Determinants of outcomes following surgery for type A acute aortic dissection: the UK National Adult Cardiac Surgical Audit

Abstract

Aims Operability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK. Methods and results We identified 4203 patients undergoing TAAAD surgery in the UK (2009–18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02–1.03; P < 0.001]; malperfusion (OR 1.79, 95% CI 1.51–2.12; P < 0.001); left ventricular ejection fraction (moderate: OR 1.40, 95% CI 1.14–1.71; P = 0.001; poor: OR 2.83, 95% CI 1.90–4.21; P < 0.001); previous cardiac surgery (OR 2.29, 95% CI 1.71–3.07; P < 0.001); preoperative mechanical ventilation (OR 2.76, 95% CI 2.00–3.80; P < 0.001); preoperative resuscitation (OR 3.36, 95% CI 1.14–9.87; P = 0.028); and concomitant coronary artery bypass grafting (OR 2.29, 95% CI 1.86–2.83; P < 0.001). We found a significant inverse relationship between surgeons but not centre annual volume with outcomes. Conclusions Patient characteristics, intraoperative factors, cardiac centre, and high-volume surgeons are strong determinants of outcomes following TAAAD surgery. These findings may help refining clinical decision-making, supporting patient counselling and be used by policy makers for quality assurance and service provision improvement.

Incidence, Risk Factors and Outcomes of Postoperative Headache After Stanford Type a Acute Aortic Dissection Surgery

“…Bezov and colleagues concluded that operator experience was a modifiable risk factors for POH ( 18 ). Benedetto and colleagues reported that high-volume surgeons, cardiac centers, and intraoperative factors were strong determinants of clinical outcomes after AADS ( 1 ).…”

“…Stanford type A acute aortic dissection is a life-threatening cardiovascular disease related to significant risk of morbidity and mortality ( 1 ). Although great improvement has been made in diagnostic techniques and initial management over the past decades, prompt surgical interventions remain the standard treatment ( 2 ).…”

“…Although great improvement has been made in diagnostic techniques and initial management over the past decades, prompt surgical interventions remain the standard treatment ( 2 ). However, survival after Stanford type A acute aortic dissection surgery (AADS) is still suboptimal and a considerable proportion of patients develop various postoperative complications ( 1 ).…”

“Time is aorta?”: Timeliness of surgical repair in type A aortic dissection

“…When surgical repair is delayed, the mortality can be as high as 35% in the first 24 h and reach 90% after 30 days, 1,2 However, even when ATAAD is repaired promptly, the operative mortality can be dishearteningly high, especially in patients presenting with malperfusion and end‐organ ischemia (cerebral, myocardial, mesenteric, and limb), which confers the poorest surgical outcomes 3 . In international registries collecting data on ATAAD, the overall in‐hospital mortality for surgical patients is around 17% and the incidence of malperfusion syndrome ~35% 4–7 …”

“…In the last years, three risk scoring systems have been developed to predict 30 mortality risks after surgical repair of ATAAD: the GERAADA, 11 IRAD, 12 and UK Aortic 6 scores. Despite being developed and tested in different cohorts of patients with ATAAD, all identified the unfavorable role of malperfusion in impacting 30‐day mortality.…”