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Strobel RJ, Young AM, Rotar EP, Kaplan EF, Hawkins RB, Norman AV, Ahmad RM, Joseph M, Quader M, Rich JB, Speir AM, Yarboro LT, Mehaffey JH, Teman NR. Center case volume is associated with Society of Thoracic Surgeons-defined failure to rescue in cardiac surgery. J Thorac Cardiovasc Surg 2024; 168:165-174.e2. [PMID: 37211243 PMCID: PMC10657908 DOI: 10.1016/j.jtcvs.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. METHODS Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. RESULTS A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001). CONCLUSIONS Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Emily F Kaplan
- University of Virginia School of Medicine, Charlottesville, Va
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Anthony V Norman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Raza M Ahmad
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Mark Joseph
- Carilion Clinic Cardiothoracic Surgery/Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alan M Speir
- Cardiac Surgery, Inova Fairfax Hospital, Fairfax, Va
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
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Applefeld WN, Jentzer JC. Initial Triage and Management of Patients with Acute Aortic Syndromes. Cardiol Clin 2024; 42:195-213. [PMID: 38631790 DOI: 10.1016/j.ccl.2024.02.007] [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] [Indexed: 04/19/2024]
Abstract
The acute aortic syndromes (AAS) are life-threatening vascular compromises within the aortic wall. These include aortic dissection (AD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), and blunt traumatic thoracic aortic injury (BTTAI). While patients classically present with chest pain, the presentation may be highly variable. Timely diagnosis is critical to initiate definitive treatment and maximize chances of survival. In high-risk patients, treatment should begin immediately, even while diagnostic evaluation proceeds. The mainstay of medical therapy is acute reduction of heart rate and blood pressure. Surgical intervention is often required but is informed by patient anatomy and extent of vascular compromise.
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Affiliation(s)
- Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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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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Ghomrawi HMK, Huang LW, Hiredesai AN, French DD. Using the Stratum-Specific Likelihood Ratio Method to Derive Outcome-Based Hospital Volume Categories for Total Knee Replacement. Med Care 2024; 62:250-255. [PMID: 38373237 PMCID: PMC10939781 DOI: 10.1097/mlr.0000000000001985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
BACKGROUND Evidence of higher hospital volume being associated with improved outcomes for patients undergoing total knee replacement (TKR) is mostly based on arbitrary distribution-based thresholds. OBJECTIVE We aimed to define outcome-based volume thresholds using data from a national database. METHODS We used the MedPAR Limited Data Set inpatient data from 2010-2015 to identify patients who had undergone primary TKR. Surgical and TKR specific complications occurring within the index hospitalization and all-cause readmission within 90 days were considered adverse events. We derived an average annual TKR case volume for each hospital and applied the stratum-specific likelihood ratio method to determine volume categories indicative of a similar likelihood of 90-day post-operative complications. Hierarchical multivariable logistic regression with a random intercept for hospital nested within study year and adjusted for patient and hospital characteristics was performed to determine if these volume thresholds were still associated with the odds of 90-day readmission for complications after adjustment. RESULTS SSLR analysis yielded 4 hospital volume categories based on the likelihood of 90-day postoperative complications: 1-31 (low), 32-127 (medium), 128-248 (high), and 429+ (very high) TKRs performed per year. The results of the hierarchical multivariable logistic regression showed significantly increased odds of 90-day complications at lower volume categories. Sensitivity analyses confirmed our main findings. CONCLUSIONS This study is the first to provide national-level volume categories that are evidence-based. Publicizing these thresholds may enhance quality measures available to patients, providers, and payors.
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Affiliation(s)
- Hassan M K Ghomrawi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Lynn W Huang
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Annika N Hiredesai
- Department of Economics, Northwestern University, Evanston, IL
- Department of Neurobiology, Northwestern University, Evanston, IL
| | - Dustin D French
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Ophthalmology, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Northwestern University, Chicago, IL
- Veterans Affairs Health Services Research and Development Service, Chicago, IL
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Ishikawa N, Narita M, Shirasaka T, Ushioda R, Tsutsui M, Azuma N, Kamiya H. Role of Helicopter Transfer and Cloud-Type Imaging for Acute Type A Aortic Dissection. Thorac Cardiovasc Surg 2024; 72:105-117. [PMID: 36758638 PMCID: PMC10914492 DOI: 10.1055/a-2031-3763] [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: 07/26/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND This study explored if long-distance transfer was safe for patients suffering from acute aortic dissection type A (AADA) and also analyzed the effectiveness of helicopter transfer and cloud-type imaging transfer systems for such patients in northern Hokkaido, Japan. METHODS AND RESULTS The study included 112 consecutive patients who underwent emergency surgical treatment for AADA from April 2014 to September 2020. The patients were divided into two groups according to the location of referral source hospitals: the Asahikawa city group (group A, n = 49) and the out-of-the-city group (group O, n = 63). Use of helicopter transfer (n = 13) and cloud-type telemedicine (n = 20) in group O were reviewed as subanalyses.Transfer distance differed between groups (4.2 ± 3.5 km in group A vs 107.3 ± 69.2 km in group O; p = 0.0001), but 30-day mortality (10.2% in group A vs 7.9% in group O; p = 0.676) and hospital mortality (12.2% in group A vs 9.5% in group O; p = 0.687) did not differ. Operative outcomes did not differ with or without helicopter and cloud-type telemedicine, but diagnosis-to-operation time was shorter with helicopter (240.0 ± 70.8 vs 320.0 ± 78.5 minutes; p = 0.031) and telemedicine (242.0 ± 75.2 vs 319.0 ± 83.8 minutes; p = 0.007). CONCLUSION We found that long-distance transfer did not impair surgical outcomes in AADA patients, and both helicopter transfer and cloud-type telemedicine system could contribute to the reduction of diagnosis-to-operation time in the large Hokkaido area. Further studies are mandatory to investigate if both the systems will improve clinical outcomes.
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Affiliation(s)
- Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Ryouhei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Masahiro Tsutsui
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Staniszewska A, Gaba K, Patterson B, Wilson S, Bell R, Bicknell C, Brooks M, Callaway M, Goode S, Grier S, Hobson A, Mouton R, Neequaye S, Owens G, Rajakaruna C, Redfern E, Tsang G, Hinchliffe R. Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study. Emerg Med J 2024; 41:153-161. [PMID: 38050049 PMCID: PMC10894809 DOI: 10.1136/emermed-2023-213362] [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: 06/05/2023] [Accepted: 10/22/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Standardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres. METHODS Consensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies. RESULTS Three consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital. CONCLUSIONS This consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.
