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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Nappi F, Schoell T, Singh SSA, Salsano A, Abdou I, Gambardella I, Francesco Santini F, Fiore A, Garufi L, Demondion P, Leprince P, Nicolas Bonnet N, Spadaccio C. Aortic arch registry of type a aortic dissection (AoArch) - rationale, design and definition criteria. J Cardiothorac Surg 2024; 19:514. [PMID: 39238045 PMCID: PMC11375872 DOI: 10.1186/s13019-024-03002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 08/13/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Type A acute aortic dissection (TAAAD) is a deadly condition that demands immediate surgery, because it involves a critically. The mortality and morbidity associated with it are significant, and it is vital that the patient's conditions and treatment strategies are fully understood to ensure the appropriate management of TAAAD. This study aims to ascertain whether hemiarch repair (HAR) versus extended arch repair (EAR) with or without descending aortic intervention results in better perioperative and late outcomes for patients with TAAAD. METHODS Four leading centers of cardiac surgery from two European countries have joined forces to create a groundbreaking multicenter observational registry (AoArch). This study was approved by the institutional review board (IRB 202201173). We conducted a retrospective review (NCT00591263) of our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from January 1, 2005 to March 2024 (NCT05927090). We will analyze how patient co-morbidities, referral conditions, and surgical strategies involving hemi-arch repair (HAR) and extended arch repair (EAR) impact early and late adverse events. We have developed a procedure urgency algorithm based on the severity of preoperative hemodynamic conditions and malperfusion due to TAAAD, and we will use it to assess the primary clinical outcomes: in-hospital mortality, late mortality, and reoperations on the aorta. We will define secondary outcomes as permanent neurologic deficit, the need for new dialysis, respiratory failure, a composite of major adverse events (myocardial infarction, cerebrovascular accidents, the need for dialysis, or the need for tracheostomy), and a composite of major adverse pulmonary events (intubation over 48 h, pneumonia, reintubation, tracheostomy), and reoperation due to bleeding. DISCUSSION This multicenter registry will definitively determine the prognostic significance of critical preoperative conditions and the efficacy of extended arch interventions and hemiarch repair in reducing the risk of early adverse events after surgery for TAAAD. This registry will provide insights into the long-term durability of different strategies of surgical repair for TAAAD.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France.
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France
| | | | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Genoa, Italy
- DISC Department, University of Genoa, Genoa, Italy
| | - Ibrahim Abdou
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France
| | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-New York. Presbyterian Medical Center, 505 E 70th St, New York, NY, USA
| | - F Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Genoa, Italy
- DISC Department, University of Genoa, Genoa, Italy
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, 94000, France
| | - Luigi Garufi
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, Paris, 75013, France
| | - Pierre Demondion
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, Paris, 75013, France
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, Paris, 75013, France
| | - N Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, 45267-0558, USA
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN, USA
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Diaz-Castrillon CE, Serna-Gallegos D, Arnaoutakis G, Szeto WY, Pompeu Sá M, Sezer A, Sultan I. The burden of major complications on failure to rescue after surgery for acute type A aortic dissection: Analysis of more than 19,000 patients. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00615-9. [PMID: 39009336 DOI: 10.1016/j.jtcvs.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/24/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND The relationship between the number and type of postoperative complications and mortality in the setting for surgery for acute type A aortic dissection (ATAAD) remains underexplored despite its critical role in the failure-to-rescue (FTR) metric. METHODS This retrospective study used data from the Society of Thoracic Surgeons Adult Cardiac Surgical Database on ATAAD surgeries performed between January 2018 and December 2022. Patients were categorized based on their number of major complications. The primary outcome was FTR. We used multilevel regression and classification and regression tree models. RESULTS We included 19,243 patients (33% females), with a median age of 61 years. Regarding complications, 47.7% of patients had 0, 20.2% had 1, 12.7% had 2, and 19.4% experienced 3 or more. The most frequently reported complications were prolonged mechanical ventilation (30.3%), unplanned reoperation (19.5%), and renal failure (17.2%). Cardiac arrest occurred in 7.1% of cases. FTR increased from 13% in patients with 1 complication to >30% in those with 4 or more complications. Cardiac arrest (adjusted odds ratio [aOR], 10.9) and renal failure (aOR, 5.3) had the highest odds for mortality, followed by limb ischemia (aOR, 2.7), stroke (aOR, 2.6), and gastrointestinal complications (aOR, 2.4). Hospitals in the top performance quartile consistently showed lower FTR rates across all levels of complication. CONCLUSIONS The study validates a dose-response association between postoperative complications and mortality in patients undergoing surgery for ATAAD. Top-performing hospitals consistently show lower FTR rates independent of the number of complications. Future research should focus on the timing of complications and interventions to reduce the burden of complications.
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Affiliation(s)
- Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - George Arnaoutakis
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin, Austin, Tex
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ahmet Sezer
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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4
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Berezowski M, Bavaria JE, Desai ND. Reply to Dr Poullis. Eur J Cardiothorac Surg 2024; 66:ezae239. [PMID: 38889265 DOI: 10.1093/ejcts/ezae239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Affiliation(s)
- Mikolaj Berezowski
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, PA, USA
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Schiele P, König AN, Meyer A, Falk V, Nienaber CA, Kurz SD. Modelling years of life lost due to acute type A aortic dissection in the German healthcare setting: a predictive study. BMJ Open 2024; 14:e078398. [PMID: 38925695 PMCID: PMC11202649 DOI: 10.1136/bmjopen-2023-078398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/23/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVES This study aimed to develop a patient-centred approach to the burden of acute type A aortic dissection (ATAAD) through modelling. The main objective was to identify potential improvements in managing this life-threatening cardiovascular condition and to provide evidence-based recommendations to optimise outcomes. DESIGN We developed a predictive model along patient pathways to estimate the burden of ATAAD through the years of life lost (YLLs) metric. The model was created based on a systematic review of the literature and was parameterised using demographic data from the German healthcare environment. The model was designed to allow interactive simulation of different scenarios resulting from changes in key impact factors. SETTING The study was conducted using data from the German healthcare environment and results from the literature review. PARTICIPANTS The study included a comprehensive modelling of ATAAD cases in Germany but did not directly involve participants. INTERVENTIONS There were no specific interventions applied in this study based on the modelling design. PRIMARY AND SECONDARY OUTCOME MEASURES The single outcome measure was the estimation of YLL due to ATAAD in Germany. RESULTS Our model estimated 102 791 YLL per year for ATAAD in Germany, with 62 432 and 40 359 YLL for men and women, respectively. Modelling an improved care setting yielded 93 191 YLL or 9.3% less YLL compared with the current standard while a worst-case scenario resulted in 113 023 or 10.0% more YLL. The model is accessible at https://acuteaorticdissection.com/ to estimate custom scenarios. CONCLUSIONS Our study provides an evidence-based approach to estimating the burden of ATAAD and identifying potential improvements in the management of pathways. This approach can be used by healthcare decision-makers to inform policy changes aimed at optimising patient outcomes. By considering patient-centred approaches in any healthcare environment, the model has the potential to improve efficient care for patients suffering from ATAAD.
