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Outcomes of Acute Type A Dissection Repair Before and After Implementation of a Multidisciplinary Thoracic Aortic Surgery Program
Study Questions:
What are the results of acute type A aortic dissection (ATAAD) repair before and after implementation of a multidisciplinary thoracic aortic surgery program (TASP), with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair?
Methods:
Between 1999 and 2011, 128 patients underwent ATAAD repair at the author’s institution. Records of patients who underwent ATAAD repair 6 years before (n = 56) and 6 years after (n = 72) implementation of the TASP were retrospectively compared. Expected operative mortality rates were calculated using the International Registry of Acute Aortic Dissection preoperative prediction model.
Results:
Baseline risk profiles and expected operative mortality rates were comparable between patients who underwent surgery before and after implementation of the TASP. Operative mortality before TASP implementation was 33.9% and was statistically equivalent to the expected operative mortality rate of 26.0% (observed-to-expected mortality ratio: 1.30, p = 0.54). Operative mortality after TASP implementation fell to 2.8% and was statistically improved compared to the expected operative mortality rate of 18.2% (observed-to-expected mortality ratio: 0.15, p = 0.005). Differences in survival persisted over long-term follow-up, with 5-year survival rates of 85% observed for TASP patients compared to 55% for pre-TASP patients (p = 0.002).
Conclusions:
The authors concluded that ATAAD repair can be performed with results approximating those of elective proximal aortic surgery when operations are performed by a high-volume multidisciplinary thoracic aortic surgery team.
Perspective:
This study reported a significant reduction in operative mortality for ATAAD repair following the implementation of a multidisciplinary TASP with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. The current study and other data suggest that outcomes of ATAAD repair could be improved through centralization of care, possibly through the credentialing and designation of regional referral centers for aortic emergencies and establishment of protocols for rapid patient transport, given that few centers are likely to achieve the center and surgeon volume thresholds associated with the best outcomes.
Keywords: Aortic Aneurysm, Thoracic, Credentialing, Survival Rate, Disease Management, Emergencies
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