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

Umberto Benedetto, Arnaldo Dimagli, Amit Kaura, Shubhra Sinha, Giovanni Mariscalco, George Krasopoulos, Narain Moorjani, Mark Field, Trivedi Uday, Simon Kendal, Graham Cooper, Rakesh Uppal, Haris Bilal, Jorge Mascaro, Andrew Goodwin, Gianni Angelini, Geoffry Tsang, Enoch Akowuah, Umberto Benedetto, Arnaldo Dimagli, Amit Kaura, Shubhra Sinha, Giovanni Mariscalco, George Krasopoulos, Narain Moorjani, Mark Field, Trivedi Uday, Simon Kendal, Graham Cooper, Rakesh Uppal, Haris Bilal, Jorge Mascaro, Andrew Goodwin, Gianni Angelini, Geoffry Tsang, Enoch Akowuah

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.

Keywords: Risk factors; Risk score; Type A aortic dissection; Volume–outcome relationship.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Trend in number of surgeries for type A acute aortic dissection (overall and by type of procedure) (left) and overall mortality rates (right).
Figure 2
Figure 2
Funnel plots for hospital mortality 2009–19 in the UK stratified by hospitals (n = 35) (left) and surgeons (n = 509) (right).

References

    1. Mahase E. Half of patients with acute aortic dissection in England die before reaching a specialist centre. BMJ 2020;368:m304.
    1. Braverman AC. Acute aortic dissection: clinician update. Circulation 2010;122:184–188.
    1. Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, Ehrlich MP, Trimarchi S, Braverman AC, Myrmel T, Harris KM, Hutchinson S, O'Gara P, Suzuki T, Nienaber CA, Eagle KA; IRAD Investigators. Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research. Circulation 2018;137:1846–1860.
    1. Richens D, Briggs T. Cardiothoracic Surgery GIRFT Programme National Specialty Report GIRFT Is Delivered in Partnership with the Royal National Orthopaedic Hospital NHS Trust and NHS Improvement; 2018. (March).
    1. Howard DPJ, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM, Study OV. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation 2013;127:2031–2037. A
    1. Bossone E, Gorla R, LaBounty TM, Suzuki T, Gilon D, Strauss C, Ballotta A, Patel HJ, Evangelista A, Ehrlich MP, Hutchison S, Kline-Rogers E, Montgomery DG, Nienaber CA, Isselbacher EM, Eagle KA. Presenting systolic blood pressure and outcomes in patients with acute aortic dissection. J Am Coll Cardiol 2018;71:1432–1440.
    1. Conzelmann LO, Weigang E, Mehlhorn U, Abugameh A, Hoffmann I, Blettner M, Etz CD, Czerny M, Vahl CF. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg 2016;49:e44–52–e52.
    1. Geirsson A, Shioda K, Olsson C, Ahlsson A, Gunn J, Hansson EC, Hjortdal V, Jeppsson A, Mennander A, Wickbom A, Zindovic I, Gudbjartsson T. Differential outcomes of open and clamp-on distal anastomosis techniques in acute type A aortic dissection. J Thorac Cardiovasc Surg 2019;157:1750–1758.
    1. O'Hara D, McLarty A, Sun E, Itagaki S, Tannous H, Chu D, Egorova N, Chikwe J. Type-A aortic dissection and cerebral perfusion: the Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg 2020;110:1461–1467.
    1. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, von Allmen RS, Vrints CJM. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873–2926.
    1. Frankel WC, Green SY, Orozco-Sevilla V, Preventza O, Coselli JS. Contemporary surgical strategies for acute type A aortic dissection. Semin Thorac Cardiovasc Surg 2020;32:617–629.
    1. Lawton JS, Liu J, Kulshrestha K, Moon MR, Damiano RJ, Maniar H, Pasque MK. The impact of surgical strategy on survival after repair of type A aortic dissection. J Thorac Cardiovasc Surg 2015;150:294–301.e1.
    1. Hickey GL, Grant SW, Cosgriff R, Dimarakis I, Pagano D, Kappetein AP, Bridgewater B. Clinical registries: governance, management, analysis and applications. Eur J Cardiothorac Surg 2013;44:605–614.
    1. Lawless JF, Singhal K. Efficient screening of nonnormal regression models. Biometrics 1978;34:318–327.