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Affiliation(s)
- Philipp Schiele
- Department of Statistics, Ludwig-Maximilians-Universität München, München, Germany
| | - Adriana N König
- Munich School of Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, München, Germany
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Christoph A Nienaber
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiology and Aortic Centre, The Royal Brompton & Harefield Hospitals as part of Guys' and St. Thomas' NHS Foundation Trust, London, UK
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Maroto LC, Ferrera C, Cobiella J, Carnero M, Beltrao R, Martínez I, Campelos P, Martín-Sánchez FJ, Carrero AM, Domínguez MJ, Álvarez E, Fernández F, Cabeza B, Colorado E, Villacastín JP, Vilacosta I. Improvement of Early Outcomes in Type A Acute Aortic Syndrome After an Aorta Code Implementation. Ann Thorac Surg 2024; 117:770-778. [PMID: 37488005 DOI: 10.1016/j.athoracsur.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Reduction of variability through process reengineering can improve surgical results for patients with type A acute aortic syndrome. We compare short-term results before and after implementation of an Aorta Code for patients with type A acute aortic syndrome who underwent surgery. METHODS The Aorta Code was implemented in a 5-hospital healthcare network in 2019. This critical pathway was based on a simple diagnostic algorithm, ongoing training, immediate patient transfer, and treatment by an expert multidisciplinary team. We retrospectively compared all patients operated on in our center before (2005-2018) and after (January 2019 to February 2023) its implementation. RESULTS One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly. CONCLUSIONS An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased.
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Affiliation(s)
- Luis C Maroto
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain.
| | - Carlos Ferrera
- Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Rosa Beltrao
- Department of Anesthesiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Isaac Martínez
- Department of Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Paula Campelos
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Ana M Carrero
- Emergency Department, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - María J Domínguez
- Emergency Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Esther Álvarez
- Emergency Department, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Fátima Fernández
- Emergency Department, Hospital Universitario de Móstoles, Madrid, Spain
| | - Beatriz Cabeza
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - Isidre Vilacosta
- Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
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Patel PM, Olakunle OE, Dong A, Chiou E, Wei J, Binongo J, Leshnower B, Chen EP. Acute type A aortic syndromes: outcomes are independent of aortic root/valve management. Indian J Thorac Cardiovasc Surg 2024; 40:123-132. [PMID: 38389780 PMCID: PMC10879474 DOI: 10.1007/s12055-023-01602-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 02/24/2024] Open
Abstract
Purpose Clinical outcomes following various surgical intervention strategies for aortic root and valve pathology during repair of acute type A aortic syndromes were studied and compared. Methods From 2004 to 2019, 634 patients underwent acute type A aortic repair. Patients were divided into 4 groups: Valve Resuspension (n = 456), Isolated Valve Replacement (AVR) (n = 24), Valve and Root Replacement (ROOT) (n = 97), and Valve Sparing Root Replacement (VSRR) (n = 57). The primary endpoint was midterm survival and multivariable risk factor analysis was performed. Results The mean age was 55.4 ± 13 years, 424 (67%) were male, and overall early mortality was 12%. Early mortality was 13%, 8%, 11%, and 7% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.43. Five-year survival was 74%, 86%, 73%, and 84% for the Valve Resuspension, AVR, ROOT, and VSRR groups respectively, p = 0.46. There was no difference in late stroke, renal failure, heart block, and late bleeding (p > 0.05 for all). At late follow-up, AVR and ROOT patients had a higher mean gradient versus Valve Resuspension and VSRR patients, p < 0.0001. For the total cohort, risk factors for late mortality included preoperative peripheral vascular disease (hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.4, p = 0.009) and preoperative dialysis (HR 2.8, 95% CI 1.3-6.1, p = 0.01). Conclusion Mid-term survival following repair of acute type A aortic dissection is not independently associated with a specific type of aortic valve intervention. Native valve preservation leads to acceptable mid-term valve hemodynamics and should be the preferred therapy in this emergent clinical setting. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-023-01602-8.
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Affiliation(s)
- Parth Mukund Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Oreoluwa Elizabeth Olakunle
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Andy Dong
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Edward Chiou
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Jane Wei
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Jose Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Bradley Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA USA
| | - Edward Po Chen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine, Duke University Medical Center, 2310 Erwin Road, 8660 HAFS Building, Durham, NC 27710 USA
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9
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Jubouri M, Kayali F, Agbobu T, Tahhan O, Moothathamby T, Abdulwahab ER, Velayudhan B, Mohammed I, Bashir M. Thoraflex Hybrid Prosthesis (THP): the profile. Expert Rev Med Devices 2024; 21:165-177. [PMID: 38431273 DOI: 10.1080/17434440.2024.2326539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority. AREAS COVERED This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted. EXPERT OPINION THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Fatima Kayali
- University Hospitals Sussex NHS Foundation Trust, Sussex, UK
| | | | - Owais Tahhan
- Aston Medical School, Aston University, Birmingham, UK
| | - Thurkga Moothathamby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Eyad R Abdulwahab
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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10
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Banceu CM, Banceu DM, Kauvar DS, Popentiu A, Voth V, Liebrich M, Halic Neamtu M, Oprean M, Cristutiu D, Harpa M, Brinzaniuc K, Suciu H. Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review. J Clin Med 2024; 13:1231. [PMID: 38592069 PMCID: PMC10932437 DOI: 10.3390/jcm13051231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.
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Affiliation(s)
- Cosmin M. Banceu
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Diana M. Banceu
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - David S. Kauvar
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Adrian Popentiu
- Faculty of Medicine, University Lucian Blaga Sibiu, 550169 Sibiu, Romania
| | | | | | - Marius Halic Neamtu
- Swiss Federal Institute of Forest, Snow and Landscape Research WSL, 8903 Birmensdorf, Switzerland
- Institute of Environmental Engineering, ETH Zurich, 8039 Zurich, Switzerland
| | - Marvin Oprean
- Mathematics and Statistics Department, Amherst College, Amherst, MA 01002, USA
| | - Daiana Cristutiu
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Marius Harpa
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Klara Brinzaniuc
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Anatomy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Horatiu Suciu
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania; (C.M.B.)
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
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11
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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12
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Perri JL, Nguyen TC. Advanced Fellowships After Training: Super or Not? Thorac Surg Clin 2024; 34:9-15. [PMID: 37953058 DOI: 10.1016/j.thorsurg.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Advanced training in cardiothoracic surgery has become more prevalent in the setting of increased complexity of interventions. Minimally invasive techniques, transcatheter and endovascular interventions, and rapid growth in mechanical circulatory support and transplant have led approximately 40% of trainees to pursue additional training. Available data suggest trainees seek additional training for 3 main reasons: gain an additional skillset, improve candidacy for a job, and/or increase proficiency in basic areas. This review provides an analysis of existing literature, categorized by specialty (cardiac, thoracic, and congenital) to determine areas where additional training is of benefit.
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Affiliation(s)
- Jennifer L Perri
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Tom C Nguyen
- Division of Adult Cardiothoracic Surgery, UCSF Medical Center, 500 Parnassus Avenue, MUW 405, Box 0118, San Francisco, CA 94143, USA.
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13
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Berezowski M, Kalva S, Bavaria JE, Zhao Y, Patrick WL, Kelly JJ, Szeto WY, Grimm JC, Desai ND. Validation of the GERAADA score to predict 30-day mortality in acute type A aortic dissection in a single high-volume aortic centre. Eur J Cardiothorac Surg 2024; 65:ezad412. [PMID: 38109506 DOI: 10.1093/ejcts/ezad412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 11/14/2023] [Accepted: 12/14/2023] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate employing the German Registry of Acute Aortic Dissection Type A (GERAADA) score to predict 30-day mortality in an aortic centre in the USA. METHODS Between January 2010 and June 2021, 689 consecutive patients underwent surgery for acute type A dissection at a single institution. Excluded were patients with missing clinical data (N = 4). The GERAADA risk score was retrospectively calculated via a web-based application. Model discrimination power was calculated with c-statistics from logistic regression and reported as the area under the receiver operating characteristic curve with 95% confidence intervals. The calibration was measured by calculating the observed versus estimated mortality ratio. The Brier score was used for the overall model evaluation. RESULTS Included were 685 patients [mean age 60.6 years (SD: 13.5), 64.8% male] who underwent surgery for acute type A aortic dissection. The 30-day mortality rate was 12.0%. The GERAADA score demonstrated very good discrimination power with an area under the receiver operating characteristic curve of 0.762 (95% confidence interval 0.703-0.821). The entire cohort's observed versus estimated mortality ratio was 0.543 (0.439-0.648), indicating an overestimation of the model-calculated risk. The Brier score was 0.010, thus revealing the model's acceptable overall performance. CONCLUSIONS The GERAADA score is a practical and easily accessible tool for reliably estimating the 30-day mortality risk of patients undergoing surgery for acute type A aortic dissection. This model may naturally overestimate risk in patients undergoing surgery in experienced aortic centres.
