection}



\author[1]{Yasushi Tashima}%
\author[1]{Yurie Toyoshima}%
\author[1]{Kota Chiba}%
\author[1]{Noriyuki Nakamura}%
\author[1]{Koichi Adachi}%
\author[1]{Yoshimitsu Inoue}%
\author[2]{Atsushi Yamaguchi}%
\affil[1]{Yokosuka General Hospital Uwamachi}%
\affil[2]{Jichi Medical University, Saitama Medical Center}%


\vspace{-1em}



  
  \date{May 07, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: Although elderly patients undergoing surgery for acute type A
aortic dissection (ATAAD) is increasing, their physical activities are
not fully understood. We report the physical activities and surgical
outcomes in the elderly patients who underwent ATAAD. Methods: From 2009
to 2019, 103 consecutive patients underwent surgery for ATAAD at our
institution. Surgical outcomes along with pre- and postoperative
physical activities in 52 elderly patients ([?]70 years old) were compared
with those in 51 younger patients (\textless{}70 years old).
Postoperative walking difficulty was defined as taking [?]30 days to
regain the ability to walk 200 m postoperatively or as the inability to
walk at discharge. Results: It took longer for elderly patients to
regain the ability to walk 100 or 200 m postoperatively. ROC analysis
revealed the AUC of the duration for walking 200 m postoperatively as a
prognostic indicator for late deaths was 0.878, with the highest
accuracy at 30 days (sensitivity = 83.3\%, specificity = 91.8\%).
Hospital mortality within 30 days was 3.8\%, and 1-, 3-, and 5-years
survival rates were 92\%, 84.7\%, 84.7\%, respectively, for elderly
patients, with no significant differences between groups. Cox
proportional hazard analysis showed postoperative walking difficulty was
an independent risk factor for late mortality in all cohorts (P =
0.017). Conclusions: Elderly patients undergoing surgical ATAAD repair
showed acceptable surgical outcomes. However, they were more likely to
decrease their physical activities postoperatively. Postoperative
difficulty in walking was an independent risk factor for the late
mortality in patients with ATAAD.%
\end{abstract}%



\sloppy


\emph{ORIGINAL ARTICLE}

\textbf{Physical activities and surgical outcomes in elderly patients
with acute type A aortic dissection}

Yasushi Tashima MD\selectlanguage{ngerman}¹\textsuperscript{,}²\textsuperscript{*} \textbar{}
Yurie Toyoshima\textsuperscript{3*} \textbar{} Kota
Chiba\textsuperscript{3} \textbar{} Noriyuki Nakamura
MD¹\textsuperscript{,}² \textbar{} Koichi Adachi MD¹\textsuperscript{,}²
\textbar{} Yoshimitsu Inoue\textsuperscript{3} \textbar{} Atsushi
Yamaguchi MD, PhD²

¹Department of Cardiovascular Surgery, Yokosuka General Hospital
Uwamachi, Japan

²Department of Cardiovascular Surgery, Saitama Medical Center, Jichi
Medical University, Japan

\textsuperscript{3}Department of Rehabilitation, Yokosuka General
Hospital Uwamachi, Japan

\textbf{Correspondence}

Yasushi Tashima

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi
Medical University,

1-847 Amanuma-cho Omiya-ku Saitama-shi Saitama Japan

Email: \emph{tyasushi42@gmail.com}

\textbf{Data Availability Statement:}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{Funding} : None

\textbf{Conflict of Interest} : None

\textbf{Date and number of IRB approval} :

Date: 2020/5/8

IRB number: 2020004



\textbf{Abstract}

\textbf{Objective:} Although elderly patients undergoing surgery for
acute type A aortic dissection (ATAAD) is increasing, their physical
activities are not fully understood. We report the physical activities
and surgical outcomes in the elderly patients who underwent ATAAD.

\textbf{Methods:} From 2009 to 2019, 103 consecutive patients underwent
surgery for ATAAD at our institution. Surgical outcomes along with pre-
and postoperative physical activities in 52 elderly patients (\selectlanguage{english}[?]70 years
old) were compared with those in 51 younger patients (\textless{}70
years old). Postoperative walking difficulty was defined as taking \selectlanguage{english}[?]30
days to regain the ability to walk 200 m postoperatively or as the
inability to walk at discharge.

\textbf{Results:} It took longer for elderly patients to regain the
ability to walk 100 or 200 m postoperatively. ROC analysis revealed the
AUC of the duration for walking 200 m postoperatively as a prognostic
indicator for late deaths was 0.878, with the highest accuracy at 30
days (sensitivity = 83.3\%, specificity = 91.8\%). Hospital mortality
within 30 days was 3.8\%, and 1-, 3-, and 5-years survival rates were
92\%, 84.7\%, 84.7\%, respectively, for elderly patients, with no
significant differences between groups. Cox proportional hazard analysis
showed postoperative walking difficulty was an independent risk factor
for late mortality in all cohorts (\emph{P} = 0.017).

\textbf{Conclusions:} Elderly patients undergoing surgical ATAAD repair
showed acceptable surgical outcomes. However, they were more likely to
decrease their physical activities postoperatively. Postoperative
difficulty in walking was an independent risk factor for the late
mortality in patients with ATAAD.

\textbf{KEYWORDS}

aortic dissection, rehabilitation, elderly patients, surgery, physical
activities

\textbf{INTRODUCTION}

Acute type A aortic dissection (ATAAD) is a serious and lethal
cardiovascular event, and surgical repair is essential to help these
patients.\textsuperscript{1} Old age is a risk factor for in-hospital
mortality in cardiovascular surgery,\textsuperscript{2} and according to
the data of The International Registry of Acute Aortic Dissection
(IRAD), age \selectlanguage{english}[?]70 years is a significant predictor of in-hospital surgical
mortality in ATAAD.\textsuperscript{3} In contrast, it has been reported
that octogenarian patients showed satisfactory surgical outcomes and
survival rates, which suggests a confident approach toward emergency
repair in elderly patients.\textsuperscript{4} Physical activities are
important prognostic factors for late mortality in elderly patients with
cardiovascular disease.\textsuperscript{5} Cassiatore et al reported
that walking ability is strongly related to mortality and morbidity in
elderly patients after cardiac coronary artery bypass
grafting.\textsuperscript{6} However, there are few studies that
investigated the rehabilitation outcomes and postoperative physical
activities for ATAAD in elderly patients.\textsuperscript{7, 8} The
specific types and intensities of rehabilitation that may be both safe
and beneficial postoperatively for patients who underwent ATAAD is still
controversial.\textsuperscript{7}

We report our experience with ATAAD surgery in patients aged \selectlanguage{english}[?]70. The
outcomes of our rehabilitation program based on walking exercise and the
surgical outcomes of ATAAD repair in these patients were compared with
those in patients aged \textless{}70 years. We also assessed how
postoperative physical activities impact late mortality in the patients
with ATAAD.

