Decade-long trends in surgery for acute Type A aortic dissection in England: A retrospective cohort study.
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ABSTRACT: Background
Little is known about variations in care and outcomes of patients undergoing surgical repair for type A aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England.Methods
Retrospective review of the National Adult Cardiac Surgery Audit, which prospectively collects demographic and peri‑operative information for all major adult cardiac surgery procedures performed in the UK. We identified patients undergoing surgery for TAAD from January 2009-December 2018, reviewed trends in operative frequency, patient demographics, and mortality.Findings
Over the 10-year period,3,680 TAAD patients underwent surgical repair in England. A doubling in the overall number of operations conducted in England was observed (235 cases in 2009 to 510 in 2018). Number of procedures per hospital per year also doubled(9 in 2009 to 23 in 2018). Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in recent years(23% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality between hospitals and surgeons. We also found that most patients presented towards the middle of the week and during winter.Interpretation
Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival has improved. Variations exist in service provision with a trend towards better survival in high volume centers.Funding
British Heart Foundation and NIHR Biomedical Research center(University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol).
SUBMITTER: Benedetto U
PROVIDER: S-EPMC8454541 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background Octogenarians (≥80 years old) are high-risk patients for acute aortic dissection (AAD) surgery. However, no population-based study has investigated the late outcomes of AAD surgery in octogenarians. This study aimed to investigate the late outcomes of AAD surgery in octogenarians. Methods and Results A total of 3998 patients who received AAD surgery from 2005 to 2013 were identified from the Taiwan National Health Insurance Research Database. In-hospital complications and late outcomes including all-cause mortality, major adverse cardiac and cerebrovascular event, respiratory failure, and redo aortic surgery were evaluated. The risks of late outcomes between octogenarians and nonoctogenarians were compared using the multivariable Cox proportional hazard model or Fine and Gray competing model. The numbers of the octogenarians who underwent type A and B AAD surgeries were 206 (6%; 206/3423) and 79 (13.7%; 79/575), respectively. Compared with the nonoctogenarians, the type A octogenarians had higher risks of in-hospital mortality and several in-hospital complications, whereas the type B octogenarians did not. Furthermore, compared with the nonoctogenarians, the type A octogenarians had a higher risk of all-cause mortality (61.7% vs 32.5%; hazard ratio [HR], 2.35; 95% CI, 1.95-2.84) and a higher cumulative incidence of major adverse cardiac and cerebrovascular event and respiratory failure, and the type B octogenarians demonstrated a higher risk of all-cause mortality (44.3% vs 30.4%; HR, 1.74; 95% CI, 1.18-2.55). The octogenarians receiving AAD surgeries had higher mortality rates than the normal octogenarian population. Conclusions Octogenarians receiving AAD surgeries exhibit worse late outcomes than nonoctogenarian counterparts.
| S-EPMC7726989 | biostudies-literature
Project description:ObjectivesSurgery for acute type A aortic dissection is associated with several perioperative complications, such as acute respiratory dysfunction (ARD). The aim of this study was to investigate perioperative risk factors involved in the development of ARD and whether antibiotic treatment has an impact.Methods243 patients underwent surgery for acute type A aortic dissection between 2008 and 2017. The patients were retrospectively divided into the ARD and NON-ARD group. ARD was defined as PaO2/FiO2 ≤ 200 mmHg (PF ratio) within 48 hours after surgery. All patients received either narrow- or broad-spectrum antibiotics.ResultsAfter the exclusion of 42 patients, 201 patients were analyzed. The PF ratio of the ARD group was significantly lower than of the NON-ARD group within the first 7 days. ARD patients (n = 111) were significantly older (p = .031) and had a higher body mass index (BMI) (p = .017). ARD patients required longer postoperative ventilation (2493 vs. 4695 [min], p = .006) and spent more days in the intensive care unit (7.0 vs. 8.9 [days], p = .043) compared to NON-ARD. The mortality was significantly lower for ARD than for NON-ARD patients (p = .030). The incidence of pneumonia was independent of the antibiotic treatment regime (p = .391). Renal and neurological complication rate was higher in patients treated with broad-spectrum antibiotic.ConclusionARD is the main complication (55%) that occurs approximately 24 hours after surgery for acute type A aortic dissection. The preoperative risk factors for ARD were higher age and increased BMI. Patients on broad-spectrum antibiotics did not show an improved postoperative outcome compared to patients with narrow-spectrum antibiotics.
