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Type A aortic dissection: optimal annual case volume for surgery

Michal J Kawczynski1,2, Sander M J van Kuijk3, Jules R Olsthoorn1,4

  • 1Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6629HX Maastricht, Limburg, The Netherlands.

European Heart Journal
|August 28, 2023
PubMed

Insights

A new meta-analysis method identified 38 annual cases as the optimal volume for acute type A aortic dissection (ATAAD) surgery. Centralizing care to high-volume hospitals improves patient survival and outcomes.

Area of Science:

  • Cardiovascular Surgery
  • Health Services Research
  • Meta-Analysis

Background:

  • Volume-outcome relationships are crucial for centralizing complex cardiovascular procedures.
  • Determining optimal hospital case volume thresholds is essential for improving patient outcomes.
  • Acute type A aortic dissection (ATAAD) surgery is a critical procedure where centralization may enhance care.

Purpose of the Study:

  • To introduce a novel meta-analytical approach for determining optimal hospital case volume thresholds.
  • To apply this method to ATAAD surgery to identify an optimal annual case volume.
  • To assess the impact of hospital volume on early and long-term mortality for ATAAD.

Main Methods:

  • A systematic literature search was conducted across three databases (2012-2023).
  • A novel volume-outcome meta-analytical approach using restricted cubic splines and the elbow method was employed.
  • Early mortality, long-term survival, and numbers needed to treat (NNTs) were analyzed in relation to annual hospital case volume quartiles.

Main Results:

  • 140 studies with 38,276 patients were included, showing a significant non-linear volume-outcome effect (P < .001).
  • The optimal annual case volume threshold for ATAAD surgery was determined to be 38 cases/year (95% CI 37-40).
  • Higher volume centers (Q4) had significantly lower early mortality (10.3%) vs. low-volume centers (Q1) (16.2%), and improved 10-year survival (69% vs. 51%).

Conclusions:

  • A novel meta-analytical method statistically determined the optimal hospital case volume threshold for cardiovascular interventions.
  • Centralizing ATAAD care to high-volume centers (≥38 cases/year) is associated with improved patient outcomes and survival.
  • This volume-outcome determination methodology can be extended to other cardiovascular procedures requiring centralization.
Abstract

Keywords:
Acute type A aortic dissectionAnnual case volumeCardiovascular interventionsHospital volumeOptimal case volumeVolume–outcome relationship

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