\textbf{MATERIALS AND METHODS}

\textbf{Patients}

We retrospectively reviewed 103 consecutive patients who were admitted
to the emergency ward of Yokosuka General Hospital Uwamachi from January
2009 to December 2019 and underwent surgical repair for ATAAD. The
patients were grouped by age; 52 patients aged \selectlanguage{english}[?]70 years were assigned
to the elderly group (median age, 78 years {[}74--83{]}; range, 70--94)
and 51 patients aged \textless{}70 years were assigned to the control
group (median age, 61 years {[}52.5--65.5{]}; range, 41--69). Surgical
outcomes and physical activities before and after surgery were compared
between the groups. In addition, rehabilitation outcomes in the patients
regaining ambulatory autonomy at discharge were compared between the
groups (30 patients in the elderly group vs 37 patients in the control
group). Our selection process and the number of selected patients are
shown in Figure 1. The Institutional Review Board approved this
retrospective observational study. Approval included a waiver of
informed consent.

\textbf{Methods}

Computed tomography angiography and echocardiography were used to
provide a definitive ATAAD diagnosis. After the diagnosis was confirmed,
the patient was promptly transferred to the operating room. The ATAAD
was confirmed by intraoperative findings. Variables were collected from
patient's medical records and preoperative examination. Preoperative
characteristics including sex, body mass index (BMI), comorbidities,
type of aortic dissection, malperfusion, shock (systolic blood pressure
(sBP) level \textless{}80 mmHg), and pre- and postoperative physical
activities were compared between the groups. Surgical variables
including operation time, cardiopulmonary bypass time, surgical
procedure, postoperative complications, intensive care unit (ICU) and
hospital stay, hospital death within 30 days, use of walking aids at
discharge, late mortality, and aortic reintervention were also compared
between the groups. In the patients who regained ambulatory autonomy at
discharge, rehabilitation outcomes including duration to ability to walk
100 and 200 m postoperatively, blood pressure levels before and after
rehabilitation, antihypertensive drug administration during
rehabilitation, intervention of speech and swallowing therapy after
extubation, and duration of ICU and hospital stay were also compared
between the groups. Long-term outcomes were obtained through patient
follow up. We examined patients at our outpatient clinic. The median
follow-up period for the entire cohort was 49 months (19.5--90.5), and
the follow-up rate was 100\%.

We applied the same surgical strategies for the elderly patients and the
young patients. Our surgical procedure comprised median sternotomy with
standard cardiopulmonary bypass. The subclavian artery, left ventricular
apex, or femoral artery was used for arterial cannulation. Antegrade or
retrograde of cold blood cardioplegic solution was infused for
myocardial protection. Surgery was performed under hypothermic
circulatory arrest (bladder temperature, 20degC--26degC), and open distal
anastomosis was performed under circulatory arrest with or without
antegrade selective cerebral perfusion. In general, a tear-oriented
surgical strategy was conducted.\textsuperscript{9} Ascending
replacement was performed in patients for whom the entry site was
located in the ascending aorta or was not found in the ascending aorta
or aortic arch (DeBakey IIIb retrograde dissection). Total or partial
arch replacement was performed in patients whose entry site extended to
or was located in the aortic arch. Although aortic valves were preserved
whenever possible, we performed aortic root replacement when the intimal
tear extended to the sinus of Valsalva or when we observed root dilation
associated with annuloaortic ectasia.

\textbf{Rehabilitation program}

Our rehabilitation program began on day 1 postoperatively. Range of
motion exercise and respiratory rehabilitation were performed on the bed
during intubation on day 1. After extubation, patients with hoarseness
and dysphagia proactively underwent speech and swallowing therapy.
Physical rehabilitation was carried out in a seated position on the bed
and included foot stepping, standing by the bedside, and walking 50 m.
Afterward, walking distance was gradually increased from 100 to 200 m,
depending on the patient's condition. Patients who walked at discharge
were confirmed to be able to walk \textgreater{}200 m before discharge.
Patients who were unable to walk postoperatively due to paraplegia or
major cerebral infarction did not participate in the rehabilitation
program. Systolic and diastolic blood pressure (dBP) levels were
monitored before and after rehabilitation. According to the guidelines
for rehabilitation in patients with cardiovascular
disease,\textsuperscript{10} patients with communicating and
noncommunicating aortic dissection after surgery had sBP level
maintained at \selectlanguage{english}[?]120 mmHg and \selectlanguage{english}[?]130 mmHg, respectively, during
rehabilitation with antihypertensive drugs including calcium blockers,
angiotensin II receptor blockers (ARBs), angiotensin-converting-enzyme
(ACE) inhibitors, or beta blockers. Postoperative computed tomography
angiography was performed within 7 days to assess whether the false
lumen of descending aorta or below was thrombosed or not. During
rehabilitation, patients who presented with leg fatigue, dyspnea, or who
were evaluated by physical therapists to be at risk of falling were
discontinued from walking. We followed the discontinuance criteria of
the rehabilitation described in the guidelines for rehabilitation in
patients with cardiovascular disease (JCS 2012).\textsuperscript{10}.

\textbf{Physical activity}

The Barthel index and walking ability were assessed before surgery and
at discharge in the patients with ATAAD. The Barthel index is a widely
used instrument that assesses activities of daily
living.\textsuperscript{11} The Barthel index score ranges from 0
(completely dependent) to 100 (totally independent), which mean that
lower scores reflect greater nursing
dependence.\textsuperscript{12}Walking ability was assessed in terms of
the patients being able to walk without any aid; with assistive devices,
such as a walker and crutches; needed a wheelchair; or were bedridden
with all assistance. Postoperative walking difficulty was defined as
patients who needed more than 30 days to be able to walk a distance of
200 m after surgery or were unable to walk at discharge.

