急性A型大動脈解離手術における外科的専門知識に応じたTEMベースの傾向スコアマッチング解析（虚血を伴わない患者対象）
Leonard Pitts1,2,3, Lina Hülsenberg1,2, Matteo Montagner1,2
1Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, Berlin, 13353, Germany.
Objectives:
This study investigates differences in short- and midterm outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons.
Methods:
Patients who underwent surgery for acute type A aortic dissection between 2013-2023 defined as M0 (no malperfusion) according to the Type-Entry-Malperfusion classification were included and divided into two groups according to the surgeon's expertise: aortic surgeon versus non-aortic surgeon group, whereas an aortic surgeon was defined by expertise in extensive aortic arch surgery including frozen elephant trunk implantation on a regular basis (average ≥5/year). After propensity score matching, the groups were compared in terms of intraoperative variables and outcomes including a primary combined end-point consisting of thirty-day mortality and/or CT-confirmed stroke.
Results:
The matched cohort comprised two balanced groups with 234 patients (117 each group). Cardiopulmonary bypass, cross-clamp and distal arrest times did not differ significantly between the groups. However, more extensive aortic surgery was performed by aortic surgeons: aortic root replacement (Bentall) (p = 0.007; OR 1.18 (CI 1.05-1.32)), valve-sparing root replacement (David) (p = 0.013; OR 1.05 (CI 1.01-1.10)) and frozen elephant trunk implantation (p < 0.001; OR 1.18 (CI 1.09-1.27)). The combined end-point of thirty-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (p = 0.54; OR 0.97 (CI 0.86-1.08)). Further clinical outcomes, including five-year survival, did not differ significantly (p = 0.170).
Conclusions:
Patients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and midterm outcomes between specialized aortic and non-aortic surgeons. However, more extensive aortic repair may be performed safely by specialized aortic surgeons. These results support the definition of an aortic surgeon based on experience with the FET technique and may advocate call coverage by an aortic surgeon for type A repair at high-volume centers.