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Affiliation(s)
- Mikolaj Berezowski
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Saiesh Kalva
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yu Zhao
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - William L Patrick
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, PA, USA
| | - John J Kelly
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, PA, USA
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14
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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15
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Lee G, Izumi A, Leroux É, Yanagawa B. Interdisciplinary Aortic Care Teams: Bring on the A-Team. Can J Cardiol 2023; 39:1499-1501. [PMID: 37949521 DOI: 10.1016/j.cjca.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, University of Toroto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Aliya Izumi
- Division of Cardiovascular Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Émilie Leroux
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiovascular Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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16
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Bima P, Giamello JD, Rubiolo P, Risi F, Balzaretti P, Lauria G, Vallino D, Lupia E, Morello F. Clinical Presentation and Emergency Department Management Checkpoints of Acute Aortic Syndromes during the First Two Waves of the COVID-19 Pandemic. J Clin Med 2023; 12:6601. [PMID: 37892739 PMCID: PMC10607079 DOI: 10.3390/jcm12206601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
The COVID-19 pandemic has deeply affected the activity and patient flows of Emergency Departments (EDs), and concern for the worsening outcome of cardiovascular emergencies has been raised. However, the impact of COVID-19 on all subtypes of acute aortic syndromes (AASs) has not been evaluated so far. Cases of AASs managed in the ED of three hub hospitals in a large area of Northern Italy were retrospectively analyzed, comparing those registered during the pandemic (March 2020 to May 2021) with corresponding pre-COVID-19 periods. A total of 124 patients with AAS were managed during the COVID-19 period vs. 118 pre-COVID-19 (p = 0.70), despite a -34.6% change in ED visits. Posterior chest pain at presentation was the only clinical variable with a different prevalence (46.0% vs. 32.2%, p = 0.03). Surgery and endovascular treatment rates were unchanged. Time intervals influenced by patient transfer to the hub center were longer during the COVID-19 period and longest during high viral circulation periods. Ninety-day mortality was unchanged, with a higher mortality trend during the pandemic surges. In conclusion, ED presentation and care of AASs were marginally affected by COVID-19, but efforts are needed to preserve efficient patient transfer to specialized centers and prevent mortality, especially during pandemic peaks.
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Affiliation(s)
- Paolo Bima
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy; (P.B.); (E.L.)
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
- Cardiovascular Research Institute Basel (CRIB), 4056 Basel, Switzerland
| | - Jacopo Davide Giamello
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
- Medicina d’Urgenza, Ospedale S. Croce e Carle, 12100 Cuneo, Italy
| | - Paolo Rubiolo
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
| | - Francesca Risi
- Dipartimento di Emergenza e Accettazione, Ospedale Mauriziano, 10128 Torino, Italy
| | - Paolo Balzaretti
- Dipartimento di Emergenza e Accettazione, Ospedale Mauriziano, 10128 Torino, Italy
| | - Giuseppe Lauria
- Medicina d’Urgenza, Ospedale S. Croce e Carle, 12100 Cuneo, Italy
| | - Domenico Vallino
- Dipartimento di Emergenza e Accettazione, Ospedale Mauriziano, 10128 Torino, Italy
| | - Enrico Lupia
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy; (P.B.); (E.L.)
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
| | - Fulvio Morello
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy; (P.B.); (E.L.)
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
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17
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Svensson LG, Desai MY. Surgery for Bicuspid Aortopathy: Precision Imaging to Time Decision-Making. JACC. ADVANCES 2023; 2:100627. [PMID: 38938345 PMCID: PMC11198613 DOI: 10.1016/j.jacadv.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Lars G. Svensson
- Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Milind Y. Desai
- Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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18
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Aranda-Michel E, Serna-Gallegos D, Brown J, Wang Y, Bianco V, Yousef S, Diaz-Castrillon CE, Sultan I. Impact of Hospital Teaching Status in Type A Aortic Dissections: An Analysis of More Than 37 000 Patients. Ann Thorac Surg 2023; 116:721-727. [PMID: 35644265 DOI: 10.1016/j.athoracsur.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/13/2022] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to assess the effect of a hospital's teaching status on survival and outcomes of patients presenting with type A aortic dissections imperative for enhancing patient care. METHODS The National Readmission Database was used to review all type A aortic dissections between 2010 and 2017. Provided sampling weights were used to generate national estimates, and baseline variables were compared with descriptive statistics. Mixed effects and logistic models were created for 30-day and 90-day readmission and inhospital mortality. RESULTS In all, 37 396 type A aortic dissections were identified, the majority of which (83%) were operated on at a teaching hospital. Inhospital mortality was higher at nonteaching hospitals A (20.3% vs 14.42%, P < .001). Median hospital charge was higher at teaching hospitals ($59 670 vs $53 220, P < .001). There was a higher rate of 30-day readmission in teaching hospitals (20.95% vs 19.36%, P = .02). On logistic regression for mortality, hospital teaching status was a significant protective factor (odds ratio 0.83, P < .001). On mixed effects logistic regression, hospital teaching status was not significant for readmissions. CONCLUSIONS Type A aortic dissections continue to be primarily managed by teaching hospitals, with superior outcomes continuing to come from teaching hospitals. Given the substantial proportion of patients presenting out of state, investigations into optimal patient transfer and postoperative monitoring and referral could improve care.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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19
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Diaz-Castrillon CE, Serna-Gallegos D, Arnaoutakis G, Grimm J, Szeto WY, Chu D, Sezer A, Sultan I. Volume-failure-to-rescue relationship in acute type A aortic dissections: An analysis of The Society of Thoracic Surgeons Database. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00748-1. [PMID: 37657715 DOI: 10.1016/j.jtcvs.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE To determine the relationship between volume of cases and failure-to-rescue (FTR) rate after surgery for acute type A aortic dissection (ATAAD) across the United States. METHODS The Society of Thoracic Surgeons adult cardiac surgery database was used to review outcomes of surgery after ATAAD between June 2017 and December 2021. Mixed-effect models and restricted cubic splines were used to determine the risk-adjusted relationships between ATAAD average volume and FTR rate. FTR calculation was based on deaths associated with the following complications: venous thromboembolism/deep venous thrombosis, stroke, renal failure, mechanical ventilation >48 hours, sepsis, gastrointestinal complications, cardiopulmonary resuscitation, and unplanned reoperation. RESULTS In total, 18,192 patients underwent surgery for ATAAD in 832 centers. The included hospitals' median volume was 2.2 cases/year (interquartile range [IQR], 0.9-5.8). Quartiles' distribution was 615 centers in the first (1.3 cases/year, IQR, 0.4-2.9); 123 centers in the second (8 cases/year, IQR, 6.7-10.2); 66 centers in the third (15.6 cases/year, IQR, 14.2-18); and 28 centers in the fourth quartile (29.3 cases/year, IQR, 28.8-46.0). Fourth-quartile hospitals performed more extensive procedures. Overall complication, mortality, and FTR rates were 52.6%, 14.2%, and 21.7%, respectively. Risk-adjusted analysis demonstrated increased odds of FTR when the average volume was fewer than 10 cases per year. CONCLUSIONS Although high-volume centers performed more complex procedures than low-volume centers, their operative mortality was lower, perhaps reflecting their ability to rescue patients and mitigate complications. An average of fewer than 10 cases per year at an institution is associated with increased odds of failure to rescue patients after ATAAD repair.