\textbf{Statistical Analysis}

Continuous data are expressed as the median (25--75 interquatile range),
although the Barthel index is expressed as mean +- SD. All continuous
data were compared between the two groups using Mann--Whitney U test.
Categorical data are expressed as frequencies (\%) and evaluated using
the chi-square test or Fisher's exact test. The prognostic value of the
duration that patients could walk 100 m or 200 m after surgery was
evaluated using receiver operating characteristic (ROC) curve for late
mortality. Overall survival was defined as the time from surgery to
death from any cause. Time-related survival was estimated using
Kaplan--Meier method and compared using a log-rank test between the two
groups. Cox proportional hazards analysis was used to determine the risk
factors for late mortality. Predictors were entered into a univariable
analysis, and any variable with a p value of \selectlanguage{english}[?]0.05 (and aged \selectlanguage{english}[?]70 years)
was entered into the multivariable analysis. All statistical analyses
were performed using EZR (Saitama Medical Center, Jichi Medical
University, Saitama, Japan) or Prism version 8.0 (GraphPad Software, San
Diego, CA, USA). A p value of \textless{}0.05 was considered
statistically significant. The overall survival and ROC curve figures
were created using Prism version 8.

\textbf{RESULTS}

\textbf{Patient characteristics}

Preoperative clinical characteristics of the patients are presented in
Table 1.

Significantly more patients in the elderly group were female
(\emph{P}\textless{} 0.001), and thus, BMI was significantly lower in
the elderly group (\emph{P} \textless{} 0.001). There were no
significant differences for hypertension, hyperlipidemia, diabetes
mellitus, chronic kidney disease, preoperative shock status (sBP
\textgreater{} 80 mmHg), cardiac tamponade, and neurologic deficit
between the groups. Interestingly, patients in the elderly group were
significantly more likely to have undergone DeBakey type II dissection
and noncommunicating dissection compared with the patients in the
control group (DeBakey type II: \emph{P} = 0.0349, noncommunicating
aortic dissection: \emph{P}\textless{} 0.001). There were no significant
differences for malperfusion between the groups. Although preoperative
walking ability was not significantly different between the groups, the
Barthel index in the elderly group was significantly lower than the
control group (\emph{P} = 0.008).

\textbf{Operative details and complications}

Operative details and complications are shown in Table 2. Ascending
aortic replacement was more likely in the elderly group (\emph{P} =
0.065). Arch replacement was less likely in the elderly group, but there
was no statistically significant difference (\emph{P} = 0.091). There
was no significant difference in aortic root replacement, concomitant
aortic valve replacement, and coronary artery bypass grafting between
the groups. Because of more ascending aortic replacement and less arch
replacement in the elderly group, pump run time, aortic cross-clamp
time, and operation time were significantly lower in the elderly group
(pump run time: \emph{P} \textless{} 0.001; aortic cross-clamp
time:\emph{P} = 0.003; operation time: \emph{P} \textless{} 0.001).

Among postoperative complications, stroke, pneumonia, mediastinitis,
intestinal ischemia, long-term intubation (\textgreater{}3 weeks), and
re-exploration for bleeding were not significantly different between the
groups. Frequency of postoperative temporary or permanent hemodialysis
were significantly lower in patients in the elderly group (\emph{P} =
0.015). Postoperative dysphagia occurred significantly more frequently
in elderly patients (\emph{P} = 0.017). ICU stay was likely to be longer
in the elderly group (\emph{P} = 0.094); hence, the duration of
hospitalization was significantly longer in the elderly group (\emph{P}=
0.045). Elderly patients with ATAAD surgery were more likely to decrease
their walking ability at discharge because they were significantly less
likely to discharge by walking without any aids (\emph{P} = 0.021) and
more likely to discharge with a wheelchair compared with patients in the
control group (\emph{P} = 0.052). Postoperative walking difficulty was
significantly more advanced in the elderly group (\emph{P} = 0.013);
therefore, the Barthel index for the elderly group on discharge was
significantly lower than the control group (\emph{P} = 0.032).

\textbf{Rehabilitation outcomes}

The rehabilitation outcomes were compared between the groups to assess
their physical activities among the patients regaining ambulatory
autonomy at discharge (30 patients in the elderly group, and 37 patients
in the control group). Preoperative characteristics and operative
details in patients are presented in Supplemental Table 1 and
Supplemental Table 2. Rehabilitation outcomes in patients regaining
ambulatory autonomy at discharge are presented in Table 3. During
rehabilitation, it was likely that elderly patients took longer to walk
100 or 200 m postoperatively (\emph{P} = 0.024 and \emph{P} = 0.025,
respectively); although, there was no difference in postoperative
walking difficulty between the groups. Elderly patients required
significantly more speaking and swallowing therapy after surgery
(\emph{P} = 0.043). However, the length of ICU stay and the total
hospitalization were not significantly different between the groups.
There was no difference in communicating dissection between the groups
postoperatively. Pre-rehabilitation sBP and dBP levels were 112.5 mmHg
(104.3--120) and 68 mmHg (61.5--74), respectively, in the elderly group
compared with 121.5 mmHg (110--130) and 72 mmHg (60--75), respectively,
in the control group. Post-rehabilitation sBP and dBP levels were 123
mmHg (112.3--133.3) and 75 mmHg (65.5--81.3), respectively, in the
elderly group compared with 121 mmHg (110--134.3) and 70 mmHg (59--80),
respectively, in the control group. There were no statistical
differences in pre-rehabilitation and post-rehabilitation blood pressure
levels between the groups. During the rehabilitation program,
antihypertensive drugs, including calcium blockers, ARB or ACE
inhibitors, and beta blockers, were prescribed to control blood
pressure. The ARB and ACE inhibitors were needed less significantly in
patients in the elderly group to control the blood pressure (\emph{P} =
0.003), although the use of calcium blockers and beta blockers was not
significantly different between the groups. The combination of the
aforementioned three drugs was needed less significantly in patients in
the elderly group to control blood pressure (\emph{P} = 0.004).

