乌鸦传媒

A center achieved timelier surgical repairs for acute type A aortic dissections and improved survival rates after nixing the requirement for admission to ICU before surgery.

The hospital's new direct-to-operating room (OR) transfer program, implemented in January 2020, was followed by sharp reductions in time from patient acceptance to OR arrival (down from 198 minutes pre-intervention to 116 minutes, P<0.001) and from hospital arrival to the operating room (from 78 minutes to 10 minutes, P<0.001).

Notably, the latter suggests the institution's improved operational efficiency, reported Christopher Mehta, MD, of Northwestern Medicine in Chicago, at the Society of Thoracic Surgeons (STS) virtual meeting.

Patients who did undergo surgery for an acute type A aortic dissection had the risk of operative mortality drop from 16.2% pre-intervention to 12.0% afterward (observed-to-expected [O/E] ratio 0.59 under the new program). Mehta highlighted the even more dramatic result in patients who had successful aortic repair, who had deaths fall from 13.9% to 8.2% (O/E 0.42).

Importantly, patient mix and operative times did not change between the two periods. There was also no difference in the number of aortic root procedures performed nor the degree of extended arch resections performed.

Instead, there was a shift toward central aortic cannulation under the new program at Northwestern, which may have contributed to better patient survival, Mehta suggested.

"This [direct transfer] paradigm started , and what we found was 4% mortality from just hanging out in the ICU, the elevators prior to getting to the OR," said STS session moderator Joseph Bavaria, MD, of the Hospital of the University of Pennsylvania in Philadelphia.

Mehta reported such "interval deaths" in the direct transfer era occurred in one person who died on the way to the hospital and three people who ruptured before they got to the OR. He recalled one patient who ruptured during axillary graft placement during surgery before program implementation, emphasizing the potential benefit of central aortic cannulation.

Mehta's group studied 42 consecutive patients taken in by an urban quaternary care referral center before the direct transfer program (January 2019-January 2020) and 84 after the change (February 2020-November 2021).

The two cohorts shared similar patient demographics at baseline. Age was 61.8 on average, and two-thirds of patients were men.

After the program was implemented, people with acute type A aortic dissections skipped the emergency department and front desk. However, 22% of them still made a stop at the ICU before considering surgery. These tended to be people of questionable surgical candidacy, people in their 80s for example, or people and their families who were refusing surgery.

People who did undergo surgery were 37 from the pre-implementation group and 76 from post-implementation.

Direct transfer to the OR did not result in significantly shorter hospital stays (from 12.5 to 11.0 days) or lower readmission (from 25% to 19.2%).

Study limitations include its retrospective, single-center nature that precludes generalizability to all hospitals or geographic environments. Patients had also been primarily transferred from other centers, leaving room for survivorship and selection biases, Mehta said. Longer-term survival data are needed to see the full effect of program, he added.

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