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Lodo V, Centofanti P. Current techniques of repair of aortic arch pathologies and the role of the aortic team. Indian J Thorac Cardiovasc Surg 2024; 40:451-460. [PMID: 38919191 PMCID: PMC11194227 DOI: 10.1007/s12055-024-01704-x] [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: 12/04/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 06/27/2024] Open
Abstract
The treatment of aortic arch pathologies is becoming progressively more complex and multidisciplinary. Despite progresses in open surgical techniques, the high rate of surgical morbidity and mortality, especially in frail and elderly patients, has led to the development of alternative treatment options to conventional open surgery such as hybrid and endovascular procedures. Our purpose is to summarize the advantages and disadvantages of the different approaches and investigate the role of a dedicated aortic team in the choice of the most appropriate treatment for each patient.
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Affiliation(s)
- Vittoria Lodo
- Division of Cardiac Surgery, Azienda Ospedaliera Ordine Mauriziano Di Torino, Largo Filippo Turati 6, 10128 Turin, Italy
| | - Paolo Centofanti
- Division of Cardiac Surgery, Azienda Ospedaliera Ordine Mauriziano Di Torino, Largo Filippo Turati 6, 10128 Turin, Italy
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2
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Long JC, Roberts N, Francis-Auton E, Sarkies MN, Nguyen HM, Westbrook JI, Levesque JF, Watson DE, Hardwick R, Churruca K, Hibbert P, Braithwaite J. Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability. BMC Health Serv Res 2024; 24:303. [PMID: 38448960 PMCID: PMC10918928 DOI: 10.1186/s12913-024-10721-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 02/14/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.
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Affiliation(s)
- Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Natalie Roberts
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Mitchell N Sarkies
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Hoa Mi Nguyen
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, NSW, Australia
- Agency for Clinical Innovation, St Leonards, NSW, Australia
| | - Diane E Watson
- Bureau of Health Information, St Leonards, NSW, Australia
| | - Rebecca Hardwick
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Hibino M, Verma S, Jarret CM, Shimamura J, Verma R, Hibino H, Baeza CR, Aune D, Yanagawa B, Usui A, Nienaber CA, Pelletier MP. Temporal trends in mortality of aortic dissection and rupture in the UK, Japan, the USA and Canada. Heart 2024; 110:331-336. [PMID: 37648437 DOI: 10.1136/heartjnl-2023-323042] [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: 05/31/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE Aortic dissection and aortic aneurysm rupture are aortic emergencies and their clinical outcomes have improved over the past two decades; however, whether this has translated into lower mortality across countries remains an open question. The purpose of this study was to compare mortality trends from aortic dissection and rupture between the UK, Japan, the USA and Canada. METHODS We analysed the WHO mortality database to determine trends in mortality from aortic dissection and rupture in four countries from 2000 to 2019. Age-standardised mortality rates per 100 000 persons were calculated, and annual percentage change was estimated using joinpoint regression. RESULTS Age-standardised mortality rates per 100 000 persons from aortic dissection and rupture in 2019 were 1.04 and 1.80 in the UK, 2.66 and 1.16 in Japan, 0.76 and 0.52 in the USA, and 0.67 and 0.81 in Canada, respectively. There was significantly decreasing trends in age-standardised mortality from aortic rupture in all four countries and decreasing trends in age-standardised mortality from aortic dissection in the UK over the study period. There was significantly increasing trends in mortality from aortic dissection in Japan over the study period. Joinpoint regression identified significant changes in the aortic dissection trends from decreasing to increasing in the USA from 2010 and Canada from 2012. In sensitivity analyses stratified by sex, similar trends were observed. CONCLUSIONS Trends in mortality from aortic rupture are decreasing; however, mortality from aortic dissection is increasing in Japan, the USA and Canada. Further study to explain these trends is warranted.
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Affiliation(s)
- Makoto Hibino
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Craig M Jarret
- Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Junichi Shimamura
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raj Verma
- Royal College of Surgeon in Ireland, Dublin, Ireland
| | - Hiromi Hibino
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Cristian R Baeza
- Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Dagfinn Aune
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- Department of Nutrition, Oslo New University College, Oslo, Norway
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Marc P Pelletier
- Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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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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Proietti R, Field M, McKay V, Lip GYH, Kuduvalli M. Screening for the vulnerable aorta: targeting high-risk groups in the population. THE BRITISH JOURNAL OF CARDIOLOGY 2023; 30:25. [PMID: 39144089 PMCID: PMC11321460 DOI: 10.5837/bjc.2023.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Thoracic aortic aneurysms are often asymptomatic until patients present with a life-threatening acute aortic syndrome. The vulnerability of an aorta to an acute aortic syndrome is determined by cross-sectional diameter and underlying aetiological factors, such as genotype or acquired disease. Screening the general population for thoracic aneurysms presents multiple resource issues including the availability of imaging modalities. Targeted screening of high-risk groups provides the only currently pragmatic solution. Opportunistic imaging through lung cancer screening programmes could pick up a proportion. Until we have a comprehensive screening programme it is incumbent on all healthcare professionals to have a low threshold for considering acute aortic pathologies when reviewing patients presenting with chest pain.
