1
|
Jankovic N, Matkovic M, Bilbija I, Milicevic V, Zlatkovic M, Aleksic N, Cvetic V, Milin-Lazovic J, Putnik S. The Clinical Impact of the Extension of Acute Type A Aortic Surgery on Long-Term Outcomes: Should We Tend to Be Conservative? MEDICINA (KAUNAS, LITHUANIA) 2023; 60:35. [PMID: 38256296 PMCID: PMC10821435 DOI: 10.3390/medicina60010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Despite advances in surgical techniques, industry adjuncts, and cerebral perfusion techniques, the in-hospital mortality rate of type A acute dissection (TAAD) remains at 15-30%. This study aimed to investigate the influence of different extents of aortic resection on survival and quality of life (QoL) after long-term follow-up. Materials and Methods: A retrospective observational trial was performed, including 165 patients operated upon for TAAD. Patients were divided into two groups according to the extent of their aortic repair: the first group comprised patients who had ascending aorta replacement and the second included patients who had hemiarch or total arch replacement. The groups were compared with regard to their baseline characteristics, operative characteristics, survival, complications, and QoL during nine years of follow-up. Results: The mean follow-up time was 75.6 months (1-108 months). The mean survival in the ascending aorta repair group was 89.651 (81.242-98.061) months and was 54.801 (40.053-69.548) months in the hemiarch and arch group; the difference between the groups was significant (log-rank p < 0.001). The rate of new postoperative neurological deficits was statistically higher in the hemiarch and arch group (17.5% vs. 8.4%, p = 0.045), the most common being stroke, and was also more frequent in the hemiarch and arch group than in the ascending aorta group (with statistical significance (15.7% vs. 6.5%)). The mean SF-12 physical score from the QoL questionnaire was higher in the ascending aorta replacement group than in the hemiarch and arch group (50.1 ± 7.3 vs. 44.0 ± 11.9, p = 0.017). Additionally, the mean SF-12 mental score was higher in the ascending aorta replacement group (52.3 ± 7.3 vs. 47.1 ± 12.8, p = 0.032). Conclusions: A more aggressive approach involving aortic arch repair means a lower survival rate and lesser quality of life after long-term follow-up in comparison with the replacement of the ascending aorta. If clinically applicable, a more defensive strategy may be considered.
Collapse
Affiliation(s)
- Natasa Jankovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Milos Matkovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Ilija Bilbija
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Vladimir Milicevic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Mina Zlatkovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Nemanja Aleksic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Vladimir Cvetic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
- Department for Cardiovascular Radiology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Jelena Milin-Lazovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
- Department of Biostatistics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Svetozar Putnik
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| |
Collapse
|
2
|
Manunga J, Smith J, Schmidt CW, Titus J, Mudy K, Pavlovec MP, Sun B, Teng X, Mirza A, Skeik N, Sharma A, Harris KM. Impact of a multidisciplinary acute aortic dissection program: Improved outcomes with a comprehensive initial surgical repair strategy. J Vasc Surg 2021; 75:484-494.e1. [PMID: 34506889 DOI: 10.1016/j.jvs.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE As part of a multidisciplinary aortic dissection (AD) program, a more comprehensive repair strategy for patients with acute type A aortic dissection (ATAAD) and frequent endografting for suitable patients with type B aortic dissection (ATBAD) was adopted in 2015. The aim of this study was to evaluate the impact of these changes. METHODS This study is a retrospective review of a prospective database containing all patients treated for acute AD between 2003 and 2020. Patients were grouped based on differing repair strategies (pre 2015 vs post 2015). Clinical characteristics, procedural details, and survival data were analyzed. RESULTS During this time, 323 patients (210 pre, 113 post) were treated for acute AD at our institution. There were 221 patients with ATAAD (149 pre, 72 post) and 102 patients with ATBAD (61 pre, 41 post). The majority (60%) were males, with a mean age of 65.9 ± 15.2 years. There were no differences in cardiovascular risk factors or demographics between the groups. After 2015, fewer patients with ATAAD underwent medical management alone (15% pre vs 4% post; P = .014), and most that underwent surgical intervention had a total arch or aggressive hemiarch repair (27% pre vs 78% post; P < .001). Seventy-four patients (73%) with ATBAD were treated medically, whereas 28 underwent medical management and endografting (23% pre, 34% post; P = .214). For all patients with AD, 30-day mortality was significantly improved (26% pre vs 10% post; P < .001) especially among patients who underwent ATAAD surgery (23% pre vs 9% post; P = .018). Three-year Kaplan-Meier survival estimates showed survival improvement among patients with ATAAD (Log rank P-value = .019); however, this improvement does not extend to type B dissections or the overall cohort. A survival analysis landmarked to 30 days after initial presentation showed no statistical difference in survival from 30 days to 3 years post-presentation. CONCLUSIONS A more comprehensive repair strategy in the management of patients with acute AD resulted in improved overall patient outcomes and significantly decreased 30-day mortality, even though more complex repairs were performed. The long-term impact of the changes made to our program remains to be evaluated.
