Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative

Michael Mazzeffi; Mehrdad Ghoreishi; Diane Alejo; Clifford E. Fonner; Kenichi Tanaka; James H. Abernathy III; Glenn Whitman; Rawn Salenger; Jennifer Lawton; Niv Ad; James Brown; James Gammie; Bradley Taylor; On behalf of the Investigators for the Maryland Cardiac Surgery Quality Initiative

doi:10.1055/s-0040-1714121

AORTA, Inhaltsverzeichnis

CC BY 4.0 · Aorta (Stamford) 2020; 08(03): 066-073
DOI: 10.1055/s-0040-1714121

Original Research Article

Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative

Michael Mazzeffi

¹Department of Anesthesiology, University of Maryland, Baltimore, Maryland

,

Mehrdad Ghoreishi

²Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland

,

Diane Alejo

³Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

,

Clifford E. Fonner

⁴Division of Cardiothoracic Surgery, Maryland Cardiac Surgery Quality Initiative Inc., Baltimore, Maryland

,

Kenichi Tanaka

¹Department of Anesthesiology, University of Maryland, Baltimore, Maryland

,

James H. Abernathy III

⁵Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland

,

Glenn Whitman

³Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

,

Rawn Salenger

⁶Department of Cardiothoracic surgery, St. Joseph Medical Center, Towson, Maryland

,

Jennifer Lawton

³Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

,

Niv Ad

⁷Department of Cardiothoracic Surgery, Washington Adventist Hospital, Takoma Park, Maryland

,

James Brown

⁸Department of Surgery, University of Maryland, Capital Region Health, Cheverly, Maryland

,

James Gammie

²Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland

,

Bradley Taylor

²Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland

,

On behalf of the Investigators for the Maryland Cardiac Surgery Quality Initiative

› Institutsangaben

Abstract

Background Stanford Type A aortic dissection repair surgery is associated with high mortality and clinical practice remains variable among hospitals. Few studies have examined statewide practice variation.

Methods Patients who had Stanford Type A aortic dissection repair surgery in Maryland between July 1, 2014 and June 30, 2018 were identified using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. Patient demographics, comorbidities, surgery details, and outcomes were compared between hospitals. We also explored the impact of arterial cannulation site and brain protection technique on outcome.

Results A total of 233 patients were included from eight hospitals during the study period. Seventy-six percent of surgeries were done in two high-volume hospitals (≥10 cases per year), while the remaining 24% were done in low-volume hospitals. Operative mortality was 12.0% and varied between 0 and 25.0% depending on the hospital. Variables that differed significantly between hospitals included patient age, the percentage of patients in shock, left ventricular ejection fraction, creatinine level, arterial cannulation site, brain protection technique, tobacco use, and intraoperative blood transfusion. The percentage of patients who underwent aortic valve repair or replacement procedures differed significantly between hospitals (p < 0.001), although the prevalence of moderate-to-severe aortic insufficiency was not significantly different (p = 0.14). There were no significant differences in clinical outcomes including mortality, renal failure, stroke, or gastrointestinal complications between hospitals or based on arterial cannulation site (all p > 0.05). Patients who had aortic cross-clamping or endovascualr repair had more embolic strokes when compared with patients who had hypothermic circulatory arrest (p = 0.03).

Conclusion There remains considerable practice variation in Stanford Type A aortic dissection repair surgery within Maryland including some modifiable factors such as intraoperative blood transfusion, arterial cannulation site, and brain protection technique. Continued efforts are needed within MCSQI and nationally to evaluate and employ the best practices for patients having acute aortic dissection repair surgery.

Keywords

aortic dissection - quality - cardiac surgery

Volltext

Referenzen

References
1 Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation 2005; 112 (24) 3802-3813
2 Hirst Jr. AE, Johns Jr. VJ, Kime Jr SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore) 1958; 37 (03) 217-279
3 Lee TC, Kon Z, Cheema FH. et al. Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery database. J Card Surg 2018; 33 (01) 7-18
4 Chikwe J, Cavallaro P, Itagaki S, Seigerman M, Diluozzo G, Adams DH. National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality. Ann Thorac Surg 2013; 95 (05) 1563-1569
5 Chikwe J, Toyoda N, Anyanwu AC. et al. Relation of mitral valve surgery volume to repair rate, durability, and survival. J Am Coll Cardiol 2017; 1097 (17) 30677
6 Cowger JA, Stulak JM, Shah P. et al. Impact of center left ventricular device volume on outcomes after implantation: an INTERMACS analysis. JACC Heart Fail 2017; 5 (10) 691-699
7 Mehta A, Efron DT, Canner JK. et al. Effect of surgeon and hospital volume on emergency general surgery outcomes. J Am Coll Surg 2017; 225 (05) 666-675.e2
8 Mehta A, Dultz LA, Joseph B. et al. Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes. J Trauma Acute Care Surg 2018; 84 (06) 864-875
9 Gulland A. High volume emergency surgery units do not improve outcomes, report finds. BMJ 2016; 353: i2054
10 Bashir M, Harky A, Fok M. et al. Acute type A aortic dissection in the United Kingdom: Surgeon volume-outcome relation. J Thorac Cardiovasc Surg 2017; 154 (02) 398-406.e1
11 Gimenez FMP, de Camargo WHB, Gomes ACB. et al. Analysis of adverse events during intrahospital transportation of critically ill patients. Crit Care Res Pract 2017; 2017: 6847124
12 Farto e Abreu P, Thomas B, Loureiro J, Roquette J, Ferreira R. Inter-hospital transfer of critically-ill patients for urgent cardiac surgery after placement of an intra-aortic balloon pump. Rev Port Cardiol 2002; 21 (10) 1115-1123
13 Kubota H. Endovascular stent graft repair of the ascending aorta-final frontier in the endovascular treatment of the aorta. J Thorac Dis 2016; 8 (10) E1358-E1360
14 Baikoussis NG, Antonopoulos CN, Papakonstantinou NA, Argiriou M, Geroulakos G. Endovascular stent grafting for ascending aorta diseases. J Vasc Surg 2017; 66 (05) 1587-1601
15 Ghoreishi M, Shah A, Jeudy J. et al. Endovascular repair of ascending aortic disease in high-risk patient yields favorable outcome. Ann Thorac Surg 2019; 4975 (19) 31237-31238
16 Leshnower BG, Thourani VH, Halkos ME. et al. Moderate versus deep hypothermia with unilateral selective antegrade cerebral perfusion for acute type A dissection. Ann Thorac Surg 2015; 100 (05) 1563-1568 , discussion 1568–1569
17 Gong M, Ma WG, Guan XL. et al. Moderate hypothermic circulatory arrest in total arch repair for acute type A aortic dissection: clinical safety and efficacy. J Thorac Dis 2016; 8 (05) 925-933
18 Yan TD, Bannon PG, Bavaria J. et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg 2013; 2 (02) 163-168
19 Hiratzka LF, Bakris GL, Beckman JA. , et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American college of cardiology foundation/American Heart Association task force on practice guidelines, American association for thoracic surgery, American college of radiology, American stroke association, society of cardiovascular anesthesiologists, society for cardiovascular angiography and interventions, society of interventional radiology, society of thoracic surgeons, and society for vascular medicine. Catheter Cardiovasc Interv 2010; 76 (02) E43-E86
20 Ghoreishi M, Sundt TM, Cameron DE. et al. Factors associated with acute stroke after type A aortic dissection repair: an analysis of the society of thoracic surgeons national adult cardiac surgery database. J Thorac Cardiovasc Surg 2019; 159 (06) 2143-2154