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Affiliation(s)
- Aleksandra Staniszewska
- South Mersey Arterial Network, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Kamran Gaba
- Wessex Vascular Network, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Benjamin Patterson
- Wessex Vascular Network, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sarah Wilson
- Emergency Department, Wexham Park Hospital, Slough, UK
| | - Rachel Bell
- Department of Vascular Surgery, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Colin Bicknell
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Marcus Brooks
- Department of Vascular Surgery, North Bristol NHS Trust, Bristol, UK
| | - Mark Callaway
- Radiology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Stephen Goode
- Sheffield Vascular Institute, Northern General Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Scott Grier
- Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
- Retrieve Adult Critical Care Transfer Service; National Critical Care Transfer Lead, NHS England, Bristol, UK
| | - Alex Hobson
- Department of Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Ronelle Mouton
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - Simon Neequaye
- Liverpool Vascular and Endovascular Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gareth Owens
- Aortic Dissection Awareness UK & Ireland, London, UK
| | - Cha Rajakaruna
- Cardiac Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Emma Redfern
- Emergency Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Geoffrey Tsang
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert Hinchliffe
- Department of Vascular Surgery, North Bristol NHS Trust, Bristol, UK
- Bristol Population Health Science Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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7
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Hoell NG, Beck CJ, Laczynski D, Lyden SP, Kirksey L, Rowse JW, Quatromoni JG, Bena J, Caputo FJ. Late Referral and Patient Transfer is Associated with Worse Outcomes for Patients Presenting with Initially Uncomplicated Type B Aortic Dissections. Ann Vasc Surg 2024; 98:131-136. [PMID: 37356655 DOI: 10.1016/j.avsg.2023.06.021] [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: 12/01/2022] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Acute type B aortic dissections (TBADs) can become complicated at any time point, necessitating surgical repair. We sought to investigate the effect of interhospital transfer on the development of delayed complications in acute type B aortic dissection (dcTBAD). METHODS All patients who presented with acute TBAD to a tertiary aortic center from 2015 to 2019 were analyzed. Patients were divided into initially complicated type B aortic dissection (icTBAD) (0-24 hours from symptom onset), dcTBAD (25 hours to 14 days), and uncomplicated type B aortic dissection (ucTBAD) groups. Criteria for complicated dissection were aortic rupture, malperfusion, or rapid aortic growth. Demographics, patient history, the timing of presentation, imaging findings, and clinical outcomes were compared between groups. RESULTS Of 120 acute TBADs included, 27 (22%) were initially complicated (aortic rupture, n = 9; malperfusion, n = 18). Twenty-one (18%) developed delayed complications (aortic rupture, n = 3; malperfusion, n = 14; rapid growth, n = 4) at a median of 7.0 [4.0, 9.0] days from symptom onset. Seventy-two (60%) remained uncomplicated. Overall, 111 (93%) presented as transfers from outside hospitals (icTBAD, n = 25; dcTBAD, n = 21; ucTBAD, n = 65). Of those, dcTBADs were more likely to have a prolonged delay between presentation to the outside hospital and referral to the tertiary center compared to ucTBADs (median = 1.00 [0.0, 5.0] days delayed vs. 0.00 [0.0, 0.0] days delayed; P < 0.001). Initially uncomplicated patients referred for transfer ≥24 hours from presentation went on to develop dcTBAD more often than those transferred in <24 hours (73% vs 13%; P < 0.001). Of dcTBADs, 38% had no high-risk features on initial imaging. Patients with dcTBAD had significantly longer length of stay (median = 12 vs 7 days; P = 0.006). In-hospital mortality was significantly higher in dcTBADs than ucTBADs (9.5% vs 0%; P = 0.047). In-hospital mortality was not significantly different between dcTBADs and icTBADs (9.5% vs. 11%; P > 0.05). CONCLUSIONS The incidence and consequence of dcTBADsare not insignificant. Late referral and transfer to a tertiary aortic center (≥24 hours from initial presentation) was associated with dcTBADsrequiring surgical intervention. The development of dcTBADwas associated with increased length of stay and increased in-hospital mortality.
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Affiliation(s)
- Nicholas G Hoell
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
| | - Cassandra J Beck
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - David Laczynski
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Levester Kirksey
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - James Bena
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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Chrusciel J, Clément MC, Steunou S, Prost T, Duclos A, Sanchez S. Effect of the Implementation of the French Hospital Regionalization Policy on Patient Mobility. Health Syst Reform 2023; 9:2267256. [PMID: 37890079 DOI: 10.1080/23288604.2023.2267256] [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: 05/11/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
A new law was voted in France in 2016 to increase cooperation between public sector hospitals. Hospitals were encouraged to work under the leadership of local referral centers and to share their support functions (e.g., information systems) with newly created hospital groups, called "Regional Hospital Groups." The law made it compulsory for each public sector hospital to become affiliated with one of 136 newly created hospital groups. The policy's aim was to ensure that all patients were sent to the hospital best qualified to treat their unique condition, among the hospitals available at the regional level. Therefore, we aimed to assess whether this regionalization policy was associated with changes in observed patterns of patient mobility between hospitals. This nationwide observational study followed an interrupted time series design. For each stay occurring from 2014 to 2019, we ascertained whether or not the stay was followed by mobility toward another hospital within 90 days, and whether or not the receiving hospital was part of the same Regional Hospital Group as the sender hospital. The proportion of mobility directed toward the same regional hospital group increased from 22.9% in 2014 (95% CI 22.7-23.1) to 24.6% in 2019 (95% CI 24.4-24.8). However, the absence of discontinuity during the policy change year was consistent with the hypothesis of a preexisting trend toward regionalization. Therefore, the policy did not achieve major changes in patterns of mobility between hospitals. Other objectives of the reform, including long-term consequences on the healthcare offer, remain to be assessed.
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Affiliation(s)
- Jan Chrusciel
- Department of Public Health, Hôpitaux Champagne Sud, Troyes, France
| | - Marie-Caroline Clément
- Department of Classifications in Healthcare, Medical Information and Financing Models, Technical Agency for Information on Hospital Care, Paris, France
| | - Sandra Steunou
- DATA Department, Technical Agency for Information on Hospital Care, Lyon, France
| | - Thierry Prost
- Department of Partnerships, Technical Agency for Information on Hospital Care, Lyon, France
| | - Antoine Duclos
- Research on Healthcare Performance Lab, INSERM U1290: RESHAPE, University Claude Bernard Lyon 1, Lyon, France
| | - Stéphane Sanchez
- Department of Public Health, Hôpitaux Champagne Sud, Troyes, France
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9
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Zhang C, Chen S, Yang J, Pan G. Postoperative nomogram and risk calculator of acute renal failure for Stanford type A aortic dissection surgery. Gen Thorac Cardiovasc Surg 2023; 71:639-647. [PMID: 37212922 DOI: 10.1007/s11748-023-01935-6] [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: 06/24/2022] [Accepted: 04/06/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND This study aimed to explore the risk factors of acute renal failure (ARF) after Stanford type A aortic dissection (AAD) surgery, establish a nomogram prediction model and calculate the risk of ARF. MATERIAL AND METHODS 241 AAD patients who received aortic surgery in the department of cardiovascular surgery, Zhongnan Hospital of Wuhan University were enrolled in this study. All enrolled patients were divided into the ARF group and non-ARF group. The clinical data of the two groups were collected and compared. The independent risk factors of ARF after aortic surgery were analyzed by univariate and multivariate logistic regression analyses. Moreover, a nomogram prediction model was generated. The calibration curve, ROC curve and independent external validation were performed to evaluate the nomogram prediction model. RESULTS 67 patients were diagnosed with ARF within 48 h after the operation. Univariate and multivariate logistic regression analyses showed that hypertension, preoperative renal artery involvement, CPB time extension and postoperative decreased platelet lymphocyte ratio were the independent risk factors of ARF after AAD surgery. The nomogram model could predict the risk of ARF with a sensitivity of 81.3% and a specificity of 78.6%. The calibration curve displayed good agreement of the predicted probability with the actual observed probability. AUC of the ROC curve was 0.839. External data validation was performed with a sensitivity of 79.2% and a specificity of 79.8%. CONCLUSIONS Hypertension, preoperative renal artery involvement, CPB time extension and postoperative decreased platelet lymphocyte ratio could predict the risk of ARF after AAD surgery.