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Affiliation(s)
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - George Arnaoutakis
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin, Austin, Tex
| | - Joshua Grimm
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin, Austin, Tex
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Pittsburgh, Pa
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ahmet Sezer
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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20
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Garg I, Grist TM, Nagpal P. MR Angiography for Aortic Diseases. Magn Reson Imaging Clin N Am 2023; 31:373-394. [PMID: 37414467 DOI: 10.1016/j.mric.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.
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Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1 University Of New Mexico, Albuquerque, NM 87131, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, E3/366 Clinical Science Center 600 Highland Avenue Madison, WI 53792, USA
| | - Prashant Nagpal
- Cardiovascular and Thoracic Radiology, University of Wisconsin School of Medicine and Public Health, E3/366 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
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21
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Vasquez M, Edson TD, Lucas DJ, Hall AB, Tadlock MD. The Impact of the Maritime Deployment Cycle on the Surgeon's Knowledge, Skills, and Abilities. Mil Med 2023; 188:e1382-e1388. [PMID: 36260423 DOI: 10.1093/milmed/usac316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/30/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. MATERIALS AND METHODS Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. RESULTS Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. CONCLUSIONS Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.
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Affiliation(s)
- Matthew Vasquez
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
- Department of Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Theodore D Edson
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
| | - Donald J Lucas
- Department of Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Andrew B Hall
- Department of Surgery, Navy Medicine Readiness and Training Command, CENTCOM, CA 33621, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA
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22
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Hattori S, Noguchi K, Gunji Y, Nagatsuka M, Kagaya H, Katayama I. Surgical outcomes in acute type A aortic dissection based on surgeon experience. Gen Thorac Cardiovasc Surg 2023; 71:225-231. [PMID: 35976598 DOI: 10.1007/s11748-022-01864-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/02/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate our surgical strategy for acute aortic dissection Stanford A and determine whether it is safe regardless of the experience of the primary surgeon. METHODS Between April 2015 and September 2020, a total of 160 patients who underwent open surgery for type A aortic dissection at Shonan Kamakura General Hospital were reviewed. Data were collected from reviews of computerized medical records. From this study cohort, we retrospectively reviewed the cases of trainee (group T) and experienced primary surgeons (group E). We evaluated rates of 30 day and in-hospital mortality, stroke, aortic reintervention, and mid-term survival for both groups. RESULTS The rates of 30 day and in-hospital mortalities in group T were 5.1 and 7.7%, respectively, whereas those in group E were 4.7 and 4.7%, respectively. One and 3 year survival rates in group T were 88.4 and 87.1% and in group E were 95.3 and 95.3%, respectively (log-rank test, p = 0.11). The 1 year and 3 year rates of freedom from reintervention were 90.9 and 72.8% in group T and 96.8 and 92.7% in group E, respectively (log-rank test, p = 0.29). The permanent neurological dysfunction rate was 8.1% overall, 8.5% in group T, and 7.0% in group E, with no significant difference. CONCLUSIONS Our surgical strategy for acute type A aortic dissection is safe and appropriate regardless of the experience of the primary surgeon.
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Affiliation(s)
- Shigeru Hattori
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Kenichiro Noguchi
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Yusuke Gunji
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Motoki Nagatsuka
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Hideo Kagaya
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Ikuo Katayama
- Department of Cardiovascular Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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23
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Newell P, Percy E, Hirji S, Harloff M, McGurk S, Malarczyk A, Chowdhury M, Yazdchi F, Kaneko T. Outcomes of Mitral Valve Repair Among High- and Low-Volume Surgeons Within a High-Volume Institution. Ann Thorac Surg 2023; 115:412-419. [PMID: 35779603 DOI: 10.1016/j.athoracsur.2022.05.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/02/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Volume-outcome relationships have been described for mitral valve repair at the institution and surgeon level. We aimed to assess whether this relationship is mitigated at high-volume (HV) mitral repair centers between HV and low-volume (LV) surgeons. METHODS All mitral repair cases at an HV mitral center (mean, 192 annual repairs) from 1992 to 2018 were considered. Cases with concomitant procedures other than tricuspid and atrial fibrillation procedures were excluded. Surgeons who performed ≥25 repairs per year were considered HV. The primary outcome was operative mortality; secondary outcomes were operative complications, long-term mortality, and reoperation. RESULTS In total, 2653 mitral repairs from 19 surgeons were included. The mean age of the patients in the HV and LV groups was 59.6 years and 61.8 years, respectively (P = .005), with no difference in other baseline characteristics. HV surgeons had significantly shorter median aortic cross-clamp times (80 vs 87 minutes; P < .001) compared with LV surgeons; however, there was no significant difference in operative mortality (0.9% vs 1.6%; P = .19), reoperation, perioperative complications, or length of stay. LV surgeons had higher repair conversion to replacement than HV surgeons did (9.0% vs 3.4%; P < .001). In the risk-adjusted analyses, surgeon volume group did not have an impact on longitudinal survival or reoperation. CONCLUSIONS At an HV mitral repair institution, LV surgeons appear to have short- and long-term outcomes similar to those of HV surgeons despite increased conversion rates. These findings suggest that institutional volume may mitigate the surgeon volume outcome. However, complex repairs may benefit from referral to HV surgeons, given the lower conversion rate.
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Affiliation(s)
- Paige Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Division of Cardiac Surgery, University of British Columbia, Vancouver, British Columbia
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Farhang Yazdchi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Chemtob RA, Ede J, Herou E, Larsson M, Nozohoor S, Sjögren J, Wierup P, Zindovic I. Limited Distal Repair Results in Low Rates of Distal Events Following Surgery for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2023; 35:7-15. [PMID: 34774770 DOI: 10.1053/j.semtcvs.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/11/2022]
Abstract
To investigate mortality and reoperation rates following limited distal repair after acute type A aortic dissection (ATAAD) at a single medium volume institution. We analyzed all patients that underwent limited distal repair (ascending aortic or hemiarch replacement) following ATAAD between January 1998 and April 2020 at our institution. During the study period, 489 patients underwent ATAAD surgery, of which 457 (94%) underwent limited distal repair with a 30-day mortality of 12.9%. Among 30-day survivors, late follow-up was 97.7% complete with a mean follow-up of 6.0 ± 5.5 years. In all, 50 patients (11%) required a reoperation during the study period at a mean of 3.4 ± 3.4 years after initial repair, with a 30-day mortality of 12%. An aortic reoperation was required in 4.1 (2.0-6.1)%, 10.3 (7.1-13.6)%, 15.1 (10.9-19.4)%, and 18.0 (13.0-22.9)% of patients at 1, 5, 10, and 15 years. A distal reoperation was required in 3.0 (1.2-4.7)%, 8.0 (5.1-10.9)%, 10.3 (6.8-13.8)%, and 12.4 (8.2-16.5)% of patients and 4.4 (2.3-6.4)%, 10.4 (7.1-13.7)%, 13.9 (9.8-18.0)%, and 16.9 (12.0-21.9)% of patents had a distal event at 1, 5, 10, and 15 years, respectively. Limited distal repair with an ascending aortic or hemiarch replacement was associated with acceptable survival and rates of reoperations and distal events. Limited distal repair is a safe and feasible standard approach to ATAAD surgery at a medium-volume center.
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Affiliation(s)
- Raphaelle A Chemtob
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Jacob Ede
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Erik Herou
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mårten Larsson
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Per Wierup
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden.