Collapse
Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn; Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn.
| | - Jenna Smith
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Christian W Schmidt
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Jessica Titus
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Karol Mudy
- Section of Cardiovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Matthew P Pavlovec
- Section of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Benjamin Sun
- Section of Cardiovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Xiaoyi Teng
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Aleem Mirza
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Amit Sharma
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Kevin M Harris
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn; Section of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| |
Collapse
|
3
|
Lu Y, Xue Y, Zhang H, Xie W, Zhao W, Wang D, Zhou Q. Management strategy of Type A Aortic Dissection in a developing center from China: 16 years experiences. J Thorac Dis 2020; 12:6780-6788. [PMID: 33282379 PMCID: PMC7711430 DOI: 10.21037/jtd-20-1866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Type A Aortic Dissection (TAAD) remains a lethal disease of increasing incidence. However the incidence, standardized treatment and survival rates of TAAD is still a lack in China. This study aims to share the management strategy of TAAD from a developing center of this country. Methods All subjects identified with TAAD in Nanjing Drum Tower Hospital, China, from Jan. 2002 to Dec. 2018 were included in this study. Of 1,037 individuals, 932 (89.9%) were underwent surgery. Based on annual case volume patients underwent surgery were stratified into three operative stages: Early, Middle and Current stage, and patient characteristics, operative trends and outcomes across the operative stages were assessed. Results The annual admissions of patients increased from approximately 20 during 2002–2013 (early era), 100 during 2014–2016 (middle era) to 200 during 2017–2018 (current era). The median age of patients increased from 49.0 to 53.0 among different eras (P<0.001). The overall in-hospital mortality was 16.5%, which significantly decreased from 21.3% to 13.1% with eras (P=0.023). The median time from admission to surgery was remarkedly shorted from 30.4 h during the early era to 14.0 h during the current era. Compared with in the early era, the percentages of aortic arch repair were increased in middle or current eras, while total arch replacement decreased. Conclusions During the last 16 years, the prevalence of TAAD was increasing, and the annual number of operations increased substantially in China. Hospital survival improved over time was challenging prompt management and suitable operations.
Collapse
Affiliation(s)
- Yuzhou Lu
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yunxing Xue
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - He Zhang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Wei Xie
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Weiwei Zhao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Dongjin Wang
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| |
Collapse
|
4
|
Mariscalco G, Maselli D, Zanobini M, Ahmed A, Bruno VD, Benedetto U, Gherli R, Gherli T, Nicolini F. Aortic centres should represent the standard of care for acute aortic syndrome. Eur J Prev Cardiol 2019; 25:3-14. [PMID: 29708034 DOI: 10.1177/2047487318764963] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Existing evidence suggests that patients affected by acute aortic syndromes (AAS) may benefit from treatment at dedicated specialized aortic centres. The purpose of the present study was to perform a meta-analysis to evaluate the impact aortic service configuration has in clinical outcomes in AAS patients. Methods The design was a quantitative and qualitative review of observational studies. We searched PubMed/ MEDLINE, EMBASE, and Cochrane Library from inception to the end of December 2017 to identify eligible articles. Areas of interest included hospital and surgeon volume activity, presence of a multidisciplinary thoracic aortic surgery program, and a dedicated on-call aortic team. Participants were patients undergoing repair for AAS, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were adopted for synthesizing hospital/30-day mortality. Results A total of 79,131 adult patients from a total of 30 studies were obtained. No randomized studies were identified. Pooled unadjusted ORs showed that patients treated in high-volume centres or by high-volume surgeons were associated with lower mortality rates (OR 0.51; 95% CI 0.46-0.56, and OR 0.41, 95% CI 0.25-0.66, respectively). Pooled adjusted estimates for both high-volume centres and surgeons confirmed these survival benefits (adjusted OR, 0.56; 95% CI 0.45-0.70, respectively). Patients treated in centres that introduced a specific multidisciplinary aortic program and a dedicated on-call aortic team also showed a significant reduction in mortality (OR 0.31; 95% CI 0.19-0.5, and OR 0.37; 95% CI 0.15-0.87, respectively). Conclusions We found that specialist aortic care improves outcomes and decreases mortality in patients affected by AAS.