The prognostic value of patients' ability to walk 200 m postoperatively
was evaluated using ROC analysis; the results showed that AUC as a
prognostic indicator for late mortality was 0.878 (95\% confidence
interval {[}CI{]}: 0.722--1; \emph{P} = 0.002), with the highest
accuracy at 30 days (sensitivity = 83.3\%, specificity = 91.8\%; Figure
2A). Evaluation of patient's ability to walk 100 m postoperatively using
the ROC analysis as well, the AUC as a prognostic indicator for late
mortality was 0.878 (95\% CI: 0.753--1; \emph{P} = 0.002), with a the
highest accuracy at 20 days (sensitivity = 83.3\%, specificity = 82\%;
Figure 2B).

\textbf{Long-term outcomes}

There were eight remote deaths in the elderly group and three in the
control group during follow up (Table 4). Median follow-up time was 49
months (19.5--90.5) for all patients; 42.5 months (18.8--75.8) for
patients in the elderly group and 53 months (22.5--99) for patients in
the control group. Survival rate at 1, 3, and 5 years from initial
surgical repair, excluding hospital deaths within 30 days, was 92\%
(95\% CI: 0.801--0.969), 84.7\% (95\% CI: 0.703--0.924); and 84.7\%
(95\% CI: 0.703-0.924), respectively, in the elderly group compared with
97.8\% (95\% CI: 0.853--0.997), 97.8\% (95\% CI: 0.853--0.997), and
94.2\% (95\% CI: 0.778--0.986), respectively, in the control group. A
log-rank test comparing the two survival curves did not indicate the
significant difference between the groups (\emph{P} = 0.117) (Figure 3).

Causes of remote deaths included heart failure (1), stroke (2), rupture
of the downstream aorta (1), and pneumonia (4) in the elderly patients.
There were eleven late reinterventions including repair for aortic root
(1), aortic arch (1), descending aorta (6), and abdominal aorta (3).
There were no significant differences in late reinterventions between
the groups.

To assess how postoperative physical activities after the surgery
impacted late mortality, patients with postoperative walking difficulty,
excluding hospital deaths within 30 days, were compared with patients
without postoperative walking difficulty. The patients with
postoperative walking difficulty were found to have significantly worse
late mortality compared with the patients without it (Figure 4A)
(\emph{P} \textless{} 0.001).

Survival rate at 1, 3, and 5 years from initial surgical repair was
89.7\% (95\% CI: 0.749--0.960), 80.6\% (95\% CI: 0.635--0.903), and
76.4\% (95\% CI: 0.576--0.877), respectively, for patients with
postoperative walking difficulty vs 98.2\% (95\% CI: 0.878--0.997),
98.2\% (95\% CI: 0.878--0.997), and 98.2\% (95\% CI: 0.878--0.997),
respectively, for patients without postoperative walking difficulty. Cox
proportional hazard analysis showed that postoperative walking
difficulty was a significant risk factor for late mortality according to
multivariable analysis, whereas age\selectlanguage{english}[?]70 and postoperative stroke were not
(Table 5) (HR 12.65; \emph{P} = 0.017).

We also assessed the risk factors for late mortality in the patients who
regained ambulatory autonomy at discharge. Patients with postoperative
walking difficulty were found to have significantly worse late mortality
compared with the patients without it difficulty (Figure 4B) (\emph{P}
\textless{} 0.001). It was also found in Cox proportional hazard
analysis that postoperative walking difficulty was a significant risk
factor for late mortality according to multivariable analysis, whereas
age\selectlanguage{english}[?]70, re-exploration for bleeding, and long-term intubation
(\textgreater{}3 weeks) were not (Table 6) (HR 15.54; P = 0.026).

\textbf{DISCUSSION}

Life expectancy is increasing steadily in many countries and
consequently presents a higher incidence of cardiovascular diseases,
including ATAAD,\textsuperscript{13, 14} which remains a potentially
lethal clinical presentation as emergency surgery is still a challenging
procedure for elderly patients. It has been reported that surgical risks
are increased in the elderly and old age is a negative prognostic factor
of early mortality after emergency surgery for ATAAD.\textsuperscript{2,
3, 15, 16} However, surgical outcomes for ATAAD have been improving in
Japan \textsuperscript{17} as well as in the rest of the
world\textsuperscript{18}, with several studies reporting good results
from the surgical repair of ATAAD in elderly
patients.\textsuperscript{4, 13} Surgical outcomes in elderly patients
with ATAAD may improve in this decade. Postoperative physical activities
may be strongly associated with quality of life, mental health, and
functional capacity in elderly patients with ATAAD.\textsuperscript{8}It
is reported that walking difficulty is an important risk factor for
mortality and morbidity in patients after elective cardiac
surgery.\textsuperscript{6, 19} However, there are few studies that
assess physical activities or rehabilitation outcomes in elderly
patients after surgery for ATAAD.

This study demonstrated that: 1) there were no significant differences
in short-term and long-term mortality and major postoperative
complications between patients undergoing surgical repair for ATAAD in
the elderly group and in the control group; 2) during rehabilitation, it
took significantly longer for elderly patients to walk 100 or 200 m and
to require speech and swallowing therapy postoperatively for dysphagia;
3) the AUC of the 200-m walk after surgery as a prognostic indicator for
late mortality was 0.878, with a highest accuracy at 30 days
(sensitivity = 83.3\%, specificity = 91.8\%); 4) intriguingly,
postoperative walking difficulty was an independent risk factor for late
mortality in patients regaining ambulatory autonomy at discharge as well
as in all cohorts.

It is still unclear what specific types and intensities of
rehabilitation may be postoperatively safe and beneficial for patients
with ATAAD. In this study, cardiopulmonary exercise testing or invasive
walking tests were not performed to assess physical activities because
the safety and efficacy of these tests have not yet been fully
established in patients with postoperative residual aortic dissection
for ATAAD.\textsuperscript{7, 20} However, we assessed the duration for
the patients to walk 100 or 200 m postoperatively, which is less
invasive and helps to assess postoperative physical activity resumption
with ease compared with cardiopulmonary exercise testing or other walk
tests.

