Robert B Hawkins1, J Hunter Mehaffey1, Emily A Downs1, Lily E Johnston1, Leora T Yarboro1, Clifford E Fonner2, Alan M Speir3, Jeffrey B Rich2, Mohammed A Quader4, Gorav Ailawadi1, Ravi K Ghanta5. 1. Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. 2. Virginia Cardiac Services Quality Initiative, Falls Church, Virginia. 3. INOVA Heart and Vascular Institute, Falls Church, Virginia. 4. Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. 5. Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address: ravighanta@gmail.com.
Abstract
BACKGROUND: The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium. METHODS: Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined. RESULTS: Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality. CONCLUSIONS: Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice.
BACKGROUND: The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium. METHODS: Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined. RESULTS: Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality. CONCLUSIONS: Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice.
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