Frailty and risk in proximal aortic surgery

Abstract

Objectives Although frailty has recently been examined in various populations as a predictor of morbidity and mortality, its effect on thoracic aortic surgery outcomes has not been studied. The objective of the present study was to evaluate the role of frailty in predicting postoperative morbidity and mortality in patients undergoing proximal aortic replacement surgery. Methods A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective proximal aortic operations (root, ascending aorta, and/or arch) at a single-referral institution from June 2005 to December 2012. A total of 581 patients underwent proximal aortic surgery, of whom 574 (98.8%) were included in the present analysis; 7 were excluded because of incomplete data. Frailty was evaluated using an index consisting of age > 70 years, body mass index < 18.5 kg/m2, anemia, history of stroke, hypoalbuminemia, and total psoas volume in the bottom quartile of the population. One point was given for each criterion met to determine a frailty score of 0 to 6. Frailty was defined as a score of ≥ 2. Risk models for length of stay > 14 days, discharge to other than home, 30-day composite major morbidity, 30-day composite major morbidity/mortality, and 30-day and 1-year mortality were calculated using multivariate regression modeling. Results Of the 574 patients, 148 (25.7%) were defined as frail (frailty score ≥ 2). The unadjusted 30-day/in-hospital and long-term outcomes were significantly worse for the frail versus nonfrail patients in all but 1 of the outcomes analyzed; no difference was found in the 30-day readmission rates between the 2 groups. In the multivariate model, a frailty score of ≥ 2 was associated with discharge to other than home and 30-day and 1-year mortality. Conclusions Frailty, as defined using a 6-component frailty index, can serve as an independent predictor of discharge disposition and early and late mortality risk in patients undergoing proximal aortic surgery. These frailty markers, all of which are easily assessed preoperatively, could provide valuable information for patient counseling and risk stratification before proximal aortic replacement.

Frailty and perioperative outcomes: a narrative review

“…Four studies involved patients having cardiac valve surgery (including transcatheter aortic valve repplacement). 4,[22][23][24] Five studies involved a mix of gastrointestinal surgical patients, [25][26][27] including abdominal 21 and other general surgery patients. 28 Two studies involved vascular surgical patients 29,30 and two involved surgical oncology patients with either gynecological neoplasms 31 or gastric adenocarcinoma.…”

“…In eight studies, mortality was a perioperative outcome associated with frailty. 4,22,24,25,29,32,33,35 There was a wide variety of odds ratios (OR) for mortality reported in these studies, likely due to the variation in surgical population and frailty assessment used. For example, one study involving cardiac surgical patients reported an OR of 1.10 (95% confidence interval [CI] 1.04 to 1.16), 22 while another study conducted in patients undergoing esophagectomy reported a very high OR of 31.84.…”

“…34 For example, patients classified as intermediately frail in this study had an incident risk ratio (IRR) of 1.5 (95% CI 1.2 to 1.8) with respect to increased LOS, while those classified as frail had an IRR of 1.7 (95% CI 1.3 to 2.2) with respect to increased LOS. Two studies 24,34 examined institutionalization in addition to other perioperative outcomes. In older adult patients undergoing many types of surgeries, odds ratios for discharge to an institution were similar between frail cardiac surgery patients 24 and intermediately frail patients 34 (OR 3.7; 95% CI 1.8 to 7.7 and OR 3.2; 95% CI 1.0 to 10.0, respectively).…”

“…Two studies 24,34 examined institutionalization in addition to other perioperative outcomes. In older adult patients undergoing many types of surgeries, odds ratios for discharge to an institution were similar between frail cardiac surgery patients 24 and intermediately frail patients 34 (OR 3.7; 95% CI 1.8 to 7.7 and OR 3.2; 95% CI 1.0 to 10.0, respectively). Importantly, when an older adult patient was classified as ''frail'' in a study involving all types of surgeries, 34 the OR increased to 20.5 and had a wide 95% CI of 5.5 to 75.7.…”

Geriatric Syndromes and Geriatric Assessment for the Generalist

“…Several studies have shown that preoperative frailty is associated with higher postoperative complications after Geriatric Assessment colorectal and cardiac surgery than nonfrail or prefrail patients. 35,36 Similarly, frail patients had longer hospital stays and higher 30-day readmission rates postoperatively than nonfrail or prefrail individuals. 35,36 Patients with chronic renal failure and frailty had increased risk of mortality than those without frailty.…”