Collapse
Affiliation(s)
- Giovanni Mariscalco
- 1 Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Daniele Maselli
- 2 Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Marco Zanobini
- 3 Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Italy
| | - Aamer Ahmed
- 4 Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Riccardo Gherli
- 6 Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Hospital, Rome, Italy
| | - Tiziano Gherli
- 7 Division of Cardiac Surgery, University of Parma, Parma, Italy
| | | |
Collapse
|
5
|
Merkle J, Sabashnikov A, Deppe AC, Zeriouh M, Maier J, Weber C, Eghbalzadeh K, Schlachtenberger G, Shostak O, Djordjevic I, Kuhn E, Rahmanian PB, Madershahian N, Rustenbach C, Liakopoulos O, Choi YH, Kuhn-Régnier F, Wahlers T. Impact of ascending aortic, hemiarch and arch repair on early and long-term outcomes in patients with Stanford A acute aortic dissection. Ther Adv Cardiovasc Dis 2018; 12:327-340. [PMID: 30295137 DOI: 10.1177/1753944718801568] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND: Stanford A acute aortic dissection (AAD) is a life-threatening emergency associated with major morbidity and mortality. The aim of this study was to compare outcomes of three different surgical approaches in patients with Stanford A AAD. METHODS: From January 2006 to March 2015 a total of 240 consecutive patients with diagnosed Stanford A AAD underwent elective, isolated surgical aortic repair in our centre. Patients were divided into three groups according to the extent of surgical repair: isolated replacement of the ascending aorta, hemiarch replacement and total arch replacement. Patients were followed up for up to 9 years. After univariate analysis multinomial logistic regression was performed for subgroup analysis. Baseline characteristics and endpoints as well as long-term survival were analysed. RESULTS: There were no statistically significant differences among the three groups in terms of demographics and preoperative baseline and clinical characteristics. Incidence of in-hospital stroke ( p = 0.034), need for reopening due to bleeding ( p = 0.031) and in-hospital mortality ( p = 0.017) increased significantly with the extent of the surgical approach. There was no statistical difference in terms of long-term survival ( p = 0.166) among the three groups. Applying multinomial logistic regression for subgroup analysis significantly higher odds for stroke ( p = 0.023), reopening for bleeding ( p = 0.010) and in-hospital mortality ( p = 0.009) for the arch surgery group in comparison to the ascending aorta surgery group as well as significantly higher odds for stroke ( p = 0.029) for the total arch surgery group in comparison to the hemiarch surgery group were identified. CONCLUSIONS: With Stanford A AAD the incidence of perioperative complications increased significantly with the extent of the surgical approach. Subgroup analysis and long-term follow up in patients undergoing isolated ascending or hemiarch surgery showed a lower incidence of cerebrovascular events compared with surgery for total arch replacement.