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Affiliation(s)
- Chong Zhang
- Operating Room, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Song Chen
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Hubei Provincial Engineering Research Center of Minimally Invasive Cardiovascular Surgery, Wuhan, 430071, China
- Wuhan Clinical Research Center for Minimally Invasive Treatment of Structural Heart Disease, Wuhan, 430071, China
| | - Jianguo Yang
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Hubei Provincial Engineering Research Center of Minimally Invasive Cardiovascular Surgery, Wuhan, 430071, China
- Wuhan Clinical Research Center for Minimally Invasive Treatment of Structural Heart Disease, Wuhan, 430071, China
| | - Gaofeng Pan
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
- Hubei Provincial Engineering Research Center of Minimally Invasive Cardiovascular Surgery, Wuhan, 430071, China.
- Wuhan Clinical Research Center for Minimally Invasive Treatment of Structural Heart Disease, Wuhan, 430071, China.
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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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Kawczynski MJ, van Kuijk SMJ, Olsthoorn JR, Maessen JG, Kats S, Bidar E, Heuts S. Type A aortic dissection: optimal annual case volume for surgery. Eur Heart J 2023; 44:4357-4372. [PMID: 37638786 DOI: 10.1093/eurheartj/ehad551] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/06/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS The current study proposes a novel volume-outcome (V-O) meta-analytical approach to determine the optimal annual hospital case volume threshold for cardiovascular interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example. METHODS A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V-O relation, and the elbow method was applied to determine the optimal case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated. RESULTS One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V-O effect was observed (P < .001), with a notable between-quartile difference in early mortality rate [10.3% (Q4) vs. 16.2% (Q1)]. The optimal annual case volume was determined at 38 cases/year [95% confidence interval (CI) 37-40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21]. More pronounced between-quartile survival differences were observed for long-term survival [10-year survival (Q4) 69% vs. (Q1) 51%, P < .01, adjusted hazard ratio 0.83, 95% CI 0.75-0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6]. CONCLUSIONS Using this novel approach, the optimal hospital case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization.
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Affiliation(s)
- Michal J Kawczynski
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Department of Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Suzanne Kats
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, Maastricht, PO Box 616, 6200 MD, Maastricht, The Netherlands
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12
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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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13
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Kothari P, Bodmer NJ, Ellis S, Kiwakyou LM, Choi C. Highlights and Perioperative Implications from the 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease. J Cardiothorac Vasc Anesth 2023; 37:1870-1883. [PMID: 37353422 DOI: 10.1053/j.jvca.2023.05.037] [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: 02/15/2023] [Revised: 05/10/2023] [Accepted: 05/22/2023] [Indexed: 06/25/2023]
Abstract
As the understanding of aortic diseases and their complications grow, increasing importance of uniformity in diagnosis and management is crucial for optimal care of this patient population. The 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease discusses these considerations in detail. The purpose of this review is to highlight essential recommendations that are of relevance to the perioperative physician who manages these patients. A few notable points include, shared decision-making with patients, creation of multidisciplinary aortic teams, lower diameter thresholds for surgery in certain situations, and increased testing for patients with heritable aortic diseases. In addition to briefly reviewing basics of aortic diseases, the authors discuss changes to guidelines that are especially relevant to perioperative care.
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Affiliation(s)
- Perin Kothari
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Natalie J Bodmer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Sarah Ellis
- Department of Anesthesiology, the University of California-San Diego, La Jolla, CA
| | - Larissa Miyachi Kiwakyou
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Christine Choi
- Department of Anesthesiology, the University of California-San Diego, La Jolla, CA
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14
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Ginzberg SP, Roberson JL, Nehemiah A, Ballester JMS, Warshauer AK, Wachtel H, Erdman MS, Dlugosz KL, George LJ, Lynn JC, Martin ND, Myers JS. Time to Transfer as a Quality Improvement Imperative: Implications of a Hub-and-Spoke Health System Model on the Timing of Emergency Procedures. Jt Comm J Qual Patient Saf 2023; 49:539-546. [PMID: 37422425 DOI: 10.1016/j.jcjq.2023.06.008] [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: 02/02/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND In the increasingly prevalent hub-and-spoke health system model, specialized services are centralized at a hub hospital, while spoke hospitals offer more limited services and transfer patients to the hub as needed. In one urban, academic health system, a community hospital without procedural capabilities was recently incorporated as a spoke. The goal of this study was to assess the timeliness of emergent procedures for patients presenting to the spoke hospital under this model. METHODS The authors performed a retrospective cohort study of patients transferred from the spoke hospital to the hub hospital for emergency procedures after the health system restructuring (April 2021-October 2022). The primary outcome was the proportion of patients who arrived within their goal transfer time. Secondary outcomes were time from transfer request to procedure start and whether procedure start occurred within guideline-recommended treatment time frames for ST-elevation myocardial infarction (STEMI), necrotizing soft tissue infection (NSTI), and acute limb ischemia (ALI). RESULTS A total of 335 patients were transferred for emergency procedural intervention during the study period, most commonly for interventional cardiology (23.9%), endoscopy or colonoscopy (11.0%), or bone or soft tissue debridement (10.7%). Overall, 65.7% of patients were transferred within the goal time. 23.5% of patients with STEMI met goal door-to-balloon time, and more patients with NSTI (55.6%) and ALI (100%) underwent intervention within the guideline-recommended time frame. CONCLUSION A hub-and-spoke health system model can provide access to specialized procedures in a high-volume, resource-rich setting. However, ongoing performance improvement is required to ensure that patients with emergency conditions receive timely intervention.
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15
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Vekstein AM, Doberne JW, Weissler EH, Wojnarski CM, Long CA, Williams AR, Plichta RP, Gaca JG, Hughes GC. Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair. J Thorac Cardiovasc Surg 2023; 166:996-1008.e1. [PMID: 35282930 DOI: 10.1016/j.jtcvs.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes. METHODS From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%). RESULTS Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01). CONCLUSIONS Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Julie W Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles M Wojnarski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam R Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan P Plichta
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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16
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Nappi F, Alzamil A, Salsano A, Avtaar Singh SS, Gambardella I, Santini F, Fiore A, Perocchio G, Demondion P, Mesnildrey P, Schoell T, Bonnet N, Leprince P. Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study. J Clin Med 2023; 12:6177. [PMID: 37834821 PMCID: PMC10573384 DOI: 10.3390/jcm12196177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. METHODS All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. RESULTS A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. CONCLUSION The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine–New York, Presbyterian Medical Center, 505 E 70th St., New York, NY 10065, USA;
| | | | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Créteil, France;
| | - Giacomo Perocchio
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Pierre Demondion
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
| | - Patrick Mesnildrey
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
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17
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Ram E, Lau C, Dimagli A, Chu NQ, Soletti G, Gaudino M, Girardi LN. Reoperative total arch replacement after previous cardiovascular surgery: Outcomes in 426 consecutive patients. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00746-8. [PMID: 37657714 DOI: 10.1016/j.jtcvs.2023.08.035] [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: 04/28/2023] [Revised: 07/30/2023] [Accepted: 08/15/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR. METHODS The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation. RESULTS The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024). CONCLUSIONS Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure.
