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Surgical Outcomes of Type A Acute Aortic Dissection
Quick Takes
- In a large national registry study from the UK, factors that were associated with operative mortality among patients with type A aortic dissection included patient age, malperfusion, LVEF, previous cardiac surgery, preoperative mechanical ventilation, preoperative resuscitation, concomitant coronary artery bypass grafting, surgeon, and center.
- There was a significant inverse relationship between surgeon volume and outcomes, but not between center annular volume and outcomes.
Study Questions:
Are there patient, operative, surgeon, and center-related variables predictive of operative mortality among patients who undergo surgery for type A acute aortic dissection?
Methods:
The study group was a cohort of 4,203 patients who underwent surgery for type A aortic dissection in the United Kingdom (UK) between 2009 and 2018, and who were enrolled in the UK National Adult Cardiac Surgical Audit dataset. Multivariable logistic regression analysis was performed with fast backward elimination of variables and bootstrap-based optimism-correction adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths.
Results:
The final variables retained in the multivariable model were patient age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02–1.03; p < 0.001); malperfusion (OR, 1.79; 95% CI, 1.51–2.12; p < 0.001); left ventricular ejection fraction (LVEF 30-49%: OR, 1.40; 95% CI, 1.14–1.71; p = 0.001; LVEF <30%: OR, 2.83; 95% CI, 1.90–4.21; p < 0.001); previous cardiac surgery (OR, 2.29; 95% CI 1.71–3.07; p < 0.001); preoperative mechanical ventilation (OR, 2.76; 95% CI, 2.00–3.80; p < 0.001); preoperative resuscitation (OR, 3.36; 95% CI, 1.14–9.87; p = 0.028); and concomitant coronary artery bypass grafting (OR, 2.29; 95% CI, 1.86–2.83; p < 0.001). After controlling for patient-predicted risk and annual hospital and surgeon volume, both individual centers and individual surgeons contributed significantly to variation in observed mortality. There was a significant inverse relationship between surgeon volume and outcomes (OR, 0.95; 95% CI, 0.92–0.99; p = 0.02), but not between center annular volume and outcomes (OR, 0.99; 95% CI, 0.98–1.01; p = 0.37).
Conclusions:
Patient characteristics, intraoperative factors, cardiac center, and high-volume surgeons were strong determinants of outcomes following type A acute aortic dissection surgery. The authors concluded that these findings may help refine clinical decision making, support patient counseling, and be useful for policy makers for quality assurance and service provision improvement.
Perspective:
This large, national registry study from the UK found a variety of patient and surgical characteristics that were associated with operative mortality among patients with type A acute aortic dissection. Both center and surgeon affected outcomes, but only surgeon volume (not center volume) was associated with mortality. Interestingly, annual surgeon volume of type A acute aortic dissection repairs did not fully account for the relationship between surgeon and mortality, suggesting the contribution of other unmeasured factors. The recognition of preoperative factors that predict high mortality might help with patient and family counseling regarding whether to undertake high-risk surgery. As with many other conditions, specific centers and specific experienced, skilled surgeons are important factors in outcomes.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Interventions and Vascular Medicine
Keywords: Aneurysm, Dissecting, Cardiac Surgical Procedures, Coronary Artery Bypass, Dissection, Outcome Assessment, Health Care, Quality Improvement, Respiration, Artificial, Resuscitation, Stroke Volume, Ventilation, Ventricular Function, Left
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