Corone et al reported 33 French patients with type I DeBakey aortic
dissection (mean age, 55.1 years) who underwent cardiac rehabilitation
soon after surgical repair.\textsuperscript{21} They reported that
noncontact aerobic activity with moderate intensity is likely safe and
effective for patients with surgical repair for ATAAD. In this study,
our rehabilitation program was based on walking exercise. During
rehabilitation, acute elevations in BP may transiently increase the risk
of recurrent aortic dissection or rupture after surgical repair for
ATAAD,\textsuperscript{22, 23} because a postdissection aorta is almost
invariably dilated and may have increased associated wall stress
compared with a nondilated aorta.\textsuperscript{24} During
rehabilitation in our study, sBP was strictly controlled between
100--130 mmHg with antihypertensive drugs without any aortic event,
which may support the safety profile of our rehabilitation program.
Elderly patients required fewer antihypertensive drugs to control blood
pressure during the rehabilitation. Because BMI in the elderly group was
significantly lower than the control group, small body size and older
age in the elderly group may affect pharmacological metabolism.

The most obvious limitations of this study were its retrospective
nature, small number of participants, and single-center design, which
are potential sources of bias. In addition, although the majority of
patients showed preoperative independence in activities of daily living
in this study, patients with impaired physical activity may not have
been transferred to our hospital because the family or patients did not
want surgical treatment or because they were assessed as inoperable by
former doctors. Furthermore, the mean follow-up period in the elderly
group was comparatively short (median 42.5 {[}18.8--75.8{]} months;
range 1--125 months), although we did not find significant differences
in long-term follow up between the elderly group and the control group.
Further studies with a larger number of patients, longer observation
time, and greater emphasis on hemodynamic and biomechanical parameters
should be performed to evaluate physical activities and surgical
outcomes in elderly patients with ATAAD.

\textbf{CONCLUSIONS}

Elderly patients who underwent surgical repair for ATAAD showed
acceptable short- and long-term survival. However, they were more likely
to experience a decrease in walking ability and to experience
postoperative dysphagia compared with younger patients. Moreover,
postoperative walking difficulty was an independent risk factor for late
mortality in patients regaining ambulatory autonomy at discharge as well
as in all cohorts.

\textbf{ACKNOWLEDGEMENTS}

The authors would like to thank Enago (\emph{www.enago.jp}) for the
English language review.

\textbf{CONFLICT OF INTERESTS}

The authors declare that there are no conflicts of interests.

\textbf{AUTHOR CONTRIBUTIONS}

Conception and design: Yasushi T, Yurie T

Analysis and interpretation: Yasushi T, Yurie T

Data collection: Yasushi T, Yurie T, NN

Writing the article: Yasushi T, Yurie T

Critical revision of the article: Yasushi T, Yurie T, KC, NN, KA, AY

Final approval of the article: Yasushi T, Yurie T, KC, NN, KA, AY

Statistical analysis: Yasushi T, Yurie T

Obtained funding: Not applicable

Overall responsibility: Yasushi T



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2005;130:677-83.

\textbf{TABLE 1} Preoperative charactaristics\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Characteristics & Total (n=103) & Age\textless{}70 (n=51) & Age[?]70
(n=52) & P value\tabularnewline
Age & 70 (61.5-78) & 61 (52.5-65.5) & 78 (74-83) & \textless{}
0.001\tabularnewline
Male & 46 (44.7\%) & 35 (68.6\%) & 11 (21.2\%) & \textless{}
0.001\tabularnewline
BMI & 24.1 (21-27.7) & 25.6 (22.5-29.8) & 23.1 (19.6-25.8) & \textless{}
0.001\tabularnewline
Hypertention & 69 (67.0\%) & 35 (65.8\%) & 34 (66.7\%) &
0.384\tabularnewline
Diabetes mellitus & 5 (4.9\%) & 2 (3.9\%) & 3 (5.9\%) & \textgreater{}
0.99\tabularnewline
Choronic kidney disease & 34 (33.0\%) & 17 (33.3\%) & 17 (33.3\%) &
\textgreater{} 0.99\tabularnewline
Hyperlipidemia & 15 (14.6\%) & 9 (17.6\%) & 6 (11.8\%) &
0.416\tabularnewline
DeBakey Ior IIIb retrograde & 79 (76.7\%) & 44 (86.3\%) & 35 (67.3\%) &
0.035\tabularnewline
DeBakey II & 24 (23.3\%) & 7 (13.7\%) & 17 (32.7\%) &
0.035\tabularnewline
Communicating dissection & 57 (55.3\%) & 37 (72.5\%) & 20 (38.5\%) &
\textless{} 0.001\tabularnewline
Preoperative shock (sBP \textless{} 80mmHg) & 19 (18.4\%) & 8 (15.9\%) &
11 (21.2\%) & 0.613\tabularnewline
Cardiac tamponade & 59 (57.3\%) & 25 (49.0\%) & 34 (65.4\%) &
0.113\tabularnewline
Cardiopulmonary resuscitation & 3 (2.9\%) & 2 (3.9\%) & 1 (1.9\%) &
0.564\tabularnewline
Neruologic deficit & 6 (5.8\%) & 3 (5.9\%) & 3 (5.8\%) & \textgreater{}
0.99\tabularnewline
Malperfusion & 19 (18.4\%) & 12 (23.5\%) & 7 (13.5\%) &
0.213\tabularnewline
Paraplegia & 1 (1.0\%) & 1 (2.0\%) & 0 (0\%) & 0.49\tabularnewline
Limb & 6 (5.8\%) & 4 (7.8\%) & 2 (3.8\%) & 0.678\tabularnewline
Renal & 6 (5.8\%) & 4 (7.8\%) & 2 (3.8\%) & 0.437\tabularnewline
Brain & 11 (10.7\%) & 5 (9.8\%) & 6 (11.5\%) & \textgreater{}
0.99\tabularnewline
Coronary & 1 (1.0\%) & 1 (2.0\%) & 0 (0\%) & 0.485\tabularnewline
Mesenteric & 7 (6.8\%) & 6 (11.8\%) & 1 (1.9\%) & 0.06\tabularnewline
Preoperative physical activities & & & &\tabularnewline
Barthel index & 96.6 \selectlanguage{ngerman}± 13.9 & 99.8 \selectlanguage{ngerman}± 1.4 & 93.6 \selectlanguage{ngerman}± 19.2 &
0.008\tabularnewline
Walking without any aids & 94 (91.3\%) & 48 (94.1\%) & 46 (88.5\%) &
0.488\tabularnewline
Walking with assistive device & 8 (7.8\%) & 3 (5.9\%) & 5 (9.6\%) &
0.715\tabularnewline
Wheelchair & 0 (0\%) & 0 (0\%) & 0 (0\%) & \textgreater{}
0.99\tabularnewline
Bedridden & 1 (1.0\%) & 0 (0\%) & 1 (1.9\%) & \textgreater{}
0.99\tabularnewline
Abbreviations: BMI, body mass index & Abbreviations: BMI, body mass
index & Abbreviations: BMI, body mass index & Abbreviations: BMI, body
mass index & Abbreviations: BMI, body mass index\tabularnewline
\bottomrule
\end{longtable}

