Author + information
- Baptiste Duceau, MD,
- Jean-Marc Alsac, MD, PhD,
- Florence Bellenfant, MD,
- Arnaud Mailloux, MD,
- Vibol Chhor, MD, PhD,
- Alix Lagrange, MD,
- Salma El Batti, MD,
- Bernard Cholley, MD, PhD,
- Paul Achouh, MD, PhD and
- Romain Pirracchio, MD, PhD∗ ()
- ↵∗Service d’Anesthésie-Réanimation chirurgicale, Hôpital Européen Georges Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
Acute aortic diseases (AADs) include mainly abdominal or thoracic aortic aneurysms and acute aortic syndromes. Referring patients with AAD to specialized centers is particularly relevant considering the well-established volume–outcome relationship for cardiovascular surgery (1). A regional dedicated network named “S.O.S. Aorta” was created in 2010 in Paris, France, to facilitate transfer of patients with suspected AAD, allowing fast diagnosis and rapid surgical treatment. It encompasses the following: 1) an aortic center localized at the European Hospital Georges Pompidou, with resources deployed 24 h per day, 7 days per week (emergency bay, senior intensivists, senior cardiovascular surgery and anesthesia teams, senior staffed cardiosurgical and coronary intensive care units, and senior staffed computed tomography scan); and 2) a network of emergency departments and emergency medical mobile unit ambulances in Paris and its suburbs referring all patients with a suspected AAD to the aortic center.
Our goal was to evaluate the impact on 30-day hospital mortality of implementing a dedicated aortic network on the prospective “S.O.S. Aorta” cohort. We hypothesized that the impact on mortality would not be linear over time, with the presence of a “training” period. We identified a breakpoint at month 58 and used it to define 2 periods of interest: from month 1 to month 57 (M1 to M57) and from month 58 to month 77 (M58 to M77). Kaplan-Meier survival curves were plotted for each period and compared by using the log-rank test. A multivariable Cox proportional hazards model with stepwise variable selection was used to model 30-day hospital mortality. The admission period (M1 to M57 vs. M58 to M77), as well as variables associated with mortality in univariate analysis, and variables significantly different between the 2 periods were included as predictors in the Cox model. As a sensitivity analysis, the Cox model was refitted in the subgroup of patients with a confirmed AAD.
We included 871 consecutive hospitalizations (n = 853) between February 2010 and July 2016. Thirty-eight patients were excluded who experienced cardiac arrest before admission; they were considered as a specific subpopulation. Of the 833 hospitalizations (n = 815: age 66 ± 16 years; male, 67.7%) included in the analysis, patients were primarily managed at EHGP (European Hospital Georges Pompidou) in 389 (46.7%) cases; the others were referred from 112 different medical facilities and 18 different emergency medical mobile unit ambulances. The final diagnosis was an AAD in 579 (69.5%) cases distributed nonexclusively as follows: 370 (44.4%) acute aortic syndrome (type A aortic dissection, n = 217 [26.1%]; type B aortic dissection, n = 115 [13.8%]; intramural hematoma, n = 24 [2.9%]; penetrating aortic ulcer, n = 7 [0.8%]; or traumatic aortic injury, n = 7 [0.8%]), 77 (9.2%) nonruptured and 127 (15.2%) ruptured aortic aneurysm, 9 (1.1%) aortic prosthesis complication, and 8 (1%) aortic thrombosis. A total of 351 (42.1%) patients underwent cardiovascular surgery in the first 24 h, with a median (interquartile range) time from admission to operating room of 53 min (23 to 109 min). The 30-day hospital mortality was 19.4% (n = 162) in the overall population and 24% (n = 139) in the subgroup of patients with a confirmed AAD. Figure 1 displays the Kaplan-Meier estimates depending on the period of admission (M1 to M57, n = 535 with 114 [21.3%] deaths vs. n = 298 with 48 [16.1%] deaths at 30 days) (log-rank test, p = 0.09). In multivariate analysis, the second period (M58 to M77) was associated with a significantly decreased risk of 30-day hospital mortality (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.89; p = 0.011). In patients with a confirmed AAD, there was a tendency of decreased mortality (hazard ratio: 0.69; 95% confidence interval: 0.47 to 1.02; p = 0.06).
Monocentric retrospective studies already reported that dedicated aortic teams may decrease mortality for type A aortic dissection (2). Our results suggest that not only dedicated aortic centers, but aortic networks with physician-staffed ambulances, may be beneficial for all patients with suspicion of an AAD. This study was not designed to assess the reasons underlying the benefit of aortic centers. Time-to-surgery is very likely to be associated with a favorable outcome in this situation. In our study, the time between the admission and the operating room was very short for patients primarily managed in the aortic center, with a median (interquartile range) of 1.27 h (0.73 to 2.62 h) compared with 3.21 h (1.58 to 10.31 h) in a similar population with acute type A aortic dissection in the International Registry of Acute Aortic Dissection (3).
Our results support the development of such specialized centers in agreement with the recent recommendations from the European Society of Cardiology (4).
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Achouh and Pirracchio contributed equally to this work.
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