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Affiliation(s)
| | | | | | - Gregory Y H Lip
- Professor at Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital; and Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Manoj Kuduvalli
- Cardiac Surgeon Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE
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7
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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: 424] [Impact Index Per Article: 212.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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8
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Trends in mortality from aortic dissection analyzed from the World Health Organization Mortality Database from 2000 to 2017. Int J Cardiol 2022; 360:83-90. [PMID: 35609714 DOI: 10.1016/j.ijcard.2022.05.043] [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: 01/26/2022] [Revised: 04/29/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND We assessed trends in aortic dissection (AD) death rates in 23 countries from 2000 to 2017. METHODS We extracted AD mortality data for countries with high usability data from the World Health Organization (WHO) Mortality Database and from the Center for Disease Control (CDC) WONDER Database for the United States of America (USA). Age Standardized Death Rates (ASDRs) per 100,000 population were computed. Trends were assessed by locally weighted scatter plot smoother (LOWESS) regression. RESULTS Between 2000 and 2017, ASDRs from AD decreased in Australia, Belgium, Croatia, Denmark, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, and the USA for both sexes. Increasing AD mortality was observed in Austria, Czech Republic, Germany, Hungary, Israel, and Japan for both sexes. The largest absolute increases in ASDR were in Japan for men (+1.59) and women (+1.11). The largest percentage decreases were in Norway for men (-0.91) and in New Zealand (-0.6) for women. In 2017, the highest mortality rates were in Japan for both sexes (3.22 and 2.09, respectively). The lowest ASDR was in Kyrgyzstan for both sexes (0.16 and 0.10, respectively). ASDRs for AD in 2017 were higher for men than women in all countries included. Spain had the greatest difference between the gender's mortality rates with a 2.71-fold higher mortality average rate in men. CONCLUSION We identified an overall decrease in AD mortality in most included countries, while an increase was noted in other countries including Israel and Japan.
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De Hert S, Ouattara A, Royston D, van der Linden J, Zacharowski K. Use and safety of aprotinin in routine clinical practice: A European postauthorisation safety study conducted in patients undergoing cardiac surgery. Eur J Anaesthesiol 2022; 39:685-694. [PMID: 35766393 PMCID: PMC9451913 DOI: 10.1097/eja.0000000000001710] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Aprotinin has been used to reduce blood loss and blood product transfusions in patients at high risk of major blood loss during cardiac surgery. Approval by the European Medicines Agency (EMA) for its current indication is limited to patients at high risk of major blood loss undergoing isolated coronary artery bypass graft surgery (iCABG). OBJECTIVE To report current real-world data on the use and certain endpoints related to the safety of aprotinin in adult patients. DESIGN The Nordic aprotinin patient registry (NAPaR) received data from 83 European centres in a noninterventional, postauthorisation safety study (PASS) performed at the request of the EMA. SETTING Cardiac surgical centres committed to enrolling patients in the NAPaR. PATIENTS Patients receiving aprotinin agreeing to participate. INTERVENTION The decision to administer aprotinin was made by the treating physicians. MAIN OUTCOME MEASURES Aprotinin safety endpoints were in-hospital death, thrombo-embolic events (TEEs), specifically stroke, renal impairment, re-exploration for bleeding/tamponade. RESULTS From 2016 to 2020, 5309 patients (male 71.5%; >75 years 18.9%) were treated with aprotinin; 1363 (25.7%) underwent iCABG and 3946 (74.3%) another procedure, including a surgical treatment for aortic dissection ( n = 660, 16.7%); 54.5% of patients received the full-dose regimen. In-hospital mortality in iCABG patients was 1.3% (95% CI, 0.66 to 1.84%) vs. 8.3% (7.21 to 8.91%) in non-iCABG patients; incidence of TEEs and postoperative rise in creatinine level greater than 44 μmol l -1 2.3% (1.48 to 3.07%) and 2.7% (1.79 to 3.49%) vs. 7.2% (6.20 to 7.79%) and 15.5% (13.84 to 16.06%); patients undergoing re-exploration for bleeding 1.4% (0.71 to 1.93%) vs. 3.0% (2.39 to 3.44%). Twelve cases of hypersensitivity/anaphylactic reaction (0.2%) were reported as Adverse Drug Reactions. CONCLUSION The data in the NApaR indicated that in this patient population, at high risk of death or blood loss undergoing cardiac surgery, including complex cardiac surgeries other than iCABG, the incidence of adverse events is in line with data from current literature, where aprotinin was not used. TRIAL REGISTRATION EU PAS register number: EUPAS11384.
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Affiliation(s)
- Stefan De Hert
- From the Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital - Ghent University, Corneel Heymanslaan 10, Ghent, Belgium (SDH), CHU Bordeaux, Department of Anaesthesia and Critical Care Diseases (AO), Univ. Bordeaux, INSERM, UMR 1034, Biology and Cardiovascular Diseases, Pessac, France (AO), Anaesthetics Department, RBH Foundation Trust, Harefield Hospital, Hill End Rd Harefield, Uxbridge, UK (DR), Department of Perioperative Medicine, Section of Cardiothoracic Anaesthesiology and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden (JVDL) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy at the University Hospital Frankfurt, Theodor-Stern-Kai 7, Goethe University, Frankfurt am Main, Germany (KZ)
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10
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Forsythe RO, Eng C, Roy C, Cafferkey J, Clinch D, Ventham N, Tambyraja AL, Burns PJ, Falah O, Chalmers RTA. Open extent IV thoracoabdominal aneurysm repair: 22-year experience of the Scottish National Service. Br J Surg 2022; 109:711-716. [PMID: 35716129 PMCID: PMC10364699 DOI: 10.1093/bjs/znac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/17/2021] [Accepted: 01/26/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Since 1999, the Scottish National Service for Thoracoabdominal Aneurysms has offered repair of thoracoabdominal aneurysms (TAAAs) to a population of 5.5 million people. The open operation most commonly performed by the service is the extent IV TAAA repair. METHODS All extent IV open TAAA repairs performed at the Scottish National Service for TAAAs from June 1999 until April 2021 were evaluated for clinical features, technical details, and clinical outcomes. The primary outcome measure was 30-day mortality; secondary outcomes included short-term (90 days, 6 months, 1 and 2 years) and long-term (5 and 10 years) survival, perioperative complications, and reintervention. Survival was assessed using Kaplan-Meier analysis. RESULTS Some 248 patients underwent extent IV TAAA repair, with elective surgery in 204 (82.3 per cent). A totally abdominal transperitoneal approach was used for all patients, with a median visceral ischaemia time of 40 (i.q.r. 35-48) min. Overall, 18 patients (7.3 per cent) died within 30 days. The proportion of patients surviving at 90 days, 6 months, 1, 2, 5, and 10 years was 0.91, 0.90, 0.89, 0.85, 0.72, and 0.41, respectively. Ten patients (4.0 per cent) required a reintervention while in hospital, four (1.6 per cent) experienced permanent spinal cord ischaemia, 19 (7.9 per cent) required temporary renal replacement therapy (RRT), and four (1.6 per cent) required permanent RRT. CONCLUSION Open extent IV TAAA repair performed in a high-volume national centre is associated with favourable short- and long-term survival, and acceptable complication rates.
