Complex aortic surgery in a regional center in the United Kingdom. Should the United Kingdom now adopt a United States–style supercenter model?

Abstract

Our outcomes are comparable with other regional centers worldwide; however, they are not as good as those reported from the aortic supercenters. There should be continued impetus regarding the establishment of thoracic aortic surgery guidelines and specialist aortic centers in the United Kingdom.

Thoracic aortic surgery in Europe: Does volume mean necessarily quality?

“…Deep hypothermic circulatory arrest to a rectal temperature of 17 C without specific cerebral perfusion protocol was also used. Although Ariyaratnam and colleagues, 1 did not provide any data on circulatory arrest length, and arch replacement occurred in just 2.9% of the cases, current data suggest that antegrade cerebral perfusion and mild-to-moderate systemic hypothermic circulatory arrest can be safely applied to complex thoracic aortic surgery, ameliorating postoperative ouctomes. 5 So although Ariyaratnam and colleagues 1 set out to demonstrate the need to adopt a US-style supercenter model for TAD, it appears that their analysis understimates the effects of an optimized patient management on the hospitalization outcome, especially in regional centers.…”

“…The use of an intra-aortic balloon pump in patients with TAD, fragile tissues, and peripheral vascular disease could partially explain the hospitalization outcomes presented in the article of Ariyaratnam and colleagues. 1 As a matter of fact, peripheral vascular disease and hypertension were independent predictors for in-hospital mortality (odds ratios of 14.428 and 9.325, respectively), especially in the dissection group, possibly reflecting the negative effects of intra-aortic balloon pumps on these patients. In addition, Ariyaratnam and colleagues 1 adopted central cannulation or femoral artery cannulation for all patients, including those affected by type A dissection.…”

“…We read with great interest the report by Ariyaratnam and colleagues 1 regarding their experience with emergency and elective thoracic aortic surgery during the last 12 years. Ariyaratnam and colleagues 1 reported in-hospital mortality figures of 23.7% and 12.8% in their dissection and nondissection groups, respectively, and concluded that regional centers do not have outcomes comparable to those of the supercenters that exist in the United States.…”

“…On the one hand, in-hospital mortality appears to be strongly associated with both surgeon and hospital volumes; on the other hand, the correct operative management of patients with TAD is another factor that affects their hospitalization outcomes. [2][3][4] In the series of Ariyaratnam and colleagues, 1 we noticed unusually high rates of intra-aortic balloon pump use in both the dissection (46%) and nondissection (50%) groups, despite low rates of poor preoperative ejection fraction (2.6% and 2.9%, respectively). The use of an intra-aortic balloon pump in patients with TAD, fragile tissues, and peripheral vascular disease could partially explain the hospitalization outcomes presented in the article of Ariyaratnam and colleagues.…”

Fate of the Aortic Arch Following Surgery on the Aortic Root and Ascending Aorta in Bicuspid Aortic Valve

“…This decision making is partly based on the estimated risk of dissection in patients with BAV to be 8 times higher than that in the general population [27]. Our series, for elective and urgent cases, is the largest reported in the United Kingdom to date, with favorable results compared with series reporting mortalities of 7% to 16% and others reporting elective and urgent mortality of 3.5% to 9% [10,[28][29][30]. Stamou and colleagues [31] analyzed the Society of Thoracic Surgeons database and reported that the median number of procedures per year was 2 per center, with an operative mortality of 4.2%.…”