\textbf{TABLE 2} Operative details and complications\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Operative details & Total (n=103) & Age\textless{}70 (n=51) & Age[?]70
(n=52) & P value\tabularnewline
Ascending aorta replacement & 79 (76.7\%) & 35 (68.6\%) & 44 (88.6\%) &
0.065\tabularnewline
Aortic arch replacement & 21 (20.4\%) & 14 (27.5\%) & 7 (13.5\%) &
0.091\tabularnewline
Aortic root replacement & 3 (2.9\%) & 2 (3.9\%) & 1 (1.9\%) &
0.618\tabularnewline
Concomitant AVR & 7 (6.8\%) & 4 (7.8\%) & 3 (5.8\%) &
0.715\tabularnewline
Concomitant CABG & 3 (2.9\%) & 1 (2.0\%) & 2 (3.8\%) & \textgreater{}
0.99\tabularnewline
Pump run time, minutes & 141 (126.5-167) & 152 (131.5-194) & 132.5
(122.8-146.8) & \textless{} 0.001\tabularnewline
Aortic cross-clamp Time, minutes & 92 (75-108.5) & 102 (84-135) & 88.5
(71.5-100.5) & 0.003\tabularnewline
Operation time, minutes & 290 (245-352) & 320 (272-420) & 264
(233.8-308.3) & \textless{} 0.001\tabularnewline
Complications & & & &\tabularnewline
Stroke & 6 (5.8\%) & 3 (5.9\%) & 3 (5.8\%) & 0.837\tabularnewline
Pneumonia & 15 (14.6\%) & 8 (15.7\%) & 7 (13.5\%) & 0.787\tabularnewline
Mediastinitis & 3 (2.9\%) & 1 (2.0\%) & 2 (3.8\%) & \textgreater{}
0.99\tabularnewline
Intestinal ischemia & 1 (1.0\%) & 0 (0\%) & 1 (1.9\%) & \textgreater{}
0.99\tabularnewline
Postoperative hemodialysis & 12(11.7\%) & 10 (19.6\%) & 2 (3.8\%) &
0.015\tabularnewline
Re-exploration for bleeding & 5 (4.9\%) & 1 (2.0\%) & 4 (7.7\%) &
0.363\tabularnewline
Long-term intubation (more than 3 weeks) & 14 (13.6\%) & 7 (13.7\%) & 7
(13.5\%) & \textgreater{} 0.99\tabularnewline
Dysphagia & 45 (43.7\%) & 16 (31.4\%) & 29 (55.8\%) &
0.017\tabularnewline
ICU stay, days & 7 (6-13.5) & 7 (5-12) & 8 (7-14) & 0.094\tabularnewline
Hospital stay, days & 24 (17-45) & 22 (14-37) & 28.5 (19-54.3) &
0.045\tabularnewline
Barthel index at discharge & 79.4 \selectlanguage{ngerman}± 35.1 & 84.7 \selectlanguage{ngerman}± 33.7 & 74.5 \selectlanguage{ngerman}± 36 &
0.034\tabularnewline
Discharged by walking without any aids & 52 (50.5\%) & 31 (60.8\%) & 21
(40.4\%) & 0.021\tabularnewline
by walking with assistive device & 15 (14.6\%) & 6 (11.8\%) & 9 (17.3\%)
& 0.587\tabularnewline
by a wheelchair & 11 (10.7\%) & 2 (3.9\%) & 9 (17.3\%) &
0.052\tabularnewline
Postoperative walking difficulty & 38 (36.9\%) & 12 (23.5\%) & 26 (50\%)
& 0.013\tabularnewline
Hospital death within 30 days & 8 (7.8\%) & 6 (11.8\%) & 2 (3.8\%) &
0.16\tabularnewline
Abbreviations: AVR, aortic valve replacement; CABG, coronary artery
bypass grafting; ICU, intensive care unit & Abbreviations: AVR, aortic
valve replacement; CABG, coronary artery bypass grafting; ICU, intensive
care unit & Abbreviations: AVR, aortic valve replacement; CABG, coronary
artery bypass grafting; ICU, intensive care unit & Abbreviations: AVR,
aortic valve replacement; CABG, coronary artery bypass grafting; ICU,
intensive care unit & Abbreviations: AVR, aortic valve replacement;
CABG, coronary artery bypass grafting; ICU, intensive care
unit\tabularnewline
\bottomrule
\end{longtable}