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Affiliation(s)
- Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Ngoc-Quynh Chu
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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18
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Mehta CK, Chiu S, Hoel AW, Vassallo P, Whippo B, Andrei AC, Schmidt MJ, Pham DT, Johnston DR, Churyla A, Malaisrie SC. Implementation of a direct-to-operating room aortic emergency transfer program: Expedited management of type A aortic dissection. Am J Emerg Med 2023; 70:113-118. [PMID: 37270850 DOI: 10.1016/j.ajem.2023.05.036] [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: 04/21/2023] [Revised: 05/10/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION Type A Aortic Dissection (TAAD) is a surgical emergency with a time-dependent rate of mortality. We hypothesized that a direct-to-operating room (DOR) transfer program for patients with TAAD would reduce time to intervention. METHODS A DOR program was started at an urban tertiary care hospital in February 2020. We performed a retrospective study of adult patients undergoing treatment for TAAD before (n = 42) and after (n = 84) implementation of DOR. Expected mortality was calculated using the International Registry of Acute Aortic Dissection risk prediction model. RESULTS Median time from acceptance of transfer from emergency physician to operating room arrival was 1.37 h (82 min) faster in DOR compared to pre-DOR (1.93 h vs 3.30 h, p < 0.001). Median time from arrival to operating room was 1.14 h (72 min) faster after DOR compared to pre-DOR (0.17 h vs 1.31 h, p < 0.001). In-hospital mortality was 16.2% in pre-DOR, with an observed-to-expected (O/E) ratio of 1.03 (p = 0.24) and 12.0% in the DOR group, with an O/E ratio of 0.59 (p < 0.001). CONCLUSION Creation of a DOR program resulted in decreased time to intervention. This was associated with a decrease in observed-to-expected operative mortality. The transfer of patients with acute type A aortic dissection to centers with direct-to-OR programs may result in decreased time from diagnosis to surgery.
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Affiliation(s)
- Christopher K Mehta
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA.
| | - Stephen Chiu
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Andrew W Hoel
- Division of Vascular Surgery, Department of Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Patricia Vassallo
- Division of Cardiology, Department of Medicine, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Beth Whippo
- Division of Cardiology, Department of Medicine, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Adin Cristian Andrei
- Division of Biostatistics, Department of Preventative Medicine, Northwestern University, Chicago, IL, USA
| | - Michael J Schmidt
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Douglas R Johnston
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Andrei Churyla
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
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19
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Iyengar A, Patrick WL, Helmers MR, Kelly JJ, Han J, Williams ML, Mackay EJ, Desai ND, Cevasco M. Neighborhood Socioeconomic Status Independently Predicts Outcomes After Mitral Valve Surgery. Ann Thorac Surg 2023; 115:940-947. [PMID: 36623633 DOI: 10.1016/j.athoracsur.2023.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 12/08/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND Socioeconomic status has increasingly recognized influence on outcomes after cardiac surgery. However, singular metrics fail to fully capture the socioeconomic context within which patients live, which vary greatly between neighborhoods. We sought to explore the impact of neighborhood-level socioeconomic status on patients undergoing mitral valve surgery in the United States. METHODS Adults undergoing first-time, isolated mitral valve surgery were queried from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2012 and 2018. Socioeconomic status was quantified using the Area Deprivation Index, a weighted composite including average housing prices, household incomes, education, and employment levels. The associations between regional deprivation, access to mitral surgery, valve repair rates, and outcomes were evaluated using logistic regression. RESULTS Among 137,100 patients included, patients with socioeconomic deprivation had fewer elective presentations, more comorbidity burden, and more urgent/emergent surgery. Patients from less disadvantaged areas received operations from higher volume surgeons and had higher repair rates (highest vs lowest quintile: 72% vs 51%, P < .001, more minimally-invasive approach (33% vs 20%, P < .001), lower composite complication rate (42% vs 50%, P < .001), and lower 30-day mortality (1.8% vs 3.9%, P < .001). After hierarchical multivariable adjustment, the Area Deprivation Index significantly predicted 30-day mortality and repair rate (P < .001). CONCLUSIONS In a risk-adjusted national analysis of mitral surgery, patients from more deprived areas were less likely to undergo mitral repair and more likely to have complications. Further work at targeting neighborhood-level disparity is important to improving mitral surgical outcomes in the United States.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew L Williams
- Division of Cardiovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Emily J Mackay
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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20
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Abstract
This JAMA Clinical Guidelines Synopsis summarizes the 2021 guidelines from the American Association for Thoracic Surgery and the Society of Thoracic Surgeons on management of type A and type B thoracic aortic dissection.
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Affiliation(s)
- Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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21
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Hou BC, Huang YT, Hsiao FC, Wu CC, Cheng YT, Liu KS, Chang SH, Chu PH, Chou AH, Chen SW. Learning curve for open surgical repair of acute type A aortic dissection. Sci Rep 2023; 13:3601. [PMID: 36869059 PMCID: PMC9984377 DOI: 10.1038/s41598-023-30397-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 02/22/2023] [Indexed: 03/05/2023] Open
Abstract
There is scarce evidence about the surgeon learning curve of acute type A aortic dissection surgery and whether the optimal procedure number exists when training a cardiovascular surgeon. A total of 704 patients with acute type A aortic dissection surgery performed by 17 junior surgeons who can identify their first career surgery from January 1, 2005, to December 31, 2018, are included. The surgeon experience volume is defined as the cumulative number of acute type A aortic dissection surgery of the surgeon since January 1, 2005. The primary outcome was in-hospital mortality. The possibility of non-linearity and cutoffs for surgeon experience volume level was explored using a restricted cubic spline model. The results revealed that more surgeon experience volume is significantly correlated to a lower in-hospital mortality rate (r = - 0.58, P = 0.010). The RCS model shows for an operator who reaches 25 cumulative volumes of acute type A aortic dissection surgery, the average in-hospital mortality rate of the patients can be below 10%. Furthermore, the longer duration from the 1st to 25th operations of the surgeon is significantly correlated to a higher average in-hospital mortality rate of the patients (r = 0.61, p = 0.045). Acute type A aortic dissection surgery has a prominent learning curve in terms of improving clinical outcomes. The findings suggest fostering high-volume surgeons at high-volume hospitals can achieve optimal clinical outcomes.
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Affiliation(s)
- Bo-Cheng Hou
- Chiayi Branch, Chang Gung Memorial Hospital, No. 8, Sec. W., Jiapu Rd., Puzi City, Chiayi County, Taiwan
- Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Fu-Chih Hsiao
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, No. 5 Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Chien-Chia Wu
- Department of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Ting Cheng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, No. 5 Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Kuo-Sheng Liu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, No. 5 Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Shang-Hung Chang
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Department of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, No. 5 Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.