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25
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Tan SZCP, Mohammed I, Bashir M. Frozen Elephant Trunk Sizing: A 30,000-Feet Perspective with Thoraflex Hybrid Stent Graft. AORTA (STAMFORD, CONN.) 2022; 10:182-190. [PMID: 36521811 PMCID: PMC9754870 DOI: 10.1055/s-0042-1756667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There is currently no standard, evidence-based approach for sizing the Thoraflex Hybrid prosthesis in frozen elephant trunk surgery. We present regional data on 906 Thoraflex grafts implanted in the United Kingdom between December 2012 and August 2021 to emphasize the heterogeneity in sizing practices and evaluate the impact this may have on clinical outcomes. Highlighting this heterogeneity will help develop an evidence-based approach to prosthesis sizing, thereby aiding decision-making for arch repair.
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Affiliation(s)
- Sven Z. C. P. Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India,Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran,Department of Vascular and Endovascular Surgery, Velindre University National Health Service Trust, Health and Education Improvement Wales, Wales, United Kingdom,Address for correspondence Mohamad Bashir, MD, PhD, MRCS Department of Vascular and Endovascular Surgery, Velindre University NHS Trust, Health and Education Improvement WalesWales CF15 7QQUnited Kingdom
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26
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 486] [Impact Index Per Article: 243.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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27
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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28
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Evangelista Masip A, López-Sainz Á, Barros Membrilla AJ, Calvo Iglesias F, López Ayerbe J, Azqueta Molluna M, Mosquera Rodríguez VX, Arregui Montoya F, Tarrío Fernández R, Revilla Orodea A, Sánchez Sánchez V, Cantero Pérez EM, Ferrera C, Toral Sepúlveda D, Nistal F, Fernández Golfín C, Sao A, Rodríguez-Palomares J. Spanish Registry of Acute Aortic Syndrome (RESA). Changes in therapeutic management and lower mortality in acute aortic syndrome. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:816-824. [PMID: 35527170 DOI: 10.1016/j.rec.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/24/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVES The Spanish Registry of Acute Aortic Syndrome (RESA) was launched in 2005 to identify the characteristics of acute aortic syndrome (AAS) in Spain. The aim of this study was to analyze the differences in management and mortality in the 3 RESA iterations. METHODS We analyzed data from patients with AAS prospectively included by 24 to 30 tertiary centers during the 3 iterations of the registry: RESA I (2005-2006), RESA-II (2012-2013), and RESA III (2018-2019). RESULTS AAS was diagnosed in 1902 patients (74% men; age, 60.7±12.5 years): 1329 (69.9%) type A and 573 (30.1%) type B. Comparison of the 3 periods revealed that the use of computed tomography increased as the first diagnostic technique (77.1%, 77.9%, and 84.2%, respectively; P=.001). In type A, surgical management increased (79.6%, 78.7%, and 84.5%; P=.045) and overall mortality decreased (41.2%, 34.5%, and 31.2%; P=.002), due to a reduction in surgical mortality (33.4%, 25.1%, and 23.9%; P=.003). In type B, endovascular treatment increased (22.8%, 32.8%, and 38.7%; P=.006), while medical and surgical treatment decreased. Overall type B mortality also decreased (21.6%, 16.1%, and 12.0%; P=.005) in line with a reduction in mortality with medical (16.8%, 13.8%, and 8.8%, P=.030) and endovascular (27.0%, 18.0%, and 9.2%; P=.009) treatments. CONCLUSIONS The iterations of RESA show a decrease in mortality from type A AAS, coinciding with an increase in surgical treatment and a reduction in surgical mortality. In type B, the use of endovascular treatment was associated with improved survival, allowing better management in patients with complications.
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Affiliation(s)
| | - Ángela López-Sainz
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Jordi López Ayerbe
- Servei de Cardiologia, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | | | - Francisco Arregui Montoya
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Ana Revilla Orodea
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | | | - Carlos Ferrera
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain
| | - David Toral Sepúlveda
- Servei de Cirurgia Cardiaca, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Nistal
- Servicio de Cirugía Cardiaca, Hospital Universitario Valdecilla, Santander, Spain
| | | | - Augusto Sao
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Mastrodicasa D, Codari M, Bäumler K, Sandfort V, Shen J, Mistelbauer G, Hahn LD, Turner VL, Desjardins B, Willemink MJ, Fleischmann D. Artificial Intelligence Applications in Aortic Dissection Imaging. Semin Roentgenol 2022; 57:357-363. [PMID: 36265987 PMCID: PMC10013132 DOI: 10.1053/j.ro.2022.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/25/2022] [Accepted: 07/02/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Stanford, CA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA.
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Kathrin Bäumler
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Veit Sandfort
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Jody Shen
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Gabriel Mistelbauer
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Lewis D Hahn
- University of California San Diego, Department of Radiology, La Jolla, CA
| | - Valery L Turner
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Benoit Desjardins
- Department of Radiology, Stanford University School of Medicine, Stanford, CA; Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
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Cocchieri R, van de Wetering B, van Tuijl S, Mousavi I, Riezebos R, de Mol B. At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology. J Cardiovasc Dev Dis 2022; 9:jcdd9080261. [PMID: 36005425 PMCID: PMC9410306 DOI: 10.3390/jcdd9080261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022] Open
Abstract
Almost 30 years after the first endoscopic mitral valve repair, Minimally Invasive Mitral Valve Surgery (MIMVS) has become the standard at many institutions due to optimal clinical results and fast recovery. The question that arises is can already good results be further improved by an Institutional Risk Management Performance (IRMP) system in decreasing risks in minimally invasive mitral valve surgery (MIMVS)? As of yet, there are no reports on IRMP and learning systems in the literature. (2) Methods: We described and appraised our five-year single institutional experience with MIMVS in isolated valve surgery included in the Netherlands Heart Registry (NHR) and investigated root causes of high-impact complications. (3) Results: The 120-day and 12-month mortality were 1.1% and 1.9%, respectively, compared to the average of 4.3% and 5.3% reported in the NHR. The regurgitation rate was 1.4% compared to 5.2% nationwide. The few high-impact complications appeared not to be preventable. (4) Discussion: In MIMVS, freedom from major and minor complications is a strong indicator of an effective IRMP but remains concealed from physicians and patients, despite its relevance to shared decision making. Innovation adds to the complexity of MIMVS and challenges surgical competence. An IRMP system may detect and control new risks earlier. (5) Conclusion: An IRMP system contributes to an effective reduction of risks, pain and discomfort; provides relevant input for shared decision making; and warrants the safe introduction of new technology. Crossroads conclusions: investment in machine learning and AI for an effective IRMP system is recommended and the roles for commanding and operating surgeons should be considered.
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Affiliation(s)
- Riccardo Cocchieri
- Cardiothoracic Surgeon, OLVG Hospital, 1091 AC Amsterdam, The Netherlands
| | - Bertus van de Wetering
- Biomedical Engineer, LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Correspondence: (B.v.d.W.); (B.d.M.)
| | - Sjoerd van Tuijl
- Biomedical Engineer, LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
| | - Iman Mousavi
- Cardiothoracic Surgery Resident, OLVG Hospital, 1091 AC Amsterdam, The Netherlands
| | - Robert Riezebos
- Cardiologist, OLVG Hospital, 1091 AC Amsterdam, The Netherlands
| | - Bastian de Mol
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands
- Correspondence: (B.v.d.W.); (B.d.M.)
