Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD

Abstract

Background: Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data. Methods: Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am. Results: Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference. Conclusions: A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

Time of the day or surgeon volume—Experience matters most?

“…In overall, we agree with Arnaoutakis et al 1 that ATAAD is a surgical emergency, and decision for surgery should be based on clinical condition; however, a dedicated aortic team and experienced surgeons with larger volumes of ATAAD operations possibly contributed to these equivocal outcomes regardless of the time of the day.…”

“…We read with great interest the study by Arnaoutakis et al, 1 They concluded that there was no difference in mortality between the two groups.…”

Making hay while the sun shines: Do outcomes after surgery for acute type A aortic dissection depend on when it is performed?

“…As such, in reality, it is possible that there is no mortality difference for OOH versus IH. This coheres with a recent International Registry for Acute Aortic Dissection study, which found no difference for mortality based upon the time of day of the operation 20 . Hence, a word of cautious optimism: while much work remains for improving outcomes after ATAAD surgery, OOH surgery may not underperform, as compared to IH surgery.…”

Time of the day or surgeon volume—What matters most in Type A aortic dissection?

“…Karadakhy and Harky for their thoughtful letter in reference to our study examining time of day and surgical outcomes for Type A dissection according to the IRAD registry. 1 The key findings of our study included a slight majority of patients undergoing surgery at night. There were no differences in operative mortality based on operative time of day, nor was there any evidence of different mortality outcomes for patients operated on during the weekend versus weekday.…”