Collapse
Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Johanna Maier
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Olga Shostak
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Madershahian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| |
Collapse
|
6
|
Merkle J, Sabashnikov A, Weber C, Schlachtenberger G, Maier J, Spieker A, Eghbalzadeh K, Deppe AC, Zeriouh M, Rahmanian PB, Madershahian N, Rustenbach C, Choi YH, Kuhn-Régnier F, Liakopoulos O, Wahlers T. Impact of age on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection. Perfusion 2018; 33:687-695. [DOI: 10.1177/0267659118786332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objectives: Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in older patients and requiring immediate surgical repair. The aim of this study was to evaluate early outcome and short- and long-term survival of patients under and above 65 years of age. Methods: Two hundred and forty patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015 in our center. After statistical analysis and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up, comprising patients under and above 65 years of age. Results: The proportion of patients above 65 years of age suffering from Stanford A AAD was 50% (n=120). The group of patients above 65 years of age compared to the group under 65 years of age showed statistically significant differences in terms of higher odds ratios (OR) for hypertension (p=0.012), peripheral vascular disease (p=0.026) and tachyarrhythmia absoluta (p=0.004). Patients over 65 years of age also showed significantly poorer short- and long-term survival. Our subgroup analysis revealed that male patients (Breslow p=0.001, Log-Rank p=0.001) and patients suffering with hypertension (Breslow p=0.003, Log-Rank p=0.001) were reasonable for these results whereas younger and older female patients showed similar short- and long-term outcome (Breslow p=0.926, Log-Rank p=0.724). After stratifying all patients into 4 age groups (<45; 55-65; 65-75; >75years), short-term survival of the patients appeared to be significantly poorer with increasing age (Breslow p=0.026, Log-Rank p=0.008) whereas long-term survival of patients free from cerebrovascular events (Breslow p=0.0494, Log-Rank p=0.489) remained similar. Conclusions: All patients referred to our hospital for repair of Stanford A AAD with higher age had poorer short- and long-term survival, caused by male patients and patients suffering from hypertension, whereas survival of women and survival free from cerebrovascular events of the entire patient cohort was similar, irrespective of age.
Collapse
Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Johanna Maier
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anna Spieker
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Parwis B. Rahmanian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Madershahian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| |
Collapse
|
7
|
Bin Mahmood SU, Ulrich A, Safdar B, Geirsson A, Mangi AA. Spontaneous rupture of the ascending aorta. J Card Surg 2018; 33:107-114. [PMID: 29405382 DOI: 10.1111/jocs.13535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Nontraumatic, spontaneous rupture of the ascending aorta is rare and the etiology is largely unknown. METHODS We reviewed seven patients from our institution, with no known aortic disease or hereditary connective tissue disorder that presented with spontaneous ascending aortic rupture from 2012 to 2017. RESULTS Most patients presented with non-radiating chest pain along with hypertension (71.4%). The mean ascending aortic diameter at rupture was 4.60 ± 0.62 cm. The median door-to-operating room time was 2.58 h, resulting from effective implementation of an aortic emergency protocol. There were no operative mortalities. CONCLUSIONS In patients with ascending aortic rupture, aortic diameter may not always correlate with the risk of rupture. Rapid diagnosis combined with a multidisciplinary approach is vital for the successful management of these high-risk patients.
Collapse
Affiliation(s)
| | - Andrew Ulrich
- Section of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Basmah Safdar
- Section of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Abeel A Mangi
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
8
|
Abstract
This article discusses the lessons learned by an interdisciplinary team in a large metropolitan specialty hospital during the implementation of the Code Aorta protocol for aortic emergencies and the subsequent application of technological enhancements to improve data transfer. Aortic dissections require rapid diagnosis and surgical treatment; thus, in order to optimize patient outcomes, clinicians must be accessible, data must be readily available, and proper prompts and notifications must be made to alert and ready teams. An interdisciplinary team reviewed our hospital's processes and architecture of systems to define how we provide care during aortic emergencies. Based on this insight into patient flow, we ultimately developed a Code Aorta protocol to streamline provision of care during aortic emergencies. This process focused on protocol development, human-technology interfaces, and outcome-oriented metrics. The team also aimed to heighten awareness of the emergent process and to understand relevant outcomes data. After introduction of the Code Aorta protocol, a 78% reduction was achieved in time-to-treatment from the previous year's average time. In addition, the average length of stay was reduced by 2.4 days (18%). The team's efforts focused on clinical communication, aiming to link technology to maximize clinical efficiency. The initial results of our Code Aorta protocol show promise that continual refinement of patient care processes during aortic emergencies will improve outcomes for patients suffering aortic dissection.