\textbf{TABLE 3} Rehabilitation-outcomes in the patients regaining
ambulatory autonomy at discharge\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Rehabilitation-outcomes & Total (n=67) & Age\textless{}70 (n=37) &
Age[?]70 (n=30) & P value\tabularnewline
Duration for walking 100m, days & 9 (6-18.5) & 7 (6-17) & 13.5 (8-24.5)
& 0.024\tabularnewline
Duration for walking 200m, days & 13 (9-22) & 11 (7-20) & 15 (10.5-26) &
0.025\tabularnewline
Postoperative walking difficulty & 10 (14.9\%) & 4 (10.8\%) & 6 (16.2\%)
& 0.324\tabularnewline
Speech and swallowing therapy & 26 (38.8\%) & 10 (27\%) & 16 (53.3\%) &
0.043\tabularnewline
Communicating dissection after surgery & 25 (37.3\%) & 16 (43.3\%) & 9
(30\%) & 0.316\tabularnewline
Pre-rehabilitation sBP, mmHg & 116.5 (106-128) & 121.5 (110-130) & 112.5
(104.3-120) & 0.061\tabularnewline
Pre-rehabilitation dBP, mmHg & 69.5 (60-74.3) & 72 (60-75) & 68
(61.5-74) & 0.917\tabularnewline
Post-rehabilitation sBP, mmHg & 121.5 (110-134) & 121 (110-134.3) & 123
(112.3-133.3) & 0.929\tabularnewline
Post-rehabilitation dBP, mmHg & 72 (64-80.5) & 70 (59-80) &
75(65.5-81.3) & 0.242\tabularnewline
Antihypertensive drugs during rehabilitation & & & &\tabularnewline
Calcium blocker & 47 (70.1\%) & 28 (75.7\%) & 19 (63.3\%) &
0.296\tabularnewline
ARB or ACE inhibitor & 34 (50.7\%) & 25 (67.6\%) & 9 (30\%) &
0.003\tabularnewline
Beta blocker & 53 (79.1\%) & 31 (83.8\%) & 22 (73.3\%) &
0.37\tabularnewline
Dual-drugs combination & 28 (41.8\%) & 13 (35.1\%) & 15 (50\%) &
0.319\tabularnewline
Triple-drugs combination & 22 (32.8\%) & 18 (48.6\%) & 4(13.3\%) &
0.004\tabularnewline
Barthel index at discharge & 96.9 \selectlanguage{ngerman}± 6.7 & 97.6 \selectlanguage{ngerman}± 5.7 & 96 \selectlanguage{ngerman}± 7.7 &
0.343\tabularnewline
ICU stay, days & 7 (6-13.5) & 7 (6-9) & 8 (7-14) & 0.276\tabularnewline
Hospital stay, days & 22.5 (16.3-34) & 22 (16-34) & 23.5 (18.3-37) &
0.315\tabularnewline
Abbreviations: ACE, angiotensin-converting-enzyme; ARB, angiotensin II
receptor blocker; dBP, diastolic blood pressure; ICU, intensive care
unit; sBP, systolic blood pressure & Abbreviations: ACE,
angiotensin-converting-enzyme; ARB, angiotensin II receptor blocker;
dBP, diastolic blood pressure; ICU, intensive care unit; sBP, systolic
blood pressure & Abbreviations: ACE, angiotensin-converting-enzyme; ARB,
angiotensin II receptor blocker; dBP, diastolic blood pressure; ICU,
intensive care unit; sBP, systolic blood pressure & Abbreviations: ACE,
angiotensin-converting-enzyme; ARB, angiotensin II receptor blocker;
dBP, diastolic blood pressure; ICU, intensive care unit; sBP, systolic
blood pressure & Abbreviations: ACE, angiotensin-converting-enzyme; ARB,
angiotensin II receptor blocker; dBP, diastolic blood pressure; ICU,
intensive care unit; sBP, systolic blood pressure\tabularnewline
\bottomrule
\end{longtable}

\textbf{TABLE 4} Long-term outcome\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Long-term outcome & Total (n=103) & Age\textless{}70 (n=51) & Age[?]70
(n=52) & P value\tabularnewline
Remote death & 11 & 3 & 8 & 0.201\tabularnewline
Aortic event & 2 (18.2\%) & 0 (0\%) & 2 (25\%) & 0.495\tabularnewline
Stroke & 1 (9.1\%) & 0 (0\%) & 1 (12.5\%) & \textgreater{}
0.99\tabularnewline
Pneumonia & 6 (54.5\%) & 2 (66.7\%) & 4 (50\%) & 0.678\tabularnewline
Cardiac failure & 1 (9.1\%) & 0 (0\%) & 1 (12.5\%) & \textgreater{}
0.99\tabularnewline
Unknown & 1 (9.1\%) & 1 (33.3\%) & 0 (0\%) & 0.495\tabularnewline
Aortic reintervention & 11 & 5 & 6 & \textgreater{} 0.99\tabularnewline
Aortic root & 1 (9.1\%) & 1 (20\%) & 0 (0\%) & 0.495\tabularnewline
Aortic arch & 1 (9.1\%) & 1 (20\%) & 0 (0\%) & 0.495\tabularnewline
Descending aorta & 6 (54.5\%) & 2 (40\%) & 4 (66.7\%) &
0.678\tabularnewline
Abdominal aorta & 3 (27.3\%) & 1 (20\%) & 2 (33.3\%) & \textgreater{}
0.99\tabularnewline
\bottomrule
\end{longtable}