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Affiliation(s)
- Rachael O Forsythe
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Calvin Eng
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe Roy
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John Cafferkey
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Darja Clinch
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicholas Ventham
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew L Tambyraja
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Phillipa J Burns
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Orwa Falah
- Correspondence to: Orwa Falah, Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK (e-mail: )
| | - Roderick T A Chalmers
- Scottish National Service for Thoracoabdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, UK
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11
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Liu C, Huang S, Hsu C. A fatal masquerade in pneumonia: Ruptured thoracic aortic aneurysm. Clin Case Rep 2022; 10:e05285. [PMID: 35035967 PMCID: PMC8752455 DOI: 10.1002/ccr3.5285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 11/08/2022] Open
Abstract
We described an 87-year-old man who presented with fever and hemoptysis. Nosocomial pneumonia was initially suspected. However, the patient had worsening hemoptysis despite defervescence. Chest computed tomography disclosed ruptured thoracic aortic aneurysm. Emergent surgery was then commenced for adequate treatment.
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Affiliation(s)
- Ching‐Han Liu
- Division of CardiologyDepartment of MedicineKaohsiung Armed Forces General HospitalKaohsiungTaiwan
- Division of CardiologyDepartment of MedicineNational Defense Medical CenterTri‐Service General HospitalTaipeiTaiwan
| | - Shih‐Chung Huang
- Division of CardiologyDepartment of MedicineKaohsiung Armed Forces General HospitalKaohsiungTaiwan
- Division of CardiologyDepartment of MedicineNational Defense Medical CenterTri‐Service General HospitalTaipeiTaiwan
| | - Ching‐Tsai Hsu
- Division of CardiologyDepartment of MedicineNational Defense Medical CenterTri‐Service General HospitalTaipeiTaiwan
- Division of CardiologyDepartment of MedicineTaoyuan Armed Forces General HospitalTaoyuanTaiwan
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12
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Sharples L, Sastry P, Freeman C, Gray J, McCarthy A, Chiu YD, Bicknell C, McMeekin P, Vallabhaneni SR, Cook A, Vale L, Large S. Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study. Health Technol Assess 2022; 26:1-166. [DOI: 10.3310/abut7744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.
Objective
To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.
Design
A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.
Setting
Thirty NHS vascular/cardiothoracic units.
Participants
Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.
Interventions
Endovascular stent grafting and open surgical replacement.
Main outcomes
Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.
Results
The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.
Limitations
The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.
Conclusions
Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.
Future work
Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.
Trial registration
Current Controlled Trials ISRCTN04044627 and NCT02010892.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Priya Sastry
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carol Freeman
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Joanne Gray
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Andrew McCarthy
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Yi-Da Chiu
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Medical Research Council (MRC) Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - S Rao Vallabhaneni
- Liverpool Vascular & Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Large
- Department of Cardiac Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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13
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Sharples L, Sastry P, Freeman C, Bicknell C, Chiu YD, Vallabhaneni SR, Cook A, Gray J, McCarthy A, McMeekin P, Vale L, Large S. Aneurysm growth, survival, and quality of life in untreated thoracic aortic aneurysms: the effective treatments for thoracic aortic aneurysms study. Eur Heart J 2021; 43:2356-2369. [PMID: 34849716 PMCID: PMC9246658 DOI: 10.1093/eurheartj/ehab784] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/02/2021] [Accepted: 11/11/2021] [Indexed: 01/16/2023] Open
Abstract
Aims To observe, describe, and evaluate management and timing of intervention for patients with untreated thoracic aortic aneurysms. Methods and results Prospective study of UK National Health Service (NHS) patients aged ≥18 years, with new/existing arch or descending thoracic aortic aneurysms of ≥4 cm diameter, followed up until death, intervention, withdrawal, or July 2019. Outcomes were aneurysm growth, survival, quality of life (using the EQ-5D-5L utility index), and hospital admissions. Between 2014 and 2018, 886 patients were recruited from 30 NHS vascular/cardiothoracic units. Maximum aneurysm diameter was in the descending aorta in 725 (82%) patients, growing at 0.2 cm (0.17–0.24) per year. Aneurysms of ≥4 cm in the arch increased by 0.07 cm (0.02–0.12) per year. Baseline diameter was related to age and comorbidities, and no clinical correlates of growth were found. During follow-up, 129 patients died, 64 from aneurysm-related events. Adjusting for age, sex, and New York Heart Association dyspnoea index, risk of death increased with aneurysm size at baseline [hazard ratio (HR): 1.88 (95% confidence interval: 1.64–2.16) per cm, P < 0.001] and with growth [HR: 2.02 (1.70–2.41) per cm, P < 0.001]. Hospital admissions increased with aneurysm size [relative risk: 1.21 (1.05–1.38) per cm, P = 0.008]. Quality of life decreased annually for each 10-year increase in age [–0.013 (–0.019 to –0.007), P < 0.001] and for current smoking [–0.043 (–0.064 to –0.023), P = 0.004]. Aneurysm size was not associated with change in quality of life. Conclusion International guidelines should consider increasing monitoring intervals to 12 months for small aneurysms and increasing intervention thresholds. Individualized decisions about surveillance/intervention should consider age, sex, size, growth, patient characteristics, and surgical risk.