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22
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Krishnan A, Dalal AR, Pedroza AJ, Nakamura K, Yokoyama N, Tognozzi E, Woo YJ, Fischbein M, MacArthur JW. Outcomes after concomitant arch replacement at the time of aortic root surgery. JTCVS OPEN 2023; 13:1-8. [PMID: 37063158 PMCID: PMC10091289 DOI: 10.1016/j.xjon.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 12/04/2022] [Accepted: 12/16/2022] [Indexed: 01/22/2023]
Abstract
Background Contemporary series of aortic arch replacement at the time of aortic root surgery are limited in number of patients and mostly address hemiarch replacement. We describe outcomes after aortic root and concomitant arch replacement, including total arch replacement. Methods This single-institution retrospective review studied 1196 consecutive patients from May 2004 to September 2020 who underwent first-time aortic root replacement. Patients undergoing surgery for endocarditis were excluded (n = 68, 5.7%). Patients undergoing concomitant root and arch replacement were propensity matched with patients undergoing isolated root surgery based on indication, clinical and operative characteristics, demographics, medical history including connective tissue disorders, and urgency. Multivariable Cox proportional hazards and logistic regression modeling were used to assess the primary outcome of all-cause mortality and the secondary outcomes of prolonged ventilator use, postoperative blood transfusion, and debilitating stroke, adjusted for patient and operative characteristics. Results Among the 1128 patients who underwent aortic root intervention during the study period, 471 (41.8%) underwent concomitant aortic arch replacement. Most underwent hemiarch replacement (n = 411, 87.4%); 59 patients (12.6%) underwent total arch replacement (with elephant trunk: n = 23, 4.9%; without elephant trunk: n = 36, 7.7%). The mean follow-up time was 4.6 years postprocedure. Operative mortality was 2.2%, and total mortality over the entire study period was 9.2%. Propensity matching generated 348 matches (295 concomitant hemiarch, 53 concomitant total arch). Concomitant hemiarch (hazard ratio, 1.00; 95% confidence interval, 0.54-1.86, P = .99) and total arch replacement (hazard ratio, 1.60, 95% confidence interval, 0.72-3.57, P = .24) were not significantly associated with increased mortality. Rates of stroke were not significantly different among each group: isolated root (n = 11/348, 3.7%), root + hemiarch (n = 17/295, 5.8%), and root + total arch (n = 3/53, 5.7%) replacement (P = .50), nor was the adjusted risk of stroke. Both concomitant arch interventions were associated with prolonged ventilator use and use of postoperative blood transfusions. Conclusions Hemiarch and total arch replacement are safe to perform at the time of aortic root intervention, with no significant differences in survival or stroke rates, but increased ventilator and blood product use.
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Affiliation(s)
- Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | | | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Emily Tognozzi
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Michael Fischbein
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
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23
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Li L, Wu W, Xu N, Zhao Q, Guo W. Treatment and referral experiences of patients with type A aortic dissection and their families: a qualitative study. BMJ Open 2023; 13:e064247. [PMID: 36806069 PMCID: PMC9943915 DOI: 10.1136/bmjopen-2022-064247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVES This study aimed to analyse the experiences and feelings of patients with type A aortic dissection (TAAD) and their families during the medical treatment and referral process, investigate the entire process's needs and problems and provide evidence for improving the aortic dissection treatment system. DESIGN A qualitative descriptive design using a phenomenological study. Face-to-face semistructured interviews were conducted. Thematic analysis was used to analyse the interview data, which was transcribed verbatim. SETTING Department of Cardiovascular Surgery of Shanxi Bethune Hospital in China. PARTICIPANTS Fifteen family groups, consisting of patients with TAAD who underwent surgical treatment and their families, were selected. RESULTS Three primary themes were discussed and developed. Theme 1: the experiences of medical treatment and referral (confusion at the onset; complex inner feelings and emotional expressions of the medical treatment and referral; preoperative inner conflict); theme 2: problems with the TAAD medical treatment system (the quality of diagnosis and medical treatment needs to be improved; deficiency of medical system policies and procedures); and theme 3: real demands (demands for TAAD-related knowledge and access to the disease; economic-related demands). CONCLUSION Patients with TAAD and their families encounter complex inner experiences, multiple requirements and numerous challenges during the medical treatment and referral process. It is advised that the treatment and referral system of TAAD in China needs to be improved. Future research and clinical practice should standardise diagnosis and treatment training, establish a fast channel for TAAD to prioritise treatment, popularise aortic dissection-related knowledge and improve the funding system.
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Affiliation(s)
- Lin Li
- Department of Cardiovascular Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Wenxian Wu
- Department of Cardiovascular Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Na Xu
- Department of Central Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Qing Zhao
- Department of Cardiovascular Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Wanpeng Guo
- Department of Cardiovascular Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
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24
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Narita M, Tsutsui M, Ushioda R, Kikuchi Y, Shirasaka T, Ishikawa N, Kamiya H. Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection. Front Surg 2023; 10:1081167. [PMID: 36860951 PMCID: PMC9968786 DOI: 10.3389/fsurg.2023.1081167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Objective This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. Subjects From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. Methods Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. Results The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). Conclusions No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.
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Affiliation(s)
- Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | | | - Ryouhei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yuta Kikuchi
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
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25
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Tran QK, O’Connell F, Hakopian A, Abrahim MSH, Beisenova K, Pourmand A. Patient care during interfacility transport: a narrative review of managing diverse disease states. World J Emerg Med 2023; 14:3-9. [PMID: 36713340 PMCID: PMC9842466 DOI: 10.5847/wjem.j.1920-8642.2023.009] [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: 08/06/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals (interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport. METHODS We conducted searches from the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases up to June 2022. Two reviewers independently screened the titles and abstracts for eligibility. Studies that were not in the English language and did not involve critically ill patients were excluded. RESULTS The search identified 75 articles, and we included 48 studies for our narrative review. Most studies were observational studies. CONCLUSION The review provided the current evidence-based management of diverse disease states during the interfacility transfer process, such as proning positioning for respiratory failure, extracorporeal membrane oxygenation (ECMO), obstetric emergencies, and hypertensive emergencies (aortic dissection and spontaneous intracranial hemorrhage).
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Affiliation(s)
- Quincy K. Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore 21201, USA,Program in Trauma, the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore 21201, USA
| | - Francis O’Connell
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Andrew Hakopian
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Marwa SH Abrahim
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Kamilla Beisenova
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA,Corresponding Author: Ali Pourmand,
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26
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Muacevic A, Adler JR, Chen A, Chilukuri D, Helton N. Improving the Hospital Transfer Process for Acute Type A Aortic Dissections. Cureus 2023; 15:e33451. [PMID: 36751239 PMCID: PMC9899483 DOI: 10.7759/cureus.33451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 01/07/2023] Open
Abstract
Patients with acute type A aortic dissection who arrive at hospitals that lack the facilities to treat them must be transferred to a tertiary care facility to receive treatment. The transfer process involves a checkpoint at which the transfer is accepted or denied. Delays in making this decision may lead to suboptimal health outcomes. In light of this, the goal of this project was to devise a way to reduce the time to decision of transfer requests for patients with an acute type A aortic dissection. The project followed the Define-Measure-Analyze-Improve-Control (DMAIC) approach. To better understand the process, data were obtained from the University of Texas Southwestern Medical Center regarding reasons for patient transfer cancellation and the average time until a transfer was denied or accepted. After data analysis, a fishbone diagram was used to display 23 root causes of the delays in time to decision of the transfer request. These were narrowed down to the following four significant causes using a nominal voting technique: (1) no standard on disease-specific information for the handoff, (2) lack of a real-time database, (3) incompatible electronic health record system between facilities, and (4) multiple communication handoffs causing confusion. Solutions to each root cause were evaluated using a solution selection matrix. The final two solutions proposed for implementation were as follows: (1) to establish checklists of required documents and patient transfer criteria and (2) to create a regional database to provide real-time information on hospital capacity.