\textbf{TABLE 5} Univariable and Multivariable Analysis of Late
Mortality, Excluding Hospital Deaths within 30days\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& \textbf{Univariable} & \textbf{Univariable} & & \textbf{Multivariable}
& \textbf{Multivariable}\tabularnewline
\textbf{Variables} & \textbf{HR (95\% CI)} & \textbf{P value} & &
\textbf{HR (95\% CI)} & \textbf{P value}\tabularnewline
Preoperative characteristics & & & & &\tabularnewline
Age[?]70 & 2.78 (0.73-10.52) & 0.133 & & 2.17 (0.55-8.59) &
0.27\tabularnewline
Male & 1.59 (0.48-5.23) & 0.445 & & - & -\tabularnewline
Obesity, BMI \textgreater{}28 kg/m\textsuperscript{2} & 0.685
(0.15-3.18) & 0.629 & & - & -\tabularnewline
Choronic kidney disease & 1.29 (0.38-4.42) & 0.683 & & - &
-\tabularnewline
DeBakey Ior IIIb retrograde & 1.34 (0.35-5.08) & 0.667 & & - &
-\tabularnewline
Communicating dissection & 0.98 (0.3-3.23) & 0.979 & & - &
-\tabularnewline
Preoperative shock (sBP \textless{} 80mmHg) & 0.53 (0.07-4.19) & 0.551 &
& - & -\tabularnewline
Cardiac tamponade & 0.89 (0.27-2.91) & 0.843 & & - & -\tabularnewline
Malperfusion & 0.55 (0.07-4.27) & 0.564 & & - & -\tabularnewline
Barthel index & - & \textgreater{} 0.99 & & - & -\tabularnewline
Operative details and complications & & & & &\tabularnewline
Aortic arch replacement & 0.97 (0.21-4.51) & 0.973 & & - &
-\tabularnewline
Pump run time \textgreater{}4hr & 2.04 (0.43-9.59) & 0.369 & & - &
-\tabularnewline
Complications & & & & &\tabularnewline
Stroke & 6.58 (1.35-31.9) & 0.02 & & 4.9 (0.92-25.95) &
0.062\tabularnewline
Pneumonia & 2.56 (0.65-10.13) & 0.18 & & - & -\tabularnewline
Postoperative hemodialysis & 0.75 (0.1-5.87) & 0.782 & & - &
-\tabularnewline
Reexploration for bleeding & 1.72 (0.22-13.43) & 0.606 & & - &
-\tabularnewline
Long-term intubation (more than 3 weeks) & 2.49 (0.66-9.45) & 0.183 & &
- & -\tabularnewline
Dysphagia & 1.44 (0.44-4.72) & 0.552 & & - & -\tabularnewline
Postoperative physical activities & & & & &\tabularnewline
Barthel index & 1.00 (0.98-1.02) & 0.845 & & - & -\tabularnewline
Walking difficulty & 16.45 (2.1-128.7) & 0.008 & & 12.65 (1.57-101.9) &
0.017\tabularnewline
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood
pressure\tabularnewline
\bottomrule
\end{longtable}

\textbf{TABLE 6} Univariable and Multivariable Analysis of Late
Mortality, in the patients regaining ambulatory autonomy at discharge\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& \textbf{Univariable} & \textbf{Univariable} & & \textbf{Multivariable}
& \textbf{Multivariable}\tabularnewline
\textbf{Variables} & \textbf{HR (95\% CI)} & \textbf{P value} & &
\textbf{HR (95\% CI)} & \textbf{P value}\tabularnewline
Preoperative characteristics & & & & &\tabularnewline
Age[?]70 & 2.76 (0.50-15.13) & 0.243 & & 3.62 (0.36-36.44) &
0.275\tabularnewline
Male & 2.19 (0.40-12.01) & 0.368 & & - & -\tabularnewline
Obesity, BMI \textgreater{}28 kg/m\textsuperscript{2} & 1.37 (0.25-7.53)
& 0.715 & & - & -\tabularnewline
Choronic kidney disease & - & \textgreater{} 0.99 & & - &
-\tabularnewline
DeBakey Ior IIIb retrograde & 1.61 (0.29-8.87) & 0.585 & & - &
-\tabularnewline
Communicating dissection & 0.25 (0.03-2.17) & 0.21 & & - &
-\tabularnewline
Preoperative shock (sBP \textless{} 80mmHg) & - & \textgreater{} 0.99 &
& - & -\tabularnewline
Cardiac tamponade & 0.37 (0.07-2.02) & 0.25 & & - & -\tabularnewline
Malperfusion & 1.31 (0.15-11.24) & 0.806 & & - & -\tabularnewline
Barthel index & - & \textgreater{} 0.99 & & - & -\tabularnewline
Operative details and complications & & & & &\tabularnewline
Aortic arch replacement & 0.75 (0.09-6.47) & 0.797 & & - &
-\tabularnewline
Pump run time \textgreater{}4hr & 1.3 (0.15-11.36) & 0.815 & & - &
-\tabularnewline
Complications & & & & &\tabularnewline
Stroke & - & \textgreater{} 0.99 & & - & -\tabularnewline
Pneumonia & 3.24 (0.54-19.43) & 0.199 & & - & -\tabularnewline
Postoperative hemodialysis & 2.35 (0.27-20.25) & 0.438 & & - &
-\tabularnewline
Reexploration for bleeding & 18.08 (1.61-203.3) & 0.019 & & 11.34
(0.6-215) & 0.106\tabularnewline
Long-term intubation (more than 3 weeks) & 7.57 (1.37-41.71) & 0.02 & &
3.14 (0.26-38.45) & 0.37\tabularnewline
Dysphagia & 1.78 (0.36-8.88) & 0.484 & & - & -\tabularnewline
Postoperative physical activities & & & & &\tabularnewline
Barthel index & 0.99 (0.89-1.1) & 0.817 & & - & -\tabularnewline
Walking difficulty & 28.24 (3.29-242.6) & 0.002 & & 15.54 (1.39-174.1) &
0.026\tabularnewline
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood pressure &
Abbreviations: BMI, body mass index; sBP, systolic blood
pressure\tabularnewline
\bottomrule
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\textbf{FIGURE LEGENDS}

\textbf{FIGURE 1} Patient selection flowchart

\textbf{FIGURE 2} ROC curves showing the duration that patients could
postoperatively walk (A) 200 m or (B) 100 m as a prognostic indicator
for late mortality (200 m walk: AUC = 0.878; \emph{P} \textless{} 0.002,
the highest accuracy at 30 days, sensitivity = 83.3\%, specificity =
91.8\%; 100 m walk: AUC = 0.878; \emph{P} \textless{} 0.002, the highest
accuracy at 20 days, sensitivity = 83.3\%, specificity = 82\%)

\textbf{FIGURE 3} Kaplan--Meier survival curves of patients undergoing
surgery for acute type A aortic dissection, excluding hospital deaths
within 30 days. The control and elderly groups are represented by blue
and red line, respectively. \emph{P} values are determined by analyzing
log-rank test

\textbf{FIGURE 4} Kaplan--Meier survival curves of patients with or
without walking difficulty after surgery for acute type A aortic
dissection, excluding hospital deaths within 30 days. A, Patients with
and without postoperative walking difficulty are represented by red and
blue lines, respectively. B, Among the patients regaining ambulatory
autonomy at discharge, the patients with and without postoperative
walking difficulty are represented by red and blue lines,
respectively.\emph{P} values are determined by analyzing log-rank test.

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