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Affiliation(s)
| | - Priya Sastry
- Department of Cardiac Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Carol Freeman
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Trumpington, Cambridge CB2 0AY, UK
| | - Colin Bicknell
- Department of Vascular Surgery, Imperial College, South Kensington Campus, London SW7 2AZ, UK
| | - Yi Da Chiu
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Trumpington, Cambridge CB2 0AY, UK
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Robinson Way, Cambridge CB2 0SR, UK
| | - Srinivasa Rao Vallabhaneni
- Liverpool Vascular & Endovascular Service, Royal Liverpool University Hospital, Prescot Street, Liverpool, Merseyside L7 8XP, UK
| | - Andrew Cook
- Wessex Institute & Southampton Clinical Trials Unit, University of Southampton, Alpha House, Enterprise Rd, Chilworth, Southampton SO16 7NS, UK
| | - Joanne Gray
- Faculty of Health and Life Sciences, Northumbria University, Wells Close, Newcastle Upon Tyne NE7 7YT, UK
| | - Andrew McCarthy
- Faculty of Health and Life Sciences, Northumbria University, Wells Close, Newcastle Upon Tyne NE7 7YT, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Wells Close, Newcastle Upon Tyne NE7 7YT, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne NE2 4AX, UK
| | - Stephen Large
- Department of Cardiac Surgery, Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Trumpington, Cambridge CB2 0AY, UK
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14
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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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15
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Benedetto U, Dimagli A, Cooper G, Uppal R, Mariscalco G, Krasopoulos G, Goodwin A, Trivedi U, Kendall S, Sinha S, Fudulu D, Angelini GD, Tsang G, Akowuah E. Neuroprotective strategies in acute aortic dissection: an analysis of the UK National Adult Cardiac Surgical Audit. Eur J Cardiothorac Surg 2021; 60:1437-1444. [PMID: 33963362 PMCID: PMC8643475 DOI: 10.1093/ejcts/ezab192] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/11/2021] [Accepted: 03/30/2021] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011-2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA <30 min and 28.6%, 30.4%, 33.3% and 33.0% for CA ≥30 min with DHCA only, uACP, bACP and retrograde cerebral perfusion, respectively. The use of DHCA only was associated with five-fold [odds ratio (OR) 5.35, 95% confidence interval (CI) 1.36-21.02] and two-fold (OR 1.77, 95% CI 1.01-3.09) increased risk of death and/or CVA compared to uACP and bACP, respectively, but the effect of uACP was significantly associated with CA duration (hazard ratio 0.97, 95% CI 0.94-0.99; P = 0.04). CONCLUSIONS In TAAD repair, the use of uACP and bACP was associated with a lower adjusted risk of death and/or CVA when compared to DHCA. uACP can offer some advantage but only for a shorter CA duration.
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Affiliation(s)
| | | | - Graham Cooper
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Rakesh Uppal
- Barts Heart Centre, William Harvey Research Institute, London, UK
| | | | | | | | - Uday Trivedi
- Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Daniel Fudulu
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Geoffrey Tsang
- Wessex Cardiothoracic Center, University Hospital Southampton NHS Trust, Southampton, UK
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16
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Lopez‐Marco A, Harky A, Verdichizzo D, Hope E, Rosser B, McPherson I, Kelly R, Holland L, Ye Oo A. Early experience of aortic surgery during the COVID-19 pandemic in the UK: A multicentre study. J Card Surg 2021; 36:848-856. [PMID: 33442890 PMCID: PMC8013563 DOI: 10.1111/jocs.15307] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND A significant restructuring of the healthcare services has taken place since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, with elective surgery put on hold to concentrate intensive care resources to treat COVID-19 as well as to protect patients who are waiting for relatively low risk surgery from exposure to potentially infected hospital environment. METHODS Multicentre study, with 19 participating centers, to define the impact of the pandemic on the provision of aortovascular services and patients' outcomes after having adapted the thresholds for intervention to guarantee access to treatment for emergency and urgent conditions. Retrospective analysis of prospectively collected data, including all patients with aortovascular conditions admitted for surgical or conservative treatment from the 1st March to the 20th May 2020. RESULTS A total of 189 patients were analyzed, and 182 underwent surgery. Diagnosis included: aneurysm (45%), acute aortic syndrome (44%), pseudoaneurysm (4%), aortic valve endocarditis (4%), and other (3%). Timing for surgery was: emergency (40%), urgent (34%), or elective (26%). In-hospital mortality was 12%. Thirteen patients were diagnosed with COVID-19 during the peri-operative period, and this subgroup was not associated with a higher mortality. CONCLUSIONS There was a significant change in service provision for aortovascular patients in the UK. Although the emergency and urgent surgical activity were maintained, elective treatment was minimal during early months of the pandemic. The preoperative COVID-19 screening protocol, combined with self-isolation and shielding, contributed to the low incidence of COVID-19 in our series and a mortality similar to that of pre-pandemic outcomes.
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Affiliation(s)
- Ana Lopez‐Marco
- Department of Cardiothoracic SurgeryBarts Heart Centre, St. Bartholomew's HospitalLondonUK
| | - Amer Harky
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest HospitalLiverpoolUK,Department of Integrative Biology, Faculty of Health and Life ScienceUniversity of LiverpoolLiverpoolUK,Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK,Department of Congenital Cardiac SurgeryAlder Hey Children HospitalLiverpoolUK
| | | | - Emma Hope
- Department of Cardiothoracic SurgeryUniversity Hospital of SouthamptonSouthamptonUK
| | - Barbara Rosser
- Department of Cardiothoracic SurgeryRoyal Brompton and Harefield NHS TrustLondonUK
| | - Iain McPherson
- Department of Cardiothoracic SurgeryFreeman HospitalNewcastleUK
| | - Ronan Kelly
- Department of Cardiothoracic SurgeryRoyal Victoria HospitalBelfastUK
| | - Luke Holland
- Department of Cardiothoracic SurgeryRoyal Sussex County HospitalBrightonUK
| | - Aung Ye Oo
- Department of Cardiothoracic SurgeryBarts Heart Centre, St. Bartholomew's HospitalLondonUK
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17
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Abstract
Aortic dissection remains a highly morbid diagnosis. The treatment of aortic dissection has undergone several paradigm shifts since it was first understood. However, despite the robust research in treatment, the epidemiology of aortic dissection is limited. In this review, we discuss the historical perspectives of aortic dissection with a review of risk factors and presentation. We review the trends in incidence during the past 40 years, with consideration for sex, race, and ethnicity in admission. We further focus our discussion of the classically described Type B aortic dissection treatment. Lastly, we review the impact of long-term events, readmissions, cost assessments, and quality of life studies of patients with aortic dissection. Care for those with aortic dissection remains a long-term challenge for providers and a multispecialty approach is needed for complete patient management.
