Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery

Abstract

Objective This study aims to determine the impact of institutional volume on mortality in reoperative proximal thoracic aortic surgery patients using national outcomes data. Methods The Nationwide Inpatient Sample was queried from 1998 to 2011 for patients with diagnoses of thoracic aneurysm and/or dissection who underwent open mediastinal repair. A total of 103,860 patients were identified. A total of 1,430 patients had prior cardiac surgery. Patients were further stratified into groups by institutional aortic volume: low (<12 cases/year), medium (12–39 cases/year), and high (40+ cases/year) volume. Multivariable risk-adjusted analysis accounting for emergent status and aortic dissection among other factors was performed to determine the impact of institutional volume on mortality. Results Overall mortality was 12% in the reoperative population. When the redo cohort was divided into tertiles, high-volume group had a 5% operative mortality compared with 9 and 15% for the medium- and low-volume groups, respectively. Multivariable analysis revealed that patients operated on at low- (odds ratio [OR] = 5.0, 95% confidence interval [CI]: 2.6–9.6, p < 0.001) and medium-volume centers (OR = 2.1, 95% CI: 1.1–4.2, p = 0.03) had higher odds of mortality when compared with patients operated on at high-volume centers. Conclusions High-volume aortic centers can significantly reduce mortality for reoperative aortic surgery, compared with lower volume institutions.

A challenging case of emergency redo surgery for acute type A aortic dissecting aneurysm of ascending and aortic arch with frozen elephant trunk following aortic root replacement

“…The incidence of redo aortic surgery is increasing due to multiple reasons, including: new aortic dissection or aneurysm, progressive aneurysm formation in non-resected dissected aortic segments during initial surgery, pseudoaneurysm formation at suture lines, prosthetic valve endocarditis, graft infection and failure of bioprosthetic valve [ 1 , 2 ]. However, redo aortic arch surgery following previous cardiac or aortic surgery is associated with significant risk of operative mortality compared to primary procedure, ranging from 5 to 19% [ 3 ], which caused by numerous factors included sternal re-entry injury secondary to dense adhesion, extensive aortic arch surgery, emergency surgery, prolonged cardiopulmonary bypass duration, poor heart function, and patients with older age. Hence, appropriate surgical approaches are the keys to a successful surgery.…”

A Technique for Safe Redo Sternotomy in Patients with Aortic Proximity to the Sternum

“…Even among experienced centers, reoperative aortic surgery has an associated mortality of greater than 10%, with permanent neurologic injury in over 5% of patients. 1,2 Particularly in the case of aneurysmal aortic disease the inherent challenges of a redo mediastinal dissection with significant adhesions can present a life-threatening bleeding risk during resternotomy. Injuries to mediastinal structures during the course of resternotomy, while rare, are associated with a mortality of 26%, 3 underscoring the importance of minimizing injury whenever possible.…”

“…Children's Hospital of Philadelphia, Philadelphia, PA, USA2 The Hospital of the University of Pennsylvania, Philadelphia, PA, USA…”