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
1  Department of Anesthesiology, University of Maryland, Baltimore, Maryland
,
Mehrdad Ghoreishi
2  Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
,
Diane Alejo
3  Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Clifford E. Fonner
4  Division of Cardiothoracic Surgery, Maryland Cardiac Surgery Quality Initiative Inc., Baltimore, Maryland
,
Kenichi Tanaka
1  Department of Anesthesiology, University of Maryland, Baltimore, Maryland
,
James H. Abernathy III
5  Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland
,
Glenn Whitman
3  Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Rawn Salenger
6  Department of Cardiothoracic surgery, St. Joseph Medical Center, Towson, Maryland
,
Jennifer Lawton
3  Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Niv Ad
7  Department of Cardiothoracic Surgery, Washington Adventist Hospital, Takoma Park, Maryland
,
James Brown
8  Department of Surgery, University of Maryland, Capital Region Health, Cheverly, Maryland
,
James Gammie
2  Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
,
Bradley Taylor
2  Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
,
On behalf of the Investigators for the Maryland Cardiac Surgery Quality Initiative› Author Affiliations
Funding None.

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.



Publication History

Received: 13 March 2019

Accepted: 24 May 2020

Publication Date:
05 November 2020 (online)

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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