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Desai MY, Svensson LG. Toward a Precision Imaging-Driven Approach to Aortic Surgical Timing: Dissecting the Root of the Matter. J Am Coll Cardiol 2022; 79:1898-1900. [PMID: 35550686 DOI: 10.1016/j.jacc.2022.03.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Milind Y Desai
- Aortic Center, the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Lars G Svensson
- Aortic Center, the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Norton EL, Farhat L, Wu X, Kim KM, Fukuhara S, Patel HJ, Deeb GM, Yang B. Specialization in Acute Type A Aortic Dissection Repair: The Outcomes and Challenges. Semin Thorac Cardiovasc Surg 2022; 35:466-475. [PMID: 35588951 DOI: 10.1053/j.semtcvs.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 11/11/2022]
Abstract
With increasing specialization within the field of cardiac surgery and a positive relationship between case volume and surgical outcomes in many areas, the concept of dedicated aortic surgeons performing acute type A aortic dissection (ATAAD) repair was investigated. From 1996 to 2014, 436 patients underwent open surgical repair of an ATAAD and were subsequently divided based on surgeon subspecialization, aortic-surgeon (AS, n = 401) vs non-aortic-surgeon (NAS, n = 35). Each aortic surgeon performed an average of 13 ATAAD repair operations per year. Preoperative comorbidities were similar between groups. Intraoperatively, the AS group had 36% aortic root replacement vs 23% in the NAS group, P = 0.12, and 36% zone 1/2/3 arch replacement vs 26% in the NAS group, P = 0.20). Postoperatively, the AS group had significantly better outcomes, including intraoperative mortality (1.2% vs 5.7%), 30-day mortality (6.5% vs 17%), and composite outcomes (23% vs 46%). Multivariable logistic regression showed NAS was a risk factor for 30-day mortality with an odds ratio (OR) of 4.4 (P = 0.03), as were COPD (OR = 4.0, P = 0.046) and cardiogenic shock (OR = 13.4, P < 0.0001). The 10-year survival was 66% in the AS group vs 46% in the NAS group, P = 0.02. NAS (HR = 2.2), Age (hazard ratio (HR) = 1.05), COPD (HR = 1.96), acute stroke (HR = 3.0), and New York Heart Association class III or IV (HR = 1.75) were significant risk factors for long-term mortality. Managing ATAAD by subspecialized aortic surgeons resulted in improved short- and long-term outcomes. Our specialty could consider ATAAD repair by high-volume aortic surgeons for better patient outcomes.
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Affiliation(s)
- Elizabeth L Norton
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Linda Farhat
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | | | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan.
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Lee JJ, Hall AB, Carr MJ, MacDonald AG, Edson TD, Tadlock MD. Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period. J Trauma Acute Care Surg 2022; 92:e57-e76. [PMID: 34797811 DOI: 10.1097/ta.0000000000003477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph J Lee
- From the Department of Surgery (J.J.L., M.J.C., M.D.T.), Navy Medicine Readiness & Training Command, San Diego, California; 96th Medical Group (A.B.H.), US Air Force Regional Hospital, Eglin AFB, Florida; Uniformed Services University of the Health Sciences (A.G.M.), Bethesda, Maryland; and 1st Medical Battalion (T.D.E.), 1st Marine Logistics Group, Camp Pendleton, California
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Takahashi B, Kamohara K, Amamoto S, Kawaguchi A. Impact of after-hours surgery on outcomes of acute type A aortic dissection repair. Surg Today 2022; 52:1453-1462. [PMID: 35338427 DOI: 10.1007/s00595-022-02487-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/16/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE To establish whether emergency surgery performed outside working hours (after hours) contributed to adverse outcomes for patients with acute type A aortic dissection (ATAAD). METHODS We reviewed the operation records of ATAAD repair in our institution from 2004 to 2019 (n = 187). Emergency surgery was performed by one of a few teams of experienced surgeons, regardless of the time of day. Patients were divided into two groups based on the surgery start time: during working hours (n = 65) and after hours (n = 122). A propensity score-matched analysis was performed for 58 pairs of patients. RESULTS The overall in-hospital mortality was 6.9% for the working-hours group and 13.8% for the after-hours group. There were no significant differences between the groups in the relatively limited study population (n = 187). Surgeon experience and aortic interventions did not differ remarkably between the groups. After-hours repair was not associated with postoperative complications. There were no significant differences in the long-term survival or aortic event-free rates between the groups. CONCLUSIONS After-hours surgery did not affect the short- or long-term outcomes of ATAAD repair under our backup system, which supports the recommendation of immediate surgical repair. Efforts to minimize the discrepancies between working hours and after hours could help to improve the surgical outcomes of patients undergoing ATAAD repair.
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Affiliation(s)
- Baku Takahashi
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-0937, Japan.
| | - Keiji Kamohara
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-0937, Japan
| | - Sojiro Amamoto
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-0937, Japan
| | - Atsushi Kawaguchi
- Research and Education Center for Comprehensive Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
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Cambios en el tratamiento y disminución de la mortalidad del síndrome aórtico agudo. Lecciones del Registro Español del Síndrome Aórtico Agudo (RESA). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Vilacosta I, San Román JA, di Bartolomeo R, Eagle K, Estrera AL, Ferrera C, Kaji S, Nienaber CA, Riambau V, Schäfers HJ, Serrano FJ, Song JK, Maroto L. Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:2106-2125. [PMID: 34794692 DOI: 10.1016/j.jacc.2021.09.022] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.
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Affiliation(s)
- Isidre Vilacosta
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain.
| | - J Alberto San Román
- Instituto de Ciencias del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - Kim Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, UTHealth, Houston, Texas, USA; Memorial Hermann Heart and Vascular Institute. University of Texas, Houston, Texas, USA
| | - Carlos Ferrera
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital, Osaka, Japan
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton and Harefield MHS Trust, London, United Kingdom
| | - Vicenç Riambau
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Hans-Joachim Schäfers
- Klinik für Thorax- und Herz-Gefäßchirurgie Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | | | - Jae-Kwan Song
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Luis Maroto
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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Dolan D, White A, Lee DN, Mazzola E, Polhemus E, Kucukak S, Wee JO, Swanson SJ. Short and Long-term Outcomes Among High-Volume vs Low-Volume Esophagectomy Surgeons at a High-Volume Center. Semin Thorac Cardiovasc Surg 2021; 34:1340-1350. [PMID: 34560249 DOI: 10.1053/j.semtcvs.2021.09.007] [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: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 11/11/2022]
Abstract
To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained 'high-volume' after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P = 0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P = 0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P = 0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36-0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.
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Affiliation(s)
- Daniel Dolan
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts.
| | - Abby White
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Daniel N Lee
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Emanuele Mazzola
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Emily Polhemus
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Suden Kucukak
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Jon O Wee
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Scott J Swanson
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
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Hall A, Qureshi I, Vasquez M, Iverson K, Tadlock MD, McClendon H, Davis E, Glaser J, Hanson M, Taylor J, Gurney JM. Military deployment's impact on the surgeon's practice. J Trauma Acute Care Surg 2021; 91:S261-S266. [PMID: 34039914 DOI: 10.1097/ta.0000000000003279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As the United States withdraws from overseas conflicts, general surgeons remain deployed in support of global operations. Surgeons and surgical teams are foundational to combat casualty care; however, currently, there are few casualty producing events. Low surgical volume and acuity can have detrimental effects on surgical readiness for those frequently deployed. The surgical team cycle of deployment involves predeployment training, drawdown of clinical practice, deployment, postdeployment reintegration, and rebuilding of a patient panel. This study aims to assess these effects on typical general surgeon practices. Quantifying the overall impact of deployment may help refine and implement measures to mitigate the effects on skill retention and patient care. METHODS Surgeon case logs of eligible surgeons deploying between January 1, 2017, and January 1, 2020, were included from participating military treatment facilities. Eligible surgeons were surgeons whose case logs were primarily at a single military treatment facility 26 weeks before and after deployment and whose deployment duration, location, and number of deployed cases were obtainable. RESULTS Starting 26 weeks prior to deployment, analyzing in 1-week intervals toward deployment time, case count decreased by 4.8% (p < 0.0001). With each 1-week interval, postdeployment up to the 26-week mark, case count increased by 6% (p < 0.0001). Cases volumes most prominently drop 3 weeks prior to deployment and do not reach normal levels until approximately 7 weeks postdeployment. Case volumes were similar across service branches. CONCLUSION There is a significant decrease in the number of cases performed before deployment and increase after return regardless of military branch. The perideployment surgical volume decline should be understood and mitigated appropriately; predeployment training, surgical skill retention, and measures to safely reintegrate surgeons back into their practice should be further developed and implemented. LEVEL OF EVIDENCE Economic/Decision, Level III.
