Effects of institutional volumes on operative outcomes for aortic root replacement in North America

Hughes, G. Chad; Zhao, Yue; Rankin, J. Scott; Scarborough, John; O’Brien, Sean M.; Bavaria, Joseph E.; Wolfe, Walter G.; Gaca, Jeffrey G.; Gammie, James S.; Shahian, David M.; Smith, Peter K.

doi:10.1016/j.jtcvs.2011.10.094

Cited by 154 publications

(105 citation statements)

References 16 publications

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“…This inherent selection bias will be impossible to eliminate from any future study. Furthermore, because valve sparing surgery is a technically demanding procedure, centers with low volumes are likely to have worse outcomes (35). Therefore the procedure should be carried out in centers with sufficient expertise.…”

Section: Discussionmentioning

confidence: 99%

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Flynn

Tian

Wilson-Smith

et al. 2017

Ann. Cardiothorac. Surg.

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Background: A major, life-limiting feature of Marfan syndrome (MFS) is the presence of aneurysmal disease. Cardiovascular intervention has dramatically improved the life expectancy of Marfan patients.Traditionally, the management of aortic root disease has been undertaken with composite-valve graft replacing the aortic valve and proximal aorta; more recently, valve sparing procedures have been developed to avoid the need for anticoagulation. This meta-analysis assesses the important surgical outcomes of the two surgical techniques.Methods: A systematic review and meta-analysis of 23 studies reporting the outcomes of aortic root surgery in Marfan patients with data extracted for outcomes of early and late mortality, thromboembolic events, late bleeding complications and surgical reintervention rates.Results: The outcomes of 2,976 Marfan patients undergoing aortic root surgery were analysed, 1,624 patients were treated with composite valve graft (CVG) and 1,352 patients were treated with valve sparing root replacement (VSRR). When compared against CVG, VSRR was associated with reduced risk of thromboembolism (OR =0.32; 95% CI, 0.16-0.62, P=0.0008), late hemorrhagic complications (OR =0.18; 95% CI, 0.07-0.45; P=0.0003) and endocarditis (OR =0.27; 95% CI, 0.10-0.68; P=0.006). Importantly there was no significant difference in reintervention rates between VSRR and CVG (OR =0.89; 95% CI, 0.35-2.24; P=0.80).Conclusions: There is an increasing body of evidence that VSRR can be reliably performed in Marfan patients, resulting in a durable repair with no increased risk of re-operation compared to CVG, thus avoiding the need for systemic anticoagulation in selected patients.

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Section: Discussionmentioning

confidence: 99%

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Flynn

Tian

Wilson-Smith

et al. 2017

Ann. Cardiothorac. Surg.

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“…In USA, the highest number of root operations are done in only few centers, by these regular guests (5). The rest of the centers are exposed to less than six roots per year!…”

Section: Viewpoint On Cardiac Surgerymentioning

confidence: 99%

Why to be cautious with the use of the frozen elephant trunk in acute type A aortic dissection

Morshuis

2018

J. Vis. Surg.

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Figure 2 By closing of the entry tear we may achieve the same results as in stenting a type B dissection with opening the true lumen and improvement of mesenteric and distal perfusion, as well as a trombosing false lumen and reducing diameter at follow up. Journal of Visualized Surgery, 2018© Journal of Visualized Surgery. All rights reserved.J Vis Surg 2018;4:73 jovs.amegroups.com Page 4 of 5 group of Sultan and Bavaria (16) in addition to ascending and hemi-arch replacement. However, this relatively easy extension of surgery, almost doubles circulatory arrest time and increases the operation time by one hour, up to 7 hours average. Yes, false lumen trombosis does occur, but not complete in even half of the patients. And yes, there is a significant increase of true lumen diameter but the total lumen diameter does not change.Techniques like this have to be used overseas as the FET is still not FDA approved, leaving the European and Asian patients being exposed to the inevitable risks of innovation. For me, in acute type A dissection, the only indication would be an entry far in the arch, especially those with distal malperfusion, although a complete arch operation is also possible (Figure 4). For all other cases, especially in setting of limited aortic surgery exposure, I think experts should advise on life saving surgery and on focus more on aortic root problems. For the audience, I think it is wise not to go along with all innovations as in the old days of Bologna with people showing off their wealth by building towers and to carefully study the reports of the expert-centers, who do have to be honored for their efforts and to be cautious to implement new techniques, as in the end only one or two techniques will remain, and even these bending over in time. AcknowledgementsNone. Footnote Conflicts of Interest:The author is consultant with Vascutek Inc.

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“…47 Similarly, high volume hospitals have lower mortality rates than low volume hospitals 40 with a suggested hinge point of 100 operations/year. 47 For aortic or combined aortic valve and root procedures, one study 50 found that mortality increased exponentially in hospitals performing fewer than 40 procedures per annum. For TAVI, better results (including early mortality and rates of readmission) have been shown for hospitals that undertake >20 procedures/ year.…”

Section: Volumesmentioning

confidence: 99%

Standards defining a ‘Heart Valve Centre’: ESC Working Group on Valvular Heart Disease and European Association for Cardiothoracic Surgery Viewpoint

Chambers

Prendergast

Iung

et al. 2017

European Journal of Cardio-Thoracic Surgery

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Effects of institutional volumes on operative outcomes for aortic root replacement in North America

Cited by 154 publications

References 16 publications

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Systematic review and meta-analysis of surgical outcomes in Marfan patients undergoing aortic root surgery by composite-valve graft or valve sparing root replacement

Why to be cautious with the use of the frozen elephant trunk in acute type A aortic dissection

Standards defining a ‘Heart Valve Centre’: ESC Working Group on Valvular Heart Disease and European Association for Cardiothoracic Surgery Viewpoint

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