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27
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Munir W, Bashir M, Idhrees M, Awad WI. Risk Prediction Models for Management of Patients following Acute Aortic Dissection. AORTA (STAMFORD, CONN.) 2022; 10:210-218. [PMID: 36521815 PMCID: PMC9754882 DOI: 10.1055/s-0042-1756671] [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
Risk prediction of adverse outcomes post aortic dissection is dependet not only on the postdissection-associated clinical factors but on the very foundation of the risk factors that lead up to the dissection itself. There are various such risk factors existing prior to the dissection which impact the postdissection outcomes. In this paper, we review the literature to critically analyze various risk models, burdened by their significant limitations, that attempt to stratify risk prediction based on postdissection patient characteristics. We further review several studies across the literature that investigate the diverse set of predissection risk factors impacting postdissection outcomes. We have discussed and appraised numerous studies which attempt to develop a tool to stratify risk prediction by incorporating the impacts of different factors: malperfusion, blood biochemistry, and perioperative outcomes. The well-validated Penn classification has clearly demonstrated in the literature the significant impact that malperfusion has on adverse outcomes postdissection. Other risk models, already severely hindered by their limitations, lack such validation. We further discuss additional alluded risk factors, including the impact of predissection aortic size, the syndromic and nonsyndromic natures of dissection, and the effects of family history and genetics, which collectively contribute to the risk of adverse outcomes postdissection and prognosis. To achieve the goal of a true risk model, there remains the vital need for appreciation and appropriate consideration for all such aforementioned factors, from before and after the dissection, as discussed in this paper. By being able to incorporate the value of true risk prediction for a patient into the decision-making framework, it will allow a new page of precision medical decision-making to be written.
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Affiliation(s)
- Wahaj Munir
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospitals), Chennai, Tamil Nadu, India,Address for correspondence Mohamad Bashir, MD, PhD, MRCS Department of Cardiovascular Clinical Research, Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospitals)Chennai 600026, Tamil NaduIndia
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospitals), Chennai, Tamil Nadu, India
| | - Wael I. Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
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28
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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: 365] [Impact Index Per Article: 182.5] [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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29
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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: 129] [Impact Index Per Article: 64.5] [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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30
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Harris KM, Nienaber CA, Peterson MD, Woznicki EM, Braverman AC, Trimarchi S, Myrmel T, Pyeritz R, Hutchison S, Strauss C, Ehrlich MP, Gleason TG, Korach A, Montgomery DG, Isselbacher EM, Eagle KA. Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. JAMA Cardiol 2022; 7:1009-1015. [PMID: 36001309 PMCID: PMC9403853 DOI: 10.1001/jamacardio.2022.2718] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/06/2022] [Indexed: 11/14/2022]
Abstract
Importance Early data revealed a mortality rate of 1% to 2% per hour for type A acute aortic dissection (TAAAD) during the initial 48 hours. Despite advances in diagnostic testing and treatment, this mortality rate continues to be cited because of a lack of contemporary data characterizing early mortality and the effect of timely surgery. Objective To examine early mortality rates for patients with TAAAD in the contemporary era. Design, Setting, and Participants This cohort study examined data for patients with TAAAD in the International Registry of Acute Aortic Dissection between 1996 and 2018. Patients were grouped according to the mode of their intended treatment, surgical or medical. Exposure Surgical treatment. Main Outcomes and Measures Mortality was assessed in the initial 48 hours after hospital arrival using Kaplan-Meier curves. In-hospital complications were also evaluated. Results A total of 5611 patients with TAAAD were identified based on intended treatment: 5131 (91.4%) in the surgical group (3442 [67.1%] male; mean [SD] age, 60.4 [14.1] years) and 480 (8.6%) in the medical group (480 [52.5%] male; mean [SD] age, 70.9 [14.7] years). Reasons for medical management included advanced age (n = 141), comorbidities (n = 281), and patient preference (n = 81). Over the first 48 hours, the mortality for all patients in the study was 5.8%. Among patients who were medically managed, mortality was 0.5% per hour (23.7% at 48 hours). For those whose intended treatment was surgical, 48-hour mortality was 4.4%. In the surgical group, 51 patients (1%) died before the operation. Conclusions and Relevance In this study, the overall mortality rate for TAAAD was 5.8% at 48 hours. For patients in the medical group, TAAAD had a mortality rate of 0.5% per hour (23.7% at 48 hours). However, among those in the surgical group, 48-hour mortality decreased to 4.4%.
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Affiliation(s)
- Kevin M. Harris
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Mark D. Peterson
- Division of Cardiac Surgery, St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Santi Trimarchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | - Reed Pyeritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Craig Strauss
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Marek P. Ehrlich
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Amit Korach
- Department of Cardiovascular Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Kim A. Eagle
- Cardiovascular Division, University of Michigan, Ann Arbor
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Lim S, Kwan S, Colvard BD, d'Audiffret A, Kashyap VS, Cho JS. Impact of Interfacility Transfer of Ruptured Abdominal Aortic Aneurysm Patients. J Vasc Surg 2022; 76:1548-1554.e1. [PMID: 35752382 DOI: 10.1016/j.jvs.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/12/2022] [Accepted: 05/01/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Interfacility transfer (IT) of patients with ruptured (r) abdominal aortic aneurysm (AAA) occurs not infrequently for a higher level of care. This study evaluates using contemporary administrative database the impact of IT on mortality after rAAA repair. METHODS Healthcare Cost and Utilization Project Database for NY (2016) and NJ/MD/FL (2016-2017) were queried using ICD-10th edition to identify patients who underwent open and endovascular repair of AAA. Hospitals were categorized into quartiles (Q) per overall volume. Mortality rates of IT vs non-transferred (NT) rAAA patients per treatment modality (open [rOAR] vs. endovascular [rEVAR]) were compared. Cox proportional hazard model was used to estimate hazard ratios (HR) for mortality. RESULTS 1475 patients presented with rAAA of whom 672 (45.6%) were not treated. Of the remaining 803 patients, 226 (28.1%) were transferred; 50 (22.1%) died without a repair after IT. The remaining 752 patients (176 IT + 576 NT) underwent 491 rEVARs and 261 rOARs. Baseline characteristics were similar between IT and NT patients except for higher proportion of Blacks (P=.03), lower-income families (P=.049) and rOAR (45.5% vs 31.4%, p=.001) in IT patients. Overall mortality rates were similar between NT (30.2%) and IT (27.3%, P=.46). On sub-group analysis, operative mortality rates after rEVAR were similar between NT and IT patients, without differences among hospital quartiles. After rOAR, however, operative mortality rates were lower in IT patients, largely due to improved outcomes in Q4 hospitals (P=.001, Q4 vs Q1, 2 & 3). Cox regression analysis demonstrated age (HR 1.03, CI 1.00-1.06, P=.02) and low-volume hospitals (Q1-3) (HR 1.89, CI 1.02-3.51, P=.04) are predictors of mortality. Total charges were similar ($286,727 IT vs $265,717 NT, P=.38). CONCLUSIONS Less than 30% of rAAA patients deemed to be a candidate for repair are transferred. IT does not affect mortality rates after rEVAR, irrespective of hospital volume. For rOAR candidates, however, regionalization of care with prompt transfer to a high-volume center improves the survival benefits without increased health care cost.