| S-EPMC7877985 | biostudies-literature
Project description:BackgroundAcute Type A aortic dissection (ATAAD) is a life-threatening cardiovascular disease associated with high mortality rates, where surgical intervention remains the primary life-saving treatment. However, the mortality rate for ATAAD operations continues to be alarmingly high. To address this critical issue, our study aimed to assess the correlation between preoperative laboratory examination, clinical imaging data, and postoperative mortality in ATAAD patients. Additionally, we sought to establish a reliable prediction model for evaluating the risk of postoperative death.MethodsIn this study, a total of 384 patients with acute type A aortic dissection (ATAAD) who were admitted to the emergency department for surgical treatment were included. Based on preoperative laboratory examination and clinical imaging data of ATAAD patients, logistic analysis was used to obtain independent risk factors for postoperative in-hospital death. The survival prediction model was based on cox regression analysis and displayed as a nomogram.ResultsLogistic analysis identified several independent risk factors for postoperative in-hospital death, including Marfan syndrome, previous cardiac surgery history, previous renal dialysis history, direct bilirubin, serum phosphorus, D-dimer, white blood cell, multiple aortic ruptures and age. A survival prediction model based on cox regression analysis was established and presented as a nomogram. The model exhibited good discrimination and significantly improved the prediction of death risk in ATAAD patients.ConclusionsIn this study, we developed a novel survival prediction model for acute type A aortic dissection based on preoperative clinical features. The model demonstrated good discriminatory power and improved accuracy in predicting the risk of death in ATAAD patients undergoing open surgery.
| S-EPMC10988835 | biostudies-literature
Project description:ObjectiveHeart rate (HR) is a risk factor of mortality in many cardiovascular diseases but no clinical studies have focused on the association between HR and prognosis in patients with acute type A aortic dissection (ATAAD). This study aimed to evaluate the association between HR and long-term mortality and establish the criteria of HR in patients with ATAAD who underwent total aortic arch replacement combined with the frozen elephant trunk (TAR+FET).Design, setting and participantsRetrospective cohort study that studied all consecutive patients with ATAAD who underwent TAR+FET in the Fuwai Hospital between 2009 and 2015.Main outcomes and measures30-day postoperative, and estimated long-term mortality.ResultsOverall, 707 patients with ATAAD who underwent TAR+FET were followed up for a median duration of 29 months (range, 5-77 months). In multivariate logistic analysis, HR (p<0.001), age (p<0.001), renal insufficiency (p=0.033), ejection fraction (p=0.005), cardiopulmonary bypass time (p<0.001) and intraoperative blood loss (p=0.002) were significantly associated with 30-day postoperative and estimated long-term mortalities. A hinge point with a sharp increase in estimated long-term mortality was identified at 80 beats/min (bpm), and compared with HR ≤80 bpm, HR >80 bpm was associated with an almost threefold higher long-term mortality. HRs ≤60, 60-70, 70-80, 80-90, 90-100, 100-110 and >110 bpm were associated with 3.9%, 4.0%, 3.8%, 7.2%, 9.5%, 10.1% and 14.4% yearly risks of death, respectively.ConclusionsHR is a powerful predictor of long-term mortality in patients with ATAAD undergoing TAR+FET. HR >80 bpm is independently associated with elevated long-term mortality for patients with ATAAD.
| S-EPMC8587588 | biostudies-literature
Project description:There are limited data available describing relatively contemporary trends in 30-day rehospitalizations among patients who survive hospitalization after an acute myocardial infarction (AMI) in the community setting. We examined decade-long (2001-2011) trends in, and factors associated with, 30-day rehospitalizations in patients discharged from 3 central Massachusetts hospitals after AMI.Residents of the Worcester, MA, metropolitan area discharged after AMI from 3 central Massachusetts hospitals on a biennial basis between 2001 and 2011 comprised the study population (N=4810). Logistic regression analyses were used to examine the association between selected factors and 30-day rehospitalizations. The average age of this population was 69 years, 42% were women, and 92% were white. During the years under study, 18.5% of patients were rehospitalized within 30 days after hospital discharge. Crude 30-day rehospitalization rates decreased from 20.5% in 2001-2003 to 15.8% in 2009-2011. After adjusting for several patient characteristics, there was a reduced odds of being rehospitalized in 2009-2011 (odds ratio 0.74, 95% CI 0.61-0.91) compared with 2001-2003; this trend was slightly attenuated after further adjustment for hospital treatment practices. Female sex, having previously diagnosed heart failure and chronic kidney disease, and the development of in-hospital cardiogenic shock and heart failure were associated with an increased odds of being rehospitalized.While the likelihood of subsequent short-term rehospitalizations remained frequent, we observed an encouraging decline during the most recent years under study. Several high-risk groups were identified for purposes of heightened surveillance and intervention efforts to reduce the likelihood of being readmitted.