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Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 2(nd) Street SW, Rochester, MN 55902
| | - Young M Erben
- Department of Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 2(nd) Street SW, Rochester, MN 55902.
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18
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Lopez-Marco A, Rosser B, Harky A, Verdichizzo D, McPherson I, Hope E, Qadri S, Oo A. The fate of patients with acute aortic syndrome during the coronavirus disease 2019 (COVID-19) pandemic: A UK multicenter study. ACTA ACUST UNITED AC 2020; 5:17-25. [PMID: 34172983 PMCID: PMC7690305 DOI: 10.1016/j.xjon.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 01/04/2023]
Abstract
Objective The coronavirus disease 2019 (COVID-19) pandemic has posed challenges to health care services across the world. There has been a significant restructuring of health care resources to protect services for patients with COVID-19–related illness and to maintain emergency and urgent medical and surgical activity. This study assessed access to emergency treatment, logistical challenges, and outcomes of patients with acute aortic syndrome during the early months of the COVID-19 pandemic in the United Kingdom. Methods This was a multicenter study, from March 1 to May 20, 2020 that included 19 cardiac centers, was a retrospective analysis of prospectively collected data obtained from individual centers' national cardiac surgical databases. Demographic details, choice of treatment, operative details, and outcomes were collected. COVID-19 screening, timing of surgery, and outcomes of COVID-19–positive and –negative patients were also analyzed. Results In total, 88 patients presented with acute aortic syndrome to participating centers from March 1 to May 20, 2020. There were 79 aortic dissections (89.8%), 7 intramural hematomas (7.9%), and 2 penetrating aortic ulcers (2.3%). Seventy-nine patients (89.8%) underwent surgery. In-hospital mortality was 25.3% (n = 20). Postoperative complications included 13.9% postoperative stroke (11.4% permanent and 2.3% temporary), 16.5% rate of hemofiltration, and 10.1% rate of tracheostomy. Nine patients were treated conservatively with a mortality of 60%. Seven patients were diagnosed with COVID-19, and there was no associated mortality. Conclusions Despite extensive restructuring of health care resources, access to emergency and urgent treatment for patients with acute aortic syndrome was maintained in the early months of the COVID-19 pandemic in the United Kingdom. Clinical outcomes were similar to the prepandemic period.
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Affiliation(s)
- Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
| | - Barbara Rosser
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, London, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Danilo Verdichizzo
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Iain McPherson
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle, United Kingdom
| | - Emma Hope
- Department of Cardiothoracic Surgery, Southampton University Hospital, Southampton, United Kingdom
| | - Syed Qadri
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Aung Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, United Kingdom
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19
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Abstract
Aortic dissection (AD) causes more deaths each year in the United Kingdom than road traffic collisions. Yet the incidence of AD is not known. The management of acute type B AD (TBAD) is changing, with the greater use of thoracic aortic stent grafts (TEVAR) in treatment and fewer open surgical procedures performed. The study’s aim is to review the worldwide, English language published, literature on acute TBAD incidence and treatment, to report on its strengths and limitations, and better understand changes in incidence over time and between countries. Thirty-one studies were identified that focus on the epidemiology and treatment of TBAD. Eight of these studies report the incidence of acute TBAD as between of 0.5–6.3 per 100,000 person years. Hospital admissions for aortic dissection are reported to be increasing in six studies and stable in one study. The proportion of patients with TBAD operated on varies between studies (range 13% to 76%). Studies identify patient age (median 51–77 years), gender (range 48%–81% male) and prevalence of cardio-vascular risk factors, specifically hypertension, in the populations studied as independent factors influencing aortic dissection incidence. Treatment of acute TBAD remains largely conservative with analgesia, hypertension control and serial cross-sectional imaging (range 24%–87% TBAD medically treated). The use of TEVAR to treat acute AD is increasing worldwide (range 13%–76% TBAD treated with TEVAR). The incidence of TBAD is under-reported due to out of hospital deaths, variable clinical presentation (miss-diagnosis) and coding errors. Importantly for research, the single International Classification of Diseases (ICD) code for aortic dissection, I17.0, does not distinguish between acute, chronic, type A or type B dissection types. Similarly, the OPCS Classification of Interventions and Procedures version 4 (OPCS-4) codes for TEVAR, L27.4 and L28.4, do not distinguish between acute and chronic AD presentation, unlike the codes for open thoracic aortic replacement. Standardised reporting of aortic dissection type, and the urgency of both the initial presentation (acute or chronic) and treatment (emergency, urgent or planned) in future studies would allow more meaningful comparisons between populations.
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20
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Abbasciano RG, Barwell J, Sayers R, Bown M, Milewicz D, Cooper G, Mariscalco G, Wheeldon N, Fowler C, Owens G, Murphy GJ. Report of a Delphi exercise to inform the design of a research programme on screening for thoracic aortic disease. Trials 2020; 21:656. [PMID: 32678053 PMCID: PMC7367380 DOI: 10.1186/s13063-020-04562-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/26/2020] [Indexed: 01/16/2023] Open
Abstract
Objectives To inform the design of a clinical trial of a targeted screening programme for relatives of individuals affected by thoracic aortic disease, we performed a consensus exercise as to the acceptability of screening, the optimal sequence and choice of tests, long-term patient management, and choice of trial design. Methods Working with the Aortic Dissection Awareness UK & Ireland patient association, we performed a Delphi exercise with clinical experts, patients, and carers, consisting of three rounds of consultation followed by a final multi-stakeholder face-to-face workshop. Results Thirty-five experts and 84 members of the public took part in the surveys, with 164 patients and clinicians attending the final workshop. There was substantial agreement on the need for a targeted screening pathway that would employ a combined approach (imaging + genetic testing). The target population would include the first- and second-degree adult (> 15 years) relatives, with no upper age limit of affected patients. Disagreement persisted about the screening process, sequence, personnel, the imaging method to adopt, computed tomography (CT) scan vs magnetic resonance imaging (MRI), and the specifics of a potential trial, including willingness to undergo randomisation, and measures of effectiveness and acceptability. Conclusion A Delphi process, initiated by patients, identified areas of uncertainty with respect to behaviour, process, and the design of a targeted screening programme for thoracic aortic disease that requires further research prior to any future trial.
