Aortic centres should represent the standard of care for acute aortic syndrome

Abstract

Background Existing evidence suggests that patients affected by acute aortic syndromes (AAS) may benefit from treatment at dedicated specialized aortic centres. The purpose of the present study was to perform a meta-analysis to evaluate the impact aortic service configuration has in clinical outcomes in AAS patients. Methods The design was a quantitative and qualitative review of observational studies. We searched PubMed/ MEDLINE, EMBASE, and Cochrane Library from inception to the end of December 2017 to identify eligible articles. Areas of interest included hospital and surgeon volume activity, presence of a multidisciplinary thoracic aortic surgery program, and a dedicated on-call aortic team. Participants were patients undergoing repair for AAS, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were adopted for synthesizing hospital/30-day mortality. Results A total of 79,131 adult patients from a total of 30 studies were obtained. No randomized studies were identified. Pooled unadjusted ORs showed that patients treated in high-volume centres or by high-volume surgeons were associated with lower mortality rates (OR 0.51; 95% CI 0.46-0.56, and OR 0.41, 95% CI 0.25-0.66, respectively). Pooled adjusted estimates for both high-volume centres and surgeons confirmed these survival benefits (adjusted OR, 0.56; 95% CI 0.45-0.70, respectively). Patients treated in centres that introduced a specific multidisciplinary aortic program and a dedicated on-call aortic team also showed a significant reduction in mortality (OR 0.31; 95% CI 0.19-0.5, and OR 0.37; 95% CI 0.15-0.87, respectively). Conclusions We found that specialist aortic care improves outcomes and decreases mortality in patients affected by AAS.

The Impact of Dedicated Aortic Teams and Centralisation of Aortic Services, and Surgeon or Centre Specific Volumes on Outcomes of Acute Type A Aortic Dissection

“…Reported operative mortality rates significantly improved from 33.9% to 2.8%. These results were further supported by a recent systematic review of observational studies [13] concluding that centres with specific multidisciplinary aortic programmes and dedicated on-call aortic teams showed a significant reduction in mortality following surgery for acute aortic syndrome (OR 0.31; 95% CI 0.19-0.5, and OR 0.37; 95% CI 0.15-0.87, respectively).…”

“…Similarly, in a systematic review of 79,131 patients by Mariscalclo and colleagues [13], high-volume centres or individual surgeons had lower mortality rates (OR 0.51; 95% CI 0.46-0.56, and OR 0.41, 95% CI 0.25-0.66, respectively). All these findings were also corroborated by several studies supporting the idea that ATAAD should be managed by high volume centres and highvolume operating surgeons [14][15][16].…”

“…Although It is clear from published literature that patients with ATAAD have better outcomes if treated in high volume centres by high-volume surgeons [3,[10][11][12][13][14][15][16]. However, the impact of establishing dedicated teams for aortic surgery on the perioperative outcomes is less well studied [17].…”

Is there a place for a multidisciplinary “Heart Team” approach to the selection of myocardial revascularization method in patients with acute coronary syndromes?

“…В 2017г, подобно термину HEART TEAM, появился термин VASCULAR TEAM, являющийся отражением необходимости мультидисциплинарного обсуждения тактики ведения пациентов с периферическим атеросклерозом, а также с мультифокальным поражением артерий [13,14]. Тот же тренд отмечен и в отношении командного подхода в лечении сложнейшей когорты пациентов, имеющих диссекцию аорты и требующих применения хирургических, эндоваскулярных и гибридных техник лечения, анестезиологического и перфузиологического сопровождения -Aortic Team [15]. К сожалению, в литературе очень скромно обсуждаются проблемы эффективного внедрения принципов HEART TEAM в реальную клиническую практику.…”

Commentary: Open versus clamp-on distal anastomosis techniques in acute type A aortic dissection: The ship has already left the port

“…There is a large consensus that patients affected by acute aortic syndromes may benefit from treatment at dedicated specialized aortic centers with significantly improved outcomes and decreased mortality. 7 Patients undergoing emergency repair of acute aortic dissection by lower-volume surgeons and centers have approximately double the risk-adjusted mortality of patients undergoing repair by the highest volume care providers. 8 Although the present study suggests that in selected circumstances, such as in very sick patients or at lower-volume hospitals, the clamp-on technique can be used with acceptable results, we think that the future treatment of acute type A aortic dissection is going toward an open-distal approach with standardized cerebral protection that should more and more be delivered by specialist aortic centers with expertise in this technique.…”