| S-EPMC4845213 | biostudies-other
Project description:ObjectiveTo examine surgical outcomes and trends in the implementation of minimally invasive surgery (MIS) use for endometrial cancer (EC).DesignRetrospective cohort study.SettingEnglish National Health Service hospitals 2011-2017/2018.Population35 304 patients having a hysterectomy for EC identified from Hospital Episode Statistics.MethodsUnivariate and multivariate analyses compared MIS to open hysterectomy (OH) by assessing the association between demographic, clinical and hospital characteristics by using logistic regression. A propensity score was created, to control for confounding factors including demographics, clinical and hospital characteristics, from a logistic regression which enabled the inverse probability weighting of treatment to be applied in order to compare outcomes of treatment.Main outcome measuresThe association between route of surgery on perioperative morbidity and mortality.ResultsThe MIS rate rose from 40.3% in 2011 to 68.7% in 2017/2018, however, there was significant geographical variation (p<0.001). The overall 90-day mortality was significantly higher with OH versus MIS (OR 0.34, 95% CI 0.18 to 0.62, p=0.0002). MIS rates were significantly lower in patients from the lowest socioeconomic group (LSEG) compared with patients from the highest group (HSEG) (55.4% vs 59.9%, p<0.01), and in the black population as compared with white and Asian populations (40.4% vs 58.6% and 56.0%, p<0.0001). When patients from LSEG and black patients were treated in hospitals with high MIS rates, the MIS rate increased close to that of the HSEG and white patients (81.0% and 74.1% vs 83.2% and 82.6%).ConclusionsFurther investigation is needed to understand the barriers to MIS and improve access so that as many patients as possible can benefit from the reduced morbidity/mortality associated with MIS.
| S-EPMC7497536 | biostudies-literature
Project description:No study has evaluated the effect of dexmedetomidine in patients who received surgery for type A aortic dissection. This is the first study to evaluate the effect of dexmedetomidine in aortic dissection patients. This study was executed using data from the Chang Gung Research Database in Taiwan. The CGRD contains the multi-institutional standardized electronic medical records from seven Chang Gung Memorial hospitals, the largest medical system in Taiwan. We retrospectively evaluate patients who received surgery for acute type A aortic dissection between January 2014 and December 2018. Overall, 511 patients were included, of whom 104 has received dexmedetomidine infusion in the postoperative period. One-to-two propensity score-matching yielded 86 cases in the dexmedetomidine group and 158 cases in the non-dexmedetomidine group. The in-hospital mortality and composite outcome including all-cause mortality, acute kidney injury, delirium, postoperative atrial fibrillation, and respiratory failure, were considered primary outcomes. The in-hospital mortality and composite outcome were similar between groups. The risk of Acute Kidney Injury Network stage 3 acute kidney injury was significantly lower in the dexmedetomidine group than in the non-dexmedetomidine group (8.1% vs 19.0%; OR, 0.38; 95% CI, 0.17-0.86; p = 0.020. The risk of newly-onset dialysis was also significantly lower in the dexmedetomidine group than in the non-dexmedetomidine group (4.7% vs 13.3%; OR, 0.32; 95% CI, 0.11-0.90; p = 0.031). Post-operative dexmedetomidine infusion significantly reduced the rate of severe acute kidney injury and newly-onset dialysis in patients who received surgery for acute type A aortic dissection.
| S-EPMC8854389 | biostudies-literature
Project description:BackgroundAlthough gender-related disparities in cardiovascular surgery have been investigated extensively in the past decades, knowledge about the impact of gender on outcomes after surgery for acute aortic dissection type A (AADA) is sparse. This study investigated the impact of gender on early morbidity and mortality and follow-up outcome in patients after surgery for AADA and to analyze gender-related risk factors for 30-day mortality.MethodsThis retrospective study included 368 consecutive patients (male 65.8% vs. female 34.2%) undergoing surgery for AADA between 2001 and 2016 at our department. Survival was estimated by Kaplan-Meier curves. Risk factors for 30-day mortality were assessed by multivariable logistic regression and interaction analysis.ResultsWomen were older (70.7?years vs. 60.6?years; p <? 0.001) and showed a higher logistic EuroSCORE I (31.0% vs. 19.7%, p?<? 0.001). In the male group, a higher portion of smokers (27.6% vs. 16.0%, p =?0.015) and intraoperatively, more complex procedures and longer cardiopulmonary bypass (CPB) (171?min vs. 149?min, p =?0.001) and cross-clamping times (94?min vs. 85?min, p =?0.018) occurred. 30-day mortality was 19.0% in the female and 16.5% in the male group (p =?0.545). Predictive for 30-day mortality in both genders was intraoperative blood transfusion, while in the female group chronic obstructive pulmonary disease (COPD), peripheral arterial disease and preoperative intubation were predictive. Preoperative cardiopulmonary resuscitation and duration of CPB time were predictors only in males. Averaged follow-up time was 5.2?years and survival did not differ between genders, even if it was stratified by age over 70?years.ConclusionsThis analysis demonstrated a similar and satisfactory survival in both genders after surgical treatment of AADA. Women and men differed significantly in age, unadjusted and adjusted risk factors and complexity of surgical treatment, but gender itself was no risk factor for mortality. These results suggest that the decision-making for surgical treatment should not depend on gender, but that accounting for sex-specific risk factors rather than common risk factors may help to improve the outcome in both genders.
| S-EPMC7301454 | biostudies-literature
Project description: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.
| S-EPMC5610067 | biostudies-literature
Project description:BackgroundPatients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes.MethodsFrom 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS.ResultsCompared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality.ConclusionsBecause of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.
| S-EPMC7736272 | biostudies-literature