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Affiliation(s)
- R G Abbasciano
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK.
| | - J Barwell
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - R Sayers
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - M Bown
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - D Milewicz
- Division of Medical Genetics, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - G Cooper
- Northern General Hospital, Herries Road, Sheffield, UK
| | - G Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - N Wheeldon
- Northern General Hospital, Herries Road, Sheffield, UK
| | | | | | - G J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
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Pisano A, Torella M, Yavorovskiy A, Landoni G. The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:711-729. [PMID: 32434720 DOI: 10.1053/j.jvca.2020.03.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/29/2020] [Indexed: 11/11/2022]
Abstract
Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.
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Affiliation(s)
- Antonio Pisano
- Department of Critical Care, Cardiac Anesthesia and Intensive Care Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Capoccia M, Maybauer MO. Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review. World J Crit Care Med 2019; 8:135-147. [PMID: 31942440 PMCID: PMC6957356 DOI: 10.5492/wjccm.v8.i8.135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation (ECMO) for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.
AIM To review the available literature to determine if there was any evidence.
METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.
RESULTS The search resulted in 29 publications relevant to the subject: 1 brief communication, 1 surgical technique report, 1 invited commentary, 1 retrospective case review, 1 observational study, 4 retrospective reviews, 13 case reports and 7 conference abstracts. A total of 194 patients were included in these publications of whom 77 survived.
CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection, it is enough to justify its use in this patient population despite current adverse attitude.
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Affiliation(s)
- Massimo Capoccia
- Department of Aortic and Cardiac Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, United Kingdom
| | - Marc O Maybauer
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Anaesthesiology and Intensive Care Medicine, Phillips University, Marburg 35037, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane QLD 4032, Queensland, Australia
- Advanced Critical Care and Transplant Institute, Integris Baptist Medical Centre, Oklahoma City, OK 73112, United States
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Bashir M, Harky A, Howard C, Bartram T. Type A Aortic Dissection in the United Kingdom: The Untold Facts. Semin Thorac Cardiovasc Surg 2019; 31:664-667. [PMID: 31283988 DOI: 10.1053/j.semtcvs.2019.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/30/2019] [Indexed: 11/11/2022]
Abstract
There is a lack of evidence on multiple levels for appropriate recognition, management, and outcome results in Type A aortic dissection management in the United Kingdom. A huge amount of retrospective data exists in the literature which provides nonmeaningful prospect to a service that meets the current era. Electronic searches were performed on PubMed and Cochrane databases with no limits placed on dates. Search terms were charted to MeSH terms and combined using Boolean operations, and also used as key words. Papers were selected on the basis of title and abstract. The reference lists of selected papers were reviewed to identify any relevant papers that might be suitable for inclusion in the study. Papers were selected based on providing primary end points of death, rupture, or dissection and/or information regarding aortic aneurysm growth. Papers were not excluded based on patient population age. We demonstrated the lack of evidence for quality outcomes in type A aortic dissection in the United Kingdom. This highlighted the unwarranted variation seen in this entity and the caveats needed to improve structuring of type A aortic dissection from early identification in emergency departments to arrival at destination site for optimum intervention. Emergency services should be restructured to meet the immediate affirmation of diagnosis with gold standard imaging modality available. Management of this dire disease should be instituted at local hospitals prior to transportation and results should be audited regularly to improve quality outcomes. Attempts should be made to create local area networks to improve the efficiencies and outcomes of the service and transfer to centers with concentration of expertise. Recognition of regional networks by the UK Government Care Quality Commission should in part based on cumulative evidence sought after from virtual multidisciplinary teams. Unwarranted variation is an avenue that requires to be addressed to rise with service provision that meets our patients aspiration and be of current evidence in the 21st era.
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Affiliation(s)
- Mohamad Bashir
- Department of Emergency Medicine, Macclesfield General Hospital, Macclesfield, United Kingdom.
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Callum Howard
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Thomas Bartram
- Department of Emergency Medicine, Macclesfield General Hospital, Macclesfield, United Kingdom
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Dufendach KA, Sultan I, Gleason TG. Distal Extent of Surgery for Acute Type A Aortic Dissection. ACTA ACUST UNITED AC 2019; 24:82-102. [PMID: 33911986 DOI: 10.1053/j.optechstcvs.2019.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute type A aortic dissection (TAAD) is a complex disease associated with extremely high morbidity and mortality for which we advocate a coordinated, protocol-driven system of care delivery that begins at patient diagnosis and continues throughout and beyond aortic reconstruction. Essential components of TAAD repair include prompt restoration of true lumen blood flow with obliteration of the false lumen flow, resection of the primary tear sites, restoration of valvular competency, and elimination of any organ malperfusion. This article focuses specifically on extent of repair of the aortic arch and explains our protocols regarding cannulation location and technique, cerebral and distal organ protection strategy, management of the brachiocephalic vessels, and extent of distal aortic reconstruction. We describe an operative strategy for TAAD repair that includes (1) continuous neurocerebral monitoring in all cases, (2) uninterrupted antegrade and/or retrograde cerebral perfusion (depending upon extent of arch repair) during open arch reconstruction, (3) aortic arch replacement technique with or without brachiocephalic vessel replacement using a custom trifurcate graft, and (4) descending aortic stabilization with or without the use of an elephant or frozen elephant trunk (distal stent graft). Our protocol for extent of aortic arch and brachiocephalic reconstruction has been standardized and is predicated on distinct pathoanatomic findings and/or cerebral malperfusion that are outlined.
