From routine to rescue: Higher elective aortic surgery volume is associated with improved outcomes after acute type A aortic dissection repair.

BACKGROUND

The association between case volume and outcomes in acute type A aortic dissection (ATAAD) repair is well established; however, the impact of elective proximal aortic surgery volume on emergent ATAAD repair outcomes remains unclear.

METHODS

Using the 2017-2020 Nationwide Readmission Database, we identified 22,700 elective proximal aortic repairs and classified hospitals into high-volume (median, 58 cases/year), medium-volume (median, 22 cases/year), and low-volume (median, 5 cases/year) groups. We analyzed 10,793 emergent ATAAD repairs performed at these hospitals. The primary outcome was in-hospital mortality. Secondary outcomes included stroke, renal failure necessitating dialysis, cardiac bleeding, respiratory failure necessitating ventilation, sepsis, vascular complications, and failure to rescue (FTR), defined as mortality occurring after any of these complications. Multivariable logistic regression assessed associations between hospital volume and outcomes.

RESULTS

Overall, 74.4% of ATAAD repairs occurred at low- or medium-volume hospitals. High-volume hospitals had greater ATAAD case volume (median, 25 vs 12 vs 5 cases/year; P < .001). Baseline characteristics and malperfusion rates were similar across the groups. In-hospital mortality was lowest at high-volume hospitals (10.7% vs 15.7% vs 19.5%; P < .001). Compared to high-volume hospitals, low-volume (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.30-1.92; P < .001) and medium-volume (OR, 1.30; 95% CI, 1.08-1.56; P = .005) hospitals were independently associated with higher mortality. Low-volume hospitals were associated with higher FTR (OR, 1.38; 95% CI, 1.10-1.73; P = .005).

CONCLUSIONS

Higher elective proximal aortic surgery volume is independently associated with improved ATAAD outcomes. Concentrating elective volume and developing dedicated aortic teams may improve preparedness and outcomes.