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Affiliation(s)
- Sungho Lim
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, Rush Medical College/Rush University Medical Center, Chicago, IL
| | - Stephen Kwan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Benjamin D Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Alexandre d'Audiffret
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, Rush Medical College/Rush University Medical Center, Chicago, IL
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH.
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Takahashi T, Yoshino H, Akutsu K, Shimokawa T, Ogino H, Kunihara T, Usui M, Watanabe K, Kawata M, Masuhara H, Yamasaki M, Yamamoto T, Nagao K, Takayama M. In-Hospital Mortality of Patients With Acute Type A Aortic Dissection Hospitalized on Weekends Versus Weekdays. JACC. ASIA 2022; 2:369-381. [PMID: 36338400 PMCID: PMC9627801 DOI: 10.1016/j.jacasi.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND In acute aortic dissection, weekend admissions are reported to be associated with increased mortality compared with weekday admissions. OBJECTIVE This study aimed to determine whether patients with acute type A aortic dissection (ATAAD) admitted on weekends had higher in-hospital mortality than those admitted on weekdays in the Tokyo metropolitan area, where we developed a patient-transfer system for aortic dissection. METHODS Data were collected during the first year after our transfer system began (cohort I) and in the subsequent years from 2013 to 2015 (cohort II). RESULTS We studied 2,339 patients (500 in cohort I; 1,839 in cohort II) with ATAAD. Patients with weekend admissions had higher in-hospital mortality than those with weekday admissions in cohort I. In association with increased interfacility transfer during weekends and reduced mortality at non-high-volume centers, the in-hospital mortality in the weekend group improved from 37.2% in cohort I to 22.2% in cohort II (P < 0.001). After inverse probability weighting adjustment, weekend admission was associated with higher in-hospital mortality in cohort I (odds ratio: 2.28; 95% confidence interval: 1.48 to 3.52; P < 0.001), but not in cohort II (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.22; P = 0.731). On multivariable analyses, weekend admission was associated with higher in-hospital mortality in combined cohort I+II; the associations between weekend admission and mortality were not significant in cohort II. CONCLUSIONS We found a significant reduction in in-hospital mortality in patients with weekend admissions for ATAAD. No mortality difference between weekend and weekday admissions was observed in the later years of the study.
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Affiliation(s)
- Toshiyuki Takahashi
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Koichi Akutsu
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | | - Hitoshi Ogino
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | | - Michio Usui
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | | | | | | | | | | - Ken Nagao
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
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Vervoort D, Chung JCY, Ouzounian M. Access to Thoracic Aortic Care: Challenges and Opportunities in Universal Health Coverage Systems. Can J Cardiol 2022; 38:726-728. [PMID: 35272002 DOI: 10.1016/j.cjca.2022.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario.
| | - Jennifer C Y Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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Increased Travel Time To The Tertiary Centre is Associated with Decreased Long-Term Survival Following Ascending Aortic Operations. Can J Cardiol 2022; 38:801-807. [DOI: 10.1016/j.cjca.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 01/16/2023] Open
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Goldstone AB, Woo YJ. Valve-sparing reoperations for failed pulmonary autografts. JTCVS Tech 2021; 10:408-412. [PMID: 34977766 PMCID: PMC8689671 DOI: 10.1016/j.xjtc.2021.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Andrew B. Goldstone
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Address for reprints: Y. Joseph Woo, MD, Department of Cardiothoracic Surgery, Stanford University, Falk Building CV-235, 300 Pasteur Dr, Stanford, CA 94305-5407.
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Mehta CK, Son AY, Chia MC, Budd AN, Allen BD, Vassallo P, Hoel AW, Brady WJ, Nable JV. Management of acute aortic syndromes from initial presentation to definitive treatment. Am J Emerg Med 2021; 51:108-113. [PMID: 34735967 DOI: 10.1016/j.ajem.2021.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute aortic syndromes comprise a spectrum of diseases including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcers. Early diagnosis, rapid intervention, and multidisciplinary team care are vital to efficiently manage time-sensitive aortic emergencies, mobilize appropriate resources, and optimize clinical outcomes. OBJECTIVE This comprehensive review outlines the multidisciplinary team approach from initial presentation to definitive interventional treatment and post-operative care. DISCUSSION Acute aortic syndromes can be life-threatening and require prompt diagnosis and aggressive initiation of blood pressure and pain control to prevent subsequent complications. Early time to diagnosis and intervention are associated with improved outcomes. CONCLUSIONS A multidisciplinary team can help promptly diagnose and manage aortic syndromes.
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Affiliation(s)
- Christopher K Mehta
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America.
| | - Andre Y Son
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - Matthew C Chia
- Division of Vascular Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - Ashley N Budd
- Department of Anesthesiology, Northwestern Medicine, Chicago, IL, United States of America
| | - Bradley D Allen
- Department of Radiology, Northwestern Medicine, Chicago, IL, United States of America
| | - Patricia Vassallo
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - Andrew W Hoel
- Division of Vascular Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - William J Brady
- Departments of Emergency Medicine and Internal Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Jose V Nable
- Department of Emergency Medicine, MedStar Georgetown University Hospital, Washington D.C., United States of America
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Benedetto U, Sinha S, Dimagli A, Cooper G, Mariscalco G, Uppal R, Moorjani N, Krasopoulos G, Kaura A, Field M, Trivedi U, Kendall S, Angelini GD, Akowuah EF, Tsang G. Decade-long trends in surgery for acute Type A aortic dissection in England: A retrospective cohort study. LANCET REGIONAL HEALTH-EUROPE 2021; 7:100131. [PMID: 34557840 PMCID: PMC8454541 DOI: 10.1016/j.lanepe.2021.100131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Little is known about variations in care and outcomes of patients undergoing surgical repair for type A aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England. Methods Retrospective review of the National Adult Cardiac Surgery Audit, which prospectively collects demographic and peri‑operative information for all major adult cardiac surgery procedures performed in the UK. We identified patients undergoing surgery for TAAD from January 2009-December 2018, reviewed trends in operative frequency, patient demographics, and mortality. Findings Over the 10-year period,3,680 TAAD patients underwent surgical repair in England. A doubling in the overall number of operations conducted in England was observed (235 cases in 2009 to 510 in 2018). Number of procedures per hospital per year also doubled(9 in 2009 to 23 in 2018). Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in recent years(23% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality between hospitals and surgeons. We also found that most patients presented towards the middle of the week and during winter. Interpretation Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival has improved. Variations exist in service provision with a trend towards better survival in high volume centers. Funding British Heart Foundation and NIHR Biomedical Research center(University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol).