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Affiliation(s)
- Keith A Dufendach
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Thomas G Gleason
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Harky A, Chan JS, Bithas C, Hof A, Sharif M, Froghi S, Bashir M. Innominate vs. Axillary Artery Cannulation in Aortic Surgery: a Systematic Review and Meta-Analysis. Braz J Cardiovasc Surg 2019; 34:213-221. [PMID: 30916132 PMCID: PMC6436790 DOI: 10.21470/1678-9741-2018-0272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/17/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery. METHODS A comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017. RESULTS Only three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups. CONCLUSION There is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.
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Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom of Great Britain and Northern Ireland
| | - Jeffrey Sk Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Region of the People's Republic of China
| | - Christiana Bithas
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom of Great Britain and Northern Ireland
| | - Alexander Hof
- Department of Cardiovascular Surgery, Heinrich-Heine-University, Medical Faculty, Dusseldrof, Germany
| | - Monira Sharif
- School of Medicine, University of Liverpool, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Saied Froghi
- Department of Surgery, Imperial College NHS Trust, Hammersmith Hospital, Du Cane Rd London, United Kingdom of Great Britain and Northern Ireland
| | - Mohamad Bashir
- Manchester Royal Infirmary, United Kingdom of Great Britain and Northern Ireland
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Mariscalco G, Maselli D, Zanobini M, Ahmed A, Bruno VD, Benedetto U, Gherli R, Gherli T, Nicolini F. Aortic centres should represent the standard of care for acute aortic syndrome. Eur J Prev Cardiol 2019; 25:3-14. [PMID: 29708034 DOI: 10.1177/2047487318764963] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Existing evidence suggests that patients affected by acute aortic syndromes (AAS) may benefit from treatment at dedicated specialized aortic centres. The purpose of the present study was to perform a meta-analysis to evaluate the impact aortic service configuration has in clinical outcomes in AAS patients. Methods The design was a quantitative and qualitative review of observational studies. We searched PubMed/ MEDLINE, EMBASE, and Cochrane Library from inception to the end of December 2017 to identify eligible articles. Areas of interest included hospital and surgeon volume activity, presence of a multidisciplinary thoracic aortic surgery program, and a dedicated on-call aortic team. Participants were patients undergoing repair for AAS, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were adopted for synthesizing hospital/30-day mortality. Results A total of 79,131 adult patients from a total of 30 studies were obtained. No randomized studies were identified. Pooled unadjusted ORs showed that patients treated in high-volume centres or by high-volume surgeons were associated with lower mortality rates (OR 0.51; 95% CI 0.46-0.56, and OR 0.41, 95% CI 0.25-0.66, respectively). Pooled adjusted estimates for both high-volume centres and surgeons confirmed these survival benefits (adjusted OR, 0.56; 95% CI 0.45-0.70, respectively). Patients treated in centres that introduced a specific multidisciplinary aortic program and a dedicated on-call aortic team also showed a significant reduction in mortality (OR 0.31; 95% CI 0.19-0.5, and OR 0.37; 95% CI 0.15-0.87, respectively). Conclusions We found that specialist aortic care improves outcomes and decreases mortality in patients affected by AAS.
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Affiliation(s)
- Giovanni Mariscalco
- 1 Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Daniele Maselli
- 2 Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Marco Zanobini
- 3 Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Italy
| | - Aamer Ahmed
- 4 Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Riccardo Gherli
- 6 Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Hospital, Rome, Italy
| | - Tiziano Gherli
- 7 Division of Cardiac Surgery, University of Parma, Parma, Italy
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Soppa G, Theodoropoulos P, Bilkhu R, Harrison DA, Alam R, Beattie R, Bleetman D, Hussain A, Jones S, Kenny L, Khorsandi M, Lea A, Mensah K, Hici TN, Pinho-Gomes AC, Rogers L, Sepehripour A, Singh S, Steele D, Weaver H, Klein A, Fletcher N, Jahangiri M. Variation between hospitals in outcomes following cardiac surgery in the UK. Ann R Coll Surg Engl 2019; 101:333-341. [PMID: 30854865 PMCID: PMC6513373 DOI: 10.1308/rcsann.2019.0029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We examine the influence of variations in provision of cardiac surgery in the UK at hospital level on patient outcomes and also to assess whether there is an inequality of access and delivery of healthcare. Cardiothoracic surgery has pioneered the reporting of surgeon-specific outcomes, which other specialties have followed. We set out to identify factors other than the individual surgeon, which can affect outcomes and enable other surgical specialties to adopt a similar model. MATERIALS AND METHODS A retrospective analysis of prospectively collected data of patient and hospital level factors between 2013 and 2016 from 16 cardiac surgical units in the UK were analysed through the Society for Cardiothoracic Surgery of Great Britain and Ireland and the Royal College of Surgeons Research Collaborative. Patient demographic data, risks factors, postoperative complications and in-hospital mortality, as well as hospital-level factors such as number of beds and operating theatres, were collected. Correlation between outcome measures was assessed using Pearson's correlation coefficient. Associations between hospital-level factors and outcomes were assessed using univariable and multivariable regression models. RESULTS Of 50,871 patients (60.5% of UK caseload), 25% were older than 75 years and 29% were female. There was considerable variation between units in patient comorbidities, bed distribution and staffing. All hospitals had dedicated cardiothoracic intensive care beds and consultants. Median survival was 97.9% (range 96.3-98.6%). Postoperative complications included re-sternotomy for bleeding (median 4.8%; range 3.5-6.9%) and mediastinitis (0.4%; 0.1-1.0%), transient ischaemic attack/cerebrovascular accident (1.7%; range 0.3-3.0%), haemofiltration (3.7%; range 0.8-6.8%), intra-aortic balloon pump use (3.3%; range 0.4-7.4%), tracheostomy (1.6%; range 1.3-2.6%) and laparotomy (0.3%; range 0.2-0.6%). There was variation in outcomes between hospitals. Univariable analysis showed a small number of positive associations between hospital-level factors and outcomes but none remained significant in multivariable models. CONCLUSIONS Variations among hospital level factors exists in both delivery of, and outcomes, following cardiac surgery in the UK. However, there was no clear association between these factors and patient outcomes. This negative finding could be explained by differences in outcome definition, differences in risk factors between centres that are not captured by standard risk stratification scores or individual surgeon/team performance.
