Acute Type A Dissection Repair by High-Volume Vs Low-Volume Surgeons at a High-Volume Aortic Center.

BACKGROUND: Previous studies suggest improved outcomes for acute type A dissections (ATAAD) treated at high-volume centers. It is unclear if outcomes are a result of individual surgeon experience or inherent resources available at high-volume centers. To explore this question, we stratified outcomes for ATAAD repair by low-volume and high-volume surgeons at a high-volume center. METHODS: We reviewed our institutional experience with ATAAD between 1999 and 2016 (n = 580). To evaluate surgeon experience with ATAAD repair, we categorized surgeons as high-volume aortic surgeons (HVASs) (> 10 cases/year) or low-volume aortic surgeons (LVASs) (≤ 10 cases/year). Analysis was stratified according to the following: HVAS in primary and first assist roles, HVAS as primary with LVAS as first assist, LVAS as primary and HVAS as first assist, and LVAS in both roles. RESULTS: The total experience for HVAS and LVAS as primary surgeon for the study period was 513 and 67, respectively. Mean annual experience as primary surgeon was 15.2 cases for HVAS and 3.4 cases for LVAS. In-hospital mortality was 14.0% if an HVAS was present and 24.0% with an all-LVAS team (P = .27). After adjusting for preoperative factors, the mortality odds ratio (OR) for an all-LVAS team was 3.72 (P = .01). CONCLUSIONS: ATAAD repair by an all-LVAS team had nearly a 4-fold increase in-hospital mortality compared with an all-HVAS team. Improved outcomes at high-volume centers may be predominantly due to surgeon experience and not from center-specific resources. This study may have implications on call coverage for ATAAD repair at high-volume centers.

Phase of Care Mortality Analysis According to Individual Patient Risk Profile.

BACKGROUND: Phase of care mortality analysis (POCMA) is a quality improvement tool categorizing triggers for mortality into phases of patient care. However, the relationship between a patient's risk profile and the triggers for mortality is incompletely understood. METHODS: POCMA was implemented for cases with available Society of Thoracic Surgeons (STS) risk models. Risk-adjusted rates were obtained from the STS database. Mortality triggers were categorized by the phase of occurrence (preoperative, intraoperative, intensive care unit [ICU], postoperative floor, and discharge). Patients were then stratified by STS risk score: low risk (<4%), intermediate (4% to 8%), and high risk (>8%). RESULTS: A total of 3,919 isolated coronary artery bypass grafting (CABG), 901 isolated valve, and 321 CABG plus single-valve procedures were performed from 2012 to 2018, with 4.6% crude mortality and a median STS risk score of 5.8%. POCMA was performed on 67 patient mortalities, with triggers occurring in the following phases of care: 49.3% preoperative, 13.4% intraoperative, 23.9% ICU, 3.0% postoperative floor, and 10.4% discharge phase. Mortality distribution was bimodal, occurring mostly in low-risk (37.3%) and high-risk (38.8%) patients. For low-risk patients, the trigger for mortality most frequently occurred during the postoperative ICU phase, while for high-risk patients, the trigger for mortality most frequently occurred during the preoperative phase. CONCLUSIONS: Mortality had a bimodal distribution with respect to patient risk profile. Phase-of-care triggers for mortality differed according to patient risk profile: low-risk triggers during the postoperative ICU phase versus high-risk triggers typically during the preoperative phase. Specific focus on phases according to the patient's risk profile represents an opportunity to improve quality and outcomes.

Minimally Invasive Mitral Valve Repair for Acute Papillary Muscle Rupture During Pregnancy.

Acute papillary muscle rupture during pregnancy is a rare cardiac condition with potential for 200% mortality. We describe a 28-year-old morbidly obese woman at 27 weeks gestation who presented with acute decompensated mitral regurgitation secondary to spontaneous papillary muscle rupture. After hemodynamic stabilization and caesarean delivery, we performed an emergent mitral valve repair through a minimally invasive right thoracotomy.