The utility of the aortic dissection team: outcomes and insights after a decade of experience

Abstract

Background: Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time.Methods: An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. in-hospital mortality rates of less than 10% were maintained over the study period.Conclusions: Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.

Invited Commentary

“…Lastly, the lack of significant improvement in patient outcomes over the time course of the study, and the important regional differences observed, suggest that major changes are needed to improve the care of these patients in North America. As has been previously reported by our group and others, [15][16][17][18] regionalization of care and the use of "aortic dissection teams" has clearly been shown to improve outcomes. However, in a nation as geographically large as the United States, the practicality of regionalization is challenging 19 given that data from the National Inpatient Sample database [20][21][22] suggest that only 15 to 20 centers in the United States perform more than 11 to 13 ATAD repairs per year.…”

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“…This program restricted all thoracic aortic surgery to be performed by cardiac surgeons specialized in aortic surgery, leading to an improvement in operative mortality. 7 Another study looking at the volume outcome relations in "all-comer" (elective þ emergent) ascending aorta/arch surgery highlighted lower midterm mortality risk for patients operated on by a high volume operator (HR: 0.67, 95% CI: 0.51-0.88). 11 Analysis of the national (U.S.) patient population by Hughes et al 12 revealed that patients operated at high volume aortic centers (30-100 cases/year) have considerably lower adjusted risk of mortality than low volume centers (< 6 cases/year) for elective ascending aortic surgery (OR: 0.42, 95% CI: 0.31-0.58).…”

“…11 Increasing evidence supports experience-outcome relationships in high-risk operations, and this relationship is also expected to be reflected in emergent aortic surgery. 7,10,12 A potential solution advocated by some centers is for referral of all aortic cases to centers specialized for aortic surgery. Volume centralization is expected to improve outcomes but this may be difficult given the emergent nature of aortic dissection and difficulty in transferring/triaging these patients in a timely fashion.…”

“…Some centers have instituted specialized aortic surgery teams that manage all emergent aortic cases. 7 In the context of temporal improvement in outcomes of aortic surgery owing to technological advancements (e.g., use of better grafts, availability of Bioglue [Cryolife, Kennasaw, GA]), 8 a contemporary benchmark for aortic surgical outcomes incorporating surgeon experience is needed.…”

Prehospital triage of acute aortic syndrome using a machine learning algorithm

“…These aortic pathologies are associated with high attributable mortality. The implementation of high‐volume aortic centres and structured institutional aortic teams could improve survival of patients with AAS. In this context, a regional dedicated network named S.O.S.…”