    1. Mehta RH, Suzuki T, Hagan P, Bossone E, Gilon D, Llovet A, Maroto L, Cooper J, Smith D, Armstrong W, Nienaber C, Eagle KA; International Registry of Acute Aortic Dissection (IRAD) Investigators. Predicting death in patients with acute type A aortic dissection. Circulation 2002;105:200–206.
    1. Spiegelhalter DJ. Funnel plots for comparing institutional performance. Stat Med 2005;24:1185–1202.
    1. Czerny M, Siepe M, Beyersdorf F, Feisst M, Gabel M, Pilz M, Pöling J, Dohle D-S, Sarvanakis K, Luehr M, Hagl C, Rawa A, Schneider W, Detter C, Holubec T, Borger M, Böning A, Rylski B. Prediction of mortality rate in acute type A dissection: the German Registry for Acute Type A Aortic Dissection score. Eur J Cardiothorac Surg 2020;58:700–706.
    1. Inoue Y, Matsuda H, Uchida K, Komiya T, Koyama T, Yoshino H, Ito T, Shiiya N, Saiki Y, Kawaharada N, Nakai M, Iba Y, Minatoya K, Ogino H. Analysis of acute type A aortic dissection in Japan Registry of Aortic Dissection (JRAD). Ann Thorac Surg 2020;110:790–798.
    1. Lee TC, Kon Z, Cheema FH, Grau-Sepulveda MV, Englum B, Kim S, Chaudhuri PS, Thourani VH, Ailawadi G, Hughes GC, Williams ML, Brennan JM, Svensson L, Gammie JS. Contemporary management and outcomes of acute type A aortic dissection: an analysis of the STS adult cardiac surgery database. J Card Surg 2018;33:7–18.
    1. Di Bartolomeo R, Leone A, Di Marco L, Pacini D. When and how to replace the aortic arch for type A dissection. Ann Cardiothorac Surg 2016;5:383–388.
    1. Ikeno Y, Yokawa K, Matsueda T, Yamanaka K, Inoue T, Tanaka H, Okita Y. Long-term outcomes of total arch replacement using a 4-branched graft. J Thorac Cardiovasc Surg 2019;157:75–85.e3.
    1. Radford PD, Derbyshire LF, Shalhoub J, Fitzgerald JEF; Council of the Association of Surgeons in Training. Publication of surgeon specific outcome data: a review of implementation, controversies and the potential impact on surgical training. Int J Surg 2015;13:211–216.
    1. Leshnower BG, Chen EP. When and how to replace the aortic root in type A aortic dissection. Ann Cardiothorac Surg 2016;5:377–382.
    1. Geirsson A, Bavaria JE, Swarr D, Keane MG, Woo YJ, Szeto WY, Pochettino A. Fate of the residual distal and proximal aorta after acute type A dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007;84:1955–1964.
    1. Berretta P, Patel HJ, Gleason TG, Sundt TM, Myrmel T, Desai N, Korach A, Panza A, Bavaria J, Khoynezhad A, Woznicki E, Montgomery D, Isselbacher EM, Di Bartolomeo R, Fattori R, Nienaber CA, Eagle KA, Trimarchi S, Di Eusanio M. IRAD experience on surgical type A acute dissection patients: results and predictors of mortality. Ann Cardiothorac Surg 2016;5:346–351.
    1. Preventza O, Simpson KH, Cooley DA, Cornwell L, Bakaeen FG, Omer S, Rodriguez V, de la Cruz KI, Rosengart T, Coselli JS. Unilateral versus bilateral cerebral perfusion for acute type A aortic dissection. Ann Thorac Surg 2015;99:80–87.
    1. Krüger T, Weigang E, Hoffmann I, Blettner M, Aebert H. Cerebral protection during surgery for acute aortic dissection type A: results of the German registry for acute aortic dissection type a (GERAADA). Circulation 2011;124:434–443.
    1. Benedetto U, Dimagli A, Cooper G, Uppal R, Mariscalco G, Krasopoulos G, Goodwin A, Trivedi U, Kendall S, Sinha S, Fudulu D, Angelini GD, Tsang G, Akowuah E. Neuroprotective strategies in acute aortic dissection: an analysis of the UK National Adult Cardiac Surgical Audit. Eur J Cardiothorac Surg 2021. doi:10.1093/ejcts/ezab192.
    1. Bashir M, Harky A, Fok M, Shaw M, Hickey GL, Grant SW, Uppal R, Oo A. Acute type A aortic dissection in the United Kingdom: surgeon volume-outcome relation. J Thorac Cardiovasc Surg 2017;154:398–406.e1.
    1. Vaja R, Talukder S, Norkunas M, Hoffman R, Nienaber C, Pepper J, Rosendahl U, Asimakopoulos G, Quarto C. Impact of a streamlined rotational system for the management of acute aortic syndrome: sharing is caring. Eur J Cardiothorac Surg 2019;55:984–989.

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