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Affiliation(s)
- G Soppa
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - P Theodoropoulos
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Bilkhu
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - DA Harrison
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Alam
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Beattie
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - D Bleetman
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Hussain
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - S Jones
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - L Kenny
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - M Khorsandi
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Lea
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - Ka Mensah
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - TN Hici
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - AC Pinho-Gomes
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - L Rogers
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Sepehripour
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - S Singh
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - D Steele
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - H Weaver
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Klein
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - N Fletcher
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - M Jahangiri
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
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Mariscalco G, Bilal H, Catarino P, Hadjinikolaou L, Kuduvalli M, Field M, Mascaro J, Oo AY, Quarto C, Kuo J, Tsang G. Reflection From UK Aortic Group: Frozen Elephant Trunk Technique as Optimal Solution in Type A Acute Aortic Dissection. Semin Thorac Cardiovasc Surg 2019; 31:686-690. [PMID: 30980933 DOI: 10.1053/j.semtcvs.2019.03.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/18/2019] [Indexed: 12/29/2022]
Abstract
Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates.
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Affiliation(s)
- Giovanni Mariscalco
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
| | - Haris Bilal
- Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Leonidas Hadjinikolaou
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Manoj Kuduvalli
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Jorge Mascaro
- University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Aung Y Oo
- Department of Cardiac Surgery, Barts Heart Center, St Bartholomew's Hospital, London, United Kingdom
| | - Cesare Quarto
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom
| | - James Kuo
- Southwest Cardiothoracic Center, Derriford Hospital, Plymouth, United Kingdom
| | - Geoff Tsang
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L. Addressing unwarranted clinical variation: A rapid review of current evidence. J Eval Clin Pract 2019; 25:53-65. [PMID: 29766616 DOI: 10.1111/jep.12930] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness. DESIGN Rapid evidence assessment (REA) methodology was used. DATA SOURCES A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature. DATA SYNTHESIS Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature. RESULTS A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV. CONCLUSION Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field.
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Affiliation(s)
- Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Elizabeth Manias
- Melbourne School of Health Sciences, The University of Melbourne and Research Professor, School of Nursing and Midwifery, Deakin University, Australia
| | - Stephen Mears
- Hunter New England Medical Library, New Lambton, Australia
| | - David Heslop
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Reece Hinchcliff
- University of Technology Sydney, Centre for Health Services Research, Ultimo, Australia
| | - Liz Hay
- Economics and Analyticss, Strategic Reform Branch, NSW Ministry of Health, North Sydney, Australia
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Mariscalco G, Debiec R, Elefteriades JA, Samani NJ, Murphy GJ. Systematic Review of Studies That Have Evaluated Screening Tests in Relatives of Patients Affected by Nonsyndromic Thoracic Aortic Disease. J Am Heart Assoc 2018; 7:e009302. [PMID: 30371227 PMCID: PMC6201478 DOI: 10.1161/jaha.118.009302] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/08/2018] [Indexed: 12/19/2022]
Abstract
Background Nonsyndromic thoracic aortic diseases ( NS - TADs ) are often silent entities until they present as life-threatening emergencies. Despite familial inheritance being common, screening is not the current standard of care in NS - TAD s. We sought to determine the incidence of aortic diseases, the predictive accuracy of available screening tests, and the effectiveness of screening programs in relatives of patients affected by NS - TADs . Methods and Results A systematic literature search on PubMed/ MEDLINE , Embase, and the Cochrane Library was conducted from inception to the end of December 2017. The search was supplemented with the Online Mendelian Inheritance in Man database. A total of 53 studies were included, and a total of 2696 NS - TAD relatives were screened. Screening was genetic in 49% of studies, followed by imaging techniques in 11% and a combination of the 2 in 40%. Newly affected individuals were identified in 33%, 24%, and 15% of first-, second-, and third-degree relatives, respectively. Familial NS - TAD s were primarily attributed to single-gene mutations, expressed in an autosomal dominant pattern with incomplete penetrance. Specific gene mutations were observed in 25% of the screened families. Disease subtype and genetic mutations stratified patients with respect to age of presentation, aneurysmal location, and aortic diameter before dissection. Relatives of patients with sporadic NS - TAD s were also found to be affected. No studies evaluated the predictive accuracy of imaging or genetic screening tests, or the clinical or cost-effectiveness of an NS - TAD screening program. Conclusions First- and second-degree relatives of patients affected by both familial and sporadic NS - TAD s may benefit from personalized screening programs.
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Affiliation(s)
- Giovanni Mariscalco
- Department of Cardiovascular SciencesUniversity of Leicester and National Institute for Health Research Leicester Cardiovascular Biomedical Research CentreLeicesterUnited Kingdom
| | - Radoslaw Debiec
- Department of Cardiovascular SciencesUniversity of Leicester and National Institute for Health Research Leicester Cardiovascular Biomedical Research CentreLeicesterUnited Kingdom
| | | | - Nilesh J. Samani
- Department of Cardiovascular SciencesUniversity of Leicester and National Institute for Health Research Leicester Cardiovascular Biomedical Research CentreLeicesterUnited Kingdom
| | - Gavin J. Murphy
- Department of Cardiovascular SciencesUniversity of Leicester and National Institute for Health Research Leicester Cardiovascular Biomedical Research CentreLeicesterUnited Kingdom
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