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Affiliation(s)
- Andrew Hall
- From the 96 Medical Group, Department of Surgery (A.H., H.M., M.H.), Eglin AFB, Florida; Naval Medical Research Unit San Antonio (I.Q., J.G.), Combat Casualty Care Directorate, San Antonio, Texas; Department of Surgery (M.V.), Naval Hospital Camp Pendleton, Camp Pendleton; Department of Surgery (K.I.), Keesler Medical Center, Keesler AFB, MS; Naval Medical Center San Diego (M.D.T.), San Diego, California; William Beaumont Army Medical Center (E.D.), El Paso, Texas; US Africa Command (J.T.), HQ Unit AFRICOM, APO AE, Stuttgart, Germany; and Joint Trauma System (J.M.G.), Defense Center of Excellence, San Antonio, Texas
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Gasser S, Stastny L, Kofler M, Zujs V, Krapf C, Semsroth S, Ströhle M, Grimm M, Dumfarth J. Surgery out of office hours for type A aortic dissection: does night-time and weekend surgery worsen outcome? Interact Cardiovasc Thorac Surg 2021; 31:806-812. [PMID: 33001169 DOI: 10.1093/icvts/ivaa190] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/11/2020] [Accepted: 07/28/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Immediate surgical repair for type A aortic dissection is gold standard and at most centres is performed by the surgeon on call during night-time and weekends. The objective was to evaluate whether emergency surgery during night-time or weekends has an influence on 30-day mortality. METHODS In 319 patients undergoing surgery for type A aortic dissection, skin incision was documented. Patients were divided into 2 groups according to the time point of skin incision (05:00 a.m. to 07:00 p.m. = daytime group; 07:01 p.m. to 04:59 a.m. = night-time group). We also noted whether their surgeries were started on weekdays (Monday 00:00 to Friday 23:59) or weekends (Saturday 00:00 to Sunday 23:59). RESULTS The median age was 61 years (interquartile range 49-70) and 69.6% (n = 222) were male. Almost 50% (n = 149) of patients presented in a critical preoperative state. Forty-one percent of patients (n = 131) underwent night-time surgery. There were no differences in baseline data, time from onset of symptoms to surgery or surgical treatment between groups, except from preferred femoral access for arterial cannulation during night-time. Advanced age [odds ratio 1.042, 95% confidence interval (CI) 1.014-1.070], preoperative malperfusion syndrome (odds ratio 2.542, 95% CI 1.279-5.051) and preoperative tamponade (odds ratio 2.562, 95% CI 1.215-5.404) emerged as risk factors for 30-day mortality. Night-time or weekend surgery did not have any impact on 30-day mortality when covariates were considered. CONCLUSIONS Based on the natural course of the disease and our results, surgery for type A aortic dissection should be performed as an emergency surgery regardless of time and day.
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Affiliation(s)
- Simone Gasser
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Stastny
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Kofler
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Vitalijs Zujs
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Severin Semsroth
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Ströhle
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Lin TW, Tsai MT, Wu HY, Wang YC, Hu YN, Kan CD, Roan JN, Luo CY. Outcomes of acute type A aortic dissection operations performed by early-career cardiovascular surgeons. JTCVS OPEN 2021; 6:1-10. [PMID: 36003577 PMCID: PMC9390692 DOI: 10.1016/j.xjon.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 12/03/2022]
Abstract
Objective Surgical outcomes of acute type A aortic dissection have been recognized to be associated with the surgical volume of individual hospitals and surgeons. In this study, we aimed to investigate the results and learning curves of acute type A aortic dissection operations performed by early-career cardiovascular surgeons. Methods A total of 248 surgical repairs of acute type A aortic dissections were conducted at a tertiary medical center between 2010 and 2018. By using the cumulative sum test, cardiovascular surgeons in their early career were identified, and their performances were assessed. The outcomes of patients who were operated by early-career cardiovascular surgeons were compared with those by experienced or senior surgeons. Results During the study period, 202 (81.5%) of the 248 acute type A aortic dissection operations were performed primarily by the 4 newly appointed attending cardiovascular surgeons. In cumulative sum curves, all surgeons exhibited a steady performance throughout the study period. On the basis of our institutional result of acute type A aortic dissection operation, early career was defined as performing fewer than 32 acute type A aortic dissection operations. The 30-day mortality rates of acute type A aortic dissection operations performed by early-career surgeons were equivalent to those performed by experienced/senior surgeons (10.9% vs 12.5%, P = .844). There was also no difference in mid-term overall survival and aortic event-free survival between the 2 groups (P = .638 and P = .574, respectively). Conclusions In a center with a well-established program, cardiovascular surgeons could accomplish surgical repair of acute type A aortic dissection with adequate early- and mid-term results from the initiation of their careers.
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Has the time come for regionalization of surgery for acute type A dissection? J Thorac Cardiovasc Surg 2021; 161:1734-1737. [DOI: 10.1016/j.jtcvs.2020.06.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 12/30/2022]
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Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, Chen EP, Fischbein MP, Gleason TG, Okita Y, Ouzounian M, Patel HJ, Roselli EE, Shrestha ML, Svensson LG, Moon MR. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:735-758.e2. [PMID: 34112502 DOI: 10.1016/j.jtcvs.2021.04.053] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Affiliation(s)
- S Christopher Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa
| | - Monika Halas
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Mich
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malakh L Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
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Association between the frequency of surgeries for video-assisted thoracic surgery and the incidence of consequent surgical site infections: a retrospective observational study based on national surveillance data. BMC Infect Dis 2021; 21:363. [PMID: 33865320 PMCID: PMC8052810 DOI: 10.1186/s12879-021-06050-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background The association between the frequency of surgeries and the incidence of surgical site infections (SSIs) has been reported for various surgeries. However, no previous study has explored this association among video-assisted thoracic surgeries (VATS). Hence, we aimed to investigate the association between the frequency of surgeries and SSI in video-assisted thoracic surgeries. Methods We analyzed the data of 26,878 thoracic surgeries, including 21,154 VATS, which were collected during a national surveillance in Japan between 2014 and 2018. The frequency of surgeries per hospital department was categorized into low (< 50/year), moderate (50–100/ year), and high (> 100/year). Chi-squared test or Fisher’s exact test was used for discrete explanatory variables, whereas Wilcoxon’s rank-sum test or Kruskal-Wallis test was used for continuous explanatory variables. Univariate analysis of the department groups was conducted to explore confounding factors associated with both SSIs and the department groups. We used a multiple logistic regression model focusing on VATS and stratified by the National Nosocomial Infections Surveillance System (NNIS) risk index. Results The rates of SSIs in the hospital groups with low, moderate, and high frequency of surgeries were 1.39, 1.05, and 1.28%, respectively. In the NNIS risk index 1 stratum, the incidence of SSIs was significantly lower in the moderate-frequency of surgeries group than that in the other groups (odds ratio [OR]: vs. low-frequency of surgeries: 2.48 [95% confidence interval [CI]: 1.20–5.13], P = 0.0143; vs. high-frequency of surgeries: 2.43 [95% CI: 1.44–4.11], P = 0.0009). In the stratum of NNIS risk indices 2 and 3, the incidence of SSI was significantly higher in the low-frequency of surgeries group (OR: 4.83, 95% CI: 1.47–15.93; P = 0.0095). Conclusion The result suggests that for departments with low-frequency of surgeries, an increase in the frequency of surgeries to > 50 per department annually potentially leads to a decrease in the incidence of SSIs. This occurs through an increase in the experience of the departmental surgeons and contributes to the improvement of VATS outcomes in thoracic surgeries. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06050-6.