Collapse
|
9
|
Bottle A, Mariscalco G, Shaw MA, Benedetto U, Saratzis A, Mariani S, Bashir M, Aylin P, Jenkins D, Oo AY, Murphy GJ. Unwarranted Variation in the Quality of Care for Patients With Diseases of the Thoracic Aorta. J Am Heart Assoc 2017; 6:JAHA.116.004913. [PMID: 28292748 PMCID: PMC5524021 DOI: 10.1161/jaha.116.004913] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England. METHODS AND RESULTS Data from the Hospital Episode Statistics (HES) and the National Adult Cardiac Surgery Audit (NACSA) were extracted. A parallel systematic review/meta-analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk-adjusted 6-month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more-complex patients and had significantly lower risk-adjusted mortality relative to low-volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high-volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England. CONCLUSIONS Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more-equitable access to treatment and improved outcomes.
Collapse
Affiliation(s)
- Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College, London, United Kingdom
| | - Giovanni Mariscalco
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | - Matthew A Shaw
- Information Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Umberto Benedetto
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, United Kingdom
| | - Athanasios Saratzis
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | - Silvia Mariani
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | - Mohamad Bashir
- Department of Health Economics, University of Liverpool, United Kingdom
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College, London, United Kingdom
| | - David Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Aung Y Oo
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gavin J Murphy
- Leicester Cardiovascular Biomedical Research Unit & Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
| | | |
Collapse
|
10
|
Preventza O, Coselli JS. Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience. Ann Cardiothorac Surg 2016; 5:352-9. [PMID: 27563548 DOI: 10.21037/acs.2016.07.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection is a deadly disease with significant morbidity and mortality. We describe the differential aspects of the disease and the North American experience with its treatment.
Collapse
Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| |
Collapse
|
11
|
Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection-the Mayo Clinic experience. Ann Cardiothorac Surg 2016; 5:296-309. [PMID: 27563542 DOI: 10.21037/acs.2016.06.01] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes. METHODS All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method. RESULTS Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support post-operatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study. DISCUSSION TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.
Collapse
Affiliation(s)
- Alduz Cabasa
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Pochettino
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
12
|
Andersen ND, Benrashid E, Ross AK, Pickett LC, Smith PK, Daneshmand MA, Schroder JN, Gaca JG, Hughes GC. The utility of the aortic dissection team: outcomes and insights after a decade of experience. Ann Cardiothorac Surg 2016; 5:194-201. [PMID: 27386406 DOI: 10.21037/acs.2016.05.12] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time. METHODS An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. RESULTS Institutional ATAAD repair volume remained constant at 12±2 cases per year from 2005-2013, but increased nearly two-fold to 22±6 cases per year (P=0.004) from 2013-2015 following implementation of the RACE-AD protocol. To accommodate this increased volume, two additional surgeons were added to the AAD team. Surgeon ATAAD repair volume was unchanged over the 10-year interval (7.9±3.9 cases per year from 2005-2013 versus 5.5±1.5 cases per year from 2013-2015; P=0.36), and all AAD team surgeons consistently met or exceeded the high-volume surgeon threshold of 5 ATAAD repairs per year. Thirty-day/in-hospital mortality rates of less than 10% were maintained over the study period. CONCLUSIONS Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.
Collapse
Affiliation(s)
- Nicholas D Andersen
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adia K Ross
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lisa C Pickett
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Peter K Smith
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mani A Daneshmand
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
13
|
Shin KC, Lee HS, Park JM, Joo HC, Ko YG, Park I, Kim MJ. Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease. Yonsei Med J 2016; 57:626-34. [PMID: 26996561 PMCID: PMC4800351 DOI: 10.3349/ymj.2016.57.3.626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/14/2015] [Accepted: 09/25/2015] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Acute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED). MATERIALS AND METHODS This was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014). RESULTS Ninety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033). CONCLUSION After the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.
Collapse
Affiliation(s)
- Kyu Chul Shin
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Min Park
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyun-Chel Joo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|