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, UK
| | - Shubhra Sinha
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, UK
| | - Arnaldo Dimagli
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, UK
| | | | | | | | | | | | - Amit Kaura
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Simon Kendall
- The James Cook University Hospital, Middlesbrough, UK
| | - Gianni D Angelini
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, UK
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Manunga J, Smith J, Schmidt CW, Titus J, Mudy K, Pavlovec MP, Sun B, Teng X, Mirza A, Skeik N, Sharma A, Harris KM. Impact of a multidisciplinary acute aortic dissection program: Improved outcomes with a comprehensive initial surgical repair strategy. J Vasc Surg 2021; 75:484-494.e1. [PMID: 34506889 DOI: 10.1016/j.jvs.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE As part of a multidisciplinary aortic dissection (AD) program, a more comprehensive repair strategy for patients with acute type A aortic dissection (ATAAD) and frequent endografting for suitable patients with type B aortic dissection (ATBAD) was adopted in 2015. The aim of this study was to evaluate the impact of these changes. METHODS This study is a retrospective review of a prospective database containing all patients treated for acute AD between 2003 and 2020. Patients were grouped based on differing repair strategies (pre 2015 vs post 2015). Clinical characteristics, procedural details, and survival data were analyzed. RESULTS During this time, 323 patients (210 pre, 113 post) were treated for acute AD at our institution. There were 221 patients with ATAAD (149 pre, 72 post) and 102 patients with ATBAD (61 pre, 41 post). The majority (60%) were males, with a mean age of 65.9 ± 15.2 years. There were no differences in cardiovascular risk factors or demographics between the groups. After 2015, fewer patients with ATAAD underwent medical management alone (15% pre vs 4% post; P = .014), and most that underwent surgical intervention had a total arch or aggressive hemiarch repair (27% pre vs 78% post; P < .001). Seventy-four patients (73%) with ATBAD were treated medically, whereas 28 underwent medical management and endografting (23% pre, 34% post; P = .214). For all patients with AD, 30-day mortality was significantly improved (26% pre vs 10% post; P < .001) especially among patients who underwent ATAAD surgery (23% pre vs 9% post; P = .018). Three-year Kaplan-Meier survival estimates showed survival improvement among patients with ATAAD (Log rank P-value = .019); however, this improvement does not extend to type B dissections or the overall cohort. A survival analysis landmarked to 30 days after initial presentation showed no statistical difference in survival from 30 days to 3 years post-presentation. CONCLUSIONS A more comprehensive repair strategy in the management of patients with acute AD resulted in improved overall patient outcomes and significantly decreased 30-day mortality, even though more complex repairs were performed. The long-term impact of the changes made to our program remains to be evaluated.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn; Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn.
| | - Jenna Smith
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Christian W Schmidt
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Jessica Titus
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Karol Mudy
- Section of Cardiovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Matthew P Pavlovec
- Section of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Benjamin Sun
- Section of Cardiovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Xiaoyi Teng
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Aleem Mirza
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Amit Sharma
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Kevin M Harris
- Minneapolis Heart Institute Foundation, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn; Section of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minn
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Elnaggar AS, Bakaeen FG, Roselli EE, Svensson LG, Vargo PR. Commentary: Daytime or nighttime acute type A aortic dissection repair? Does it really matter? JTCVS OPEN 2021; 7:21-22. [PMID: 36003725 PMCID: PMC9390171 DOI: 10.1016/j.xjon.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 12/05/2022]
Affiliation(s)
| | | | | | | | - Patrick R. Vargo
- Address for reprints: Patrick R. Vargo, MD, Department of Thoracic and Cardiovascular Surgery, Aortic Center, Cleveland Clinic, 9500 Euclid Ave, J4-1, Cleveland, OH 44195.
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Brown JA, Navid F, Serna-Gallegos D, Aranda-Michel E, Wang Y, Bianco V, Sultan I. Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01137-5. [PMID: 34420792 DOI: 10.1016/j.jtcvs.2021.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/11/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease. METHODS This was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement. RESULTS A total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790). CONCLUSIONS Morbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, 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, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine. Crit Care Med 2021; 50:37-49. [PMID: 34259453 DOI: 10.1097/ccm.0000000000005147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.
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MacKay EJ, Zhang B, Heng S, Ye T, Neuman MD, Augoustides JG, Feinman JW, Desai ND, Groeneveld PW. Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery. J Am Soc Echocardiogr 2021; 34:571-581. [DOI: 10.1016/j.echo.2021.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 12/18/2022]
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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: 127] [Impact Index Per Article: 42.3] [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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MacKay EJ, Salmon MK, Fatuzzo MR, Neuman MD, Desai ND, Groeneveld PW, Augoustides JG. Validation of Claims Data for the Identification of Intraoperative Transesophageal Echocardiography During Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:3193-3198. [PMID: 34023202 DOI: 10.1053/j.jvca.2021.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The goal of this study was to assess the validity of Current Procedural Terminology (CPT) claims data for the identification of intraoperative transesophageal echocardiography (TEE) during cardiac surgery. DESIGN This study was a retrospective, cohort analysis. SETTING This study used data from electronic medical records (EMRs), in combination with CPT billing claims data, from two hospitals within the Penn Medicine Health System-Penn Presbyterian Medical Center and the Hospital of the University of Pennsylvania. PARTICIPANTS The cohort consisted of adult patients, aged ≥18 years, undergoing open cardiac valve surgery (repair or replacement), coronary artery bypass graft surgery, or aortic surgery between April 1 and October 31, 2019. INTERVENTIONS Agreement between TEE identified using CPT billing code(s) (93312-8 with or without 93320-1 or 93325) and TEE identified by manual EMR review. MEASUREMENTS AND MAIN RESULTS As identified by a reference standard (ie, EMR review) of the 873 cases that met inclusion criteria, 867 (99.31%) cases were performed with TEE and six cases were performed without TEE (<1%). Of the 867 cases performed with TEE, CPT code(s) correctly identified 866 cases, as indicated by having at least one of the CPT codes (93312-8 with or without 93320-1 or 93325). These CPT codes identified intraoperative TEE with a 99.88% sensitivity, 100.00% specificity, 100.00% positive predictive value, and 85.71% negative predictive value. When billing claims for TEE were restricted to the CPT code 93312 alone, the results were identical. CONCLUSIONS Billing claims using CPT code(s) identified true intraoperative TEE with a high sensitivity, specificity, excellent positive predictive value, and moderate negative predictive value. These results demonstrated that claims data are a valuable data source from which to study the effect of TEE in cardiac surgical patients.
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Affiliation(s)
- Emily J MacKay
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA; Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA.
| | - Mandy K Salmon
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mia R Fatuzzo
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA
| | - Nimesh D Desai
- Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA; Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Peter W Groeneveld
- Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA; Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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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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Type A Aortic Dissection—Experience Over 5 Decades. J Am Coll Cardiol 2020; 76:1703-1713. [DOI: 10.1016/j.jacc.2020.07.061] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
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Baiocchi M, Woo YJ, Chiu P, Goldstone AB. The role and significance of sensitivity analyses in enhancing the statistical validity of clinical studies. J Thorac Cardiovasc Surg 2020; 163:749-753. [DOI: 10.1016/j.jtcvs.2020.09.134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 01/30/2023]
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