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McClure RS, Berry RF, Dagenais F, Forbes TL, Grewal J, Keir M, Klass D, Kotha VK, McMurtry MS, Moore RD, Payne D, Rommens K. The Many Care Models to Treat Thoracic Aortic Disease in Canada: A Nationwide Survey of Cardiac Surgeons, Cardiologists, Interventional Radiologists, and Vascular Surgeons. CJC Open 2021; 3:787-800. [PMID: 34169258 PMCID: PMC8209400 DOI: 10.1016/j.cjco.2021.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Several specialties treat thoracic aortic disease, resulting in multiple patient care pathways. This study aimed to characterize these varied care models to guide health policy. Methods A 57-question e-survey was sent to staff cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons at 7 Canadian medical societies. Results For 914 physicians, the response rate was 76% (86 of 113) for cardiac surgeons, 40% (58 of 146) for vascular surgeons, 24% (34 of 140) for radiologists, and 14% (70 of 515) for cardiologists. Several services admitted type B dissections (vascular 37%, cardiology 31%, cardiac 18%, other 7%), and care was heterogeneous. Ownership of disease management was overestimated relative to the perspective of the other specialties. Type A dissection admissions and treatment were more uniform, but emergent call coverage varied. A 24/7 aortic specialist on-call schedule was present only 4% of the time. “Aortic” case rounds promoted attendance by a broader aortic specialty contingency relative to rounds that were specialty specific. Although 89% of respondents felt an aortic team was best for patient care, only 54% worked at an institution with an aortic team present, and only 28% utilized an aortic clinic. Questions designed to define an aortic team derived 63 different combinations. Conclusions Thoracic aortic disease follows a network of undefined and variable care pathways, despite its high-risk population in need of complex treatment considerations. Multidisciplinary aortic teams and clinics exist in low volume, and the “aortic team” remains an obscure construct. A multispecialty initiative to define the aortic team and outline standardized navigation pathways within the health systems hospitals is advocated.
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Affiliation(s)
- R Scott McClure
- Department of Cardiac Sciences, Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Robert F Berry
- Department of Diagnostic Radiology, Division of Interventional Radiology, Queen Elizabeth II Health Sciences Centre, Victoria General Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Francois Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiology et Pneumologie de Québec, Québec City, Québec, Canada
| | - Thomas L Forbes
- Department of Surgery, Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Department of Medicine, Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle Keir
- Department of Cardiac Sciences, Division of Cardiology, Libin Cardiovascular Institute, Southern Alberta Adult Congenital Heart Clinic, University of Calgary, Calgary, Alberta, Canada
| | - Darren Klass
- Department of Diagnostic Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vamshi K Kotha
- Department of Diagnostic Imaging, Division of Interventional Radiology, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - M Sean McMurtry
- Department of Medicine, Division of Cardiology, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Randy D Moore
- Department of Surgery, Division of Vascular Surgery, Libin Cardiovascular Institute, Peter Lougheed Centre, University of Calgary, Calgary, Alberta Canada
| | - Darrin Payne
- Department of Surgery, Division of Cardiac Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Kenton Rommens
- Department of Surgery, Division of Vascular Surgery, Libin Cardiovascular Institute, Peter Lougheed Centre, University of Calgary, Calgary, Alberta Canada
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Luc JGY, Nguyen TC, Antonoff MB. The Safety of Tomorrow's Patients Relies on the Education of Today's Residents. Ann Thorac Surg 2021; 112:1729-1730. [PMID: 33581161 DOI: 10.1016/j.athoracsur.2020.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School Houston, Texas, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1489, Houston, TX 77030.
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Samanidis G, Kanakis M, Khoury M, Balanika M, Antoniou T, Giannopoulos N, Stavridis G, Perreas K. Antegrade and Retrograde Cerebral Perfusion During Acute Type A Aortic Dissection Repair in 290 Patients. Heart Lung Circ 2021; 30:1075-1083. [PMID: 33495130 DOI: 10.1016/j.hlc.2020.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/11/2020] [Accepted: 12/12/2020] [Indexed: 11/18/2022]
Abstract
AIM Hypothermia and selective brain perfusion is used for brain protection during an acute type A aortic dissection (ATAAD) correction. We compared the outcomes between antegrade and retrograde cerebral perfusion techniques after ATAAD surgery. METHOD Between January 1995 and August 2017, 290 patients underwent ATAAD repair under deep hypothermic circulatory arrest/retrograde cerebral perfusion (DHCA/RCP) in 173 patients and moderate hypothermic circulatory arrest/antegrade cerebral perfusion (MHCA/ACP) in 117 patients. Outcomes of interest were: 30-day mortality, new-onset postoperative neurological complications, and length of intensive care unit (ICU) and in-hospital stays. RESULTS No differences were observed between the preoperative details of both groups (p>0.05). Thirty-day (30-day) mortality did not differ between groups (RCP vs ACP, 22% vs 21.4%; p=0.90). New-onset postoperative permanent neurological dysfunctions and coma was similar in two group in 6.9% versus 10.3% of patients and 3.8% versus 6.8% patients of patients, respectively (p=0.69). The incidence of 30-day mortality and new postoperative neurological complications were similar in the RCP and ACP groups (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.39-2.83 [p=0.91] and OR, 1.7; 95% CI, 0.87-3.23 [p=0.11], respectively). There was no difference between length of stay in the ICU and overall stay in hospital between the RCP and ACP groups (p=0.31 and p=0.14, respectively). No difference in survival rate was observed between the RCP and ACP groups (hazard ratio, 1.2; 95% CI, 0.76-2.01 [p=0.39]). CONCLUSIONS Thirty-day (30-day) mortality rate, new-onset postoperative neurological dysfunctions, ICU stay, and in-hospital stay did not differ between the MHCA/ACP and DHCA/RCP groups after ATAAD correction. Although the rates of 30-day mortality and postoperative neurological complications were high after ATAAD repair, ACP had no advantages over the RCP technique.
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Affiliation(s)
- George Samanidis
- First Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece; Laboratory of Experimental Surgery and Surgical Research "N.S Christeas", Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Mazen Khoury
- Second Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Marina Balanika
- Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Theofani Antoniou
- Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Nicholas Giannopoulos
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - George Stavridis
- Third Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Konstantinos Perreas
- First Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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Pichert M, Geirsson A. What's so special about a specialist? J Card Surg 2021; 36:959-960. [PMID: 33415728 DOI: 10.1111/jocs.15296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew Pichert
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
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Morello F, Santoro M, Fargion AT, Grifoni S, Nazerian P. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med 2021; 16:171-181. [PMID: 32358680 DOI: 10.1007/s11739-020-02354-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
Abstract
Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.
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Affiliation(s)
- Fulvio Morello
- S.C.U. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, Torino, Italy
| | - Marco Santoro
- S.C.U. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
| | | | - Stefano Grifoni
- Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy.
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Guo MH, Fei LYN, Boodhwani M. Specialized thoracic aortic team is the next step in improving outcome in acute aortic dissection care. J Thorac Dis 2020; 12:6112-6114. [PMID: 33209444 PMCID: PMC7656349 DOI: 10.21037/jtd-2020-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ming-Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Linda Y N Fei
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Coselli JS, Orozco-Sevilla V. Commentary: A situation where time is of the essence except when it is not. J Thorac Cardiovasc Surg 2020; 161:1739-1741. [PMID: 33160615 DOI: 10.1016/j.jtcvs.2020.07.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex.
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
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