High-Volume Hospitals for Patients Affected by Thoracic Aortic Diseases.
Do We Really Need them?
Giovanni Mariscalco1*, Aleassandra Frontera2, Carmelo Dominici2 and Daniele Maselli2
1Leicester Cardiovascular Biomedical Research Unit and Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
2Department of Cardiovascular Surgery, Cardiac Surgery Unit, S.Anna Hospital Catanzaro, Italy
- *Corresponding Author:
- Giovanni Mariscalco
Leicester Cardiovascular Biomedical Research Unit and Department of Cardiovascular Sciences
University of Leicester, Clinical Science Wing, Glenfield Hospital Leicester, United Kingdom
Tel: +44-(0)116.258 3019
E-mail: [email protected]
Received date: January 27, 2016; Accepted date: January 28, 2016; Published date: January 30, 2016
Citation: Mariscalco G, Frontera A, Dominici C, Maselli D (2016) High-Volume Hospitals for Patients Affected by Thoracic Aortic Diseases. Do We Really Need them?. Angiol 4:e114. doi:10.4172/2329-9495.1000e114
Copyright: © 2016 Mariscalco G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Visit for more related articles at Angiology: Open Access
The term “thoracic aortic disease” (TAD) includes a wide range of aortic diseases with variable clinical presentations and prognosis. The Global Burden Disease 2010 project demonstrated that the overall global death rate from aortic aneurysms and aortic dissection increased from 2.49 per 100000 to 2.78 per 100000 inhabitants between 1990 and 2010, with higher rates for men . At the same time, admissions for thoracic aortic aneurysms have increased from 4.4 to 9.0 per 100000 in the UK, mainly due to an increase in elderly patients, over 75 years of age .
Despite this emerging epidemic, standard of care for TAD has not been established. The 2010 American Heart Association (AHA) guidelines for the management of TAD  include a level I recommendation for the “evidence-based referral” of TAD patients, limiting their care to large volume centres, with experienced physicians, and supporting teams. However, the evidence to support this recommendation is level C, based on the consensus of opinion of the experts and small studies, retrospective studies and registries. Similarly, the European Society of Cardiology (ESC) 2014 guidelines on TAD  primarily consist of recommendations based on level C evidence. This contrasts with the evidence base for the management of other cardiovascular conditions [5,6].
Therefore, do we really need high-volume hospitals for dealing with patients affected by TAD? Yes, we do. However, despite this intuitive evidence, a large variety in outcomes and results across cardiac centres and countries is still present. Only few studies have investigated the relationship between hospital volume and mortality in patients affected by TAD, including both aortic aneurysms and dissections [7-12]. Although limited in numbers, these studies underpin the need of dedicated super-centers in order to improve survival of such disease. Chikwe et al.  evaluated the impact of low-volume, mediumvolume and high-volume hospitals in patient mortality. Their data fully support the need for super-center in dealing with TAD. Even more impressive were the data published by the Duke University: after the introduction of specific thoracic program for aortic dissection (mainly based on dedicated surgeons for type A dissection case) hospital mortality declined from 34% to 2.8% .
Based on these evidence, it appears clear the need of high-volume centers for thoracic disease. The knowledge gap in the standard of care for TAD is waiting to be filled.
- Sampson UK, Norman PE, Fowkes FG, Aboyans V, Yanna Song, et al. (2014) Global and regional burden of aortic dissection and aneurysms. Global Heart 8: 171-180.
- Von Allmen RS, Anjum A, Powell JT (2013) Incidence of descending aortic pathology and evaluation of the impact of thoracic endovascular aortic repair: a population-based study in England and Wales from 1999 to 2010. Eur J Vasc Endovasc Surg 45: 154-9.
- Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF et al. (2010) 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 121: e266-369.
- Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, et al. (2014) 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 35: 2873-2926.
- Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED (2007) Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation 115: 881-887.
- Landon BE, O Malley AJ, Giles K, Cotterill P, Schermerhorn ML (2010) Volume outcome relationships and abdominal aortic aneurysm repair. Circulation 122: 1290-1297.
- Hughes GC, Zhao Y, Rankin JS, Scarborough JE, O'Brien S, et al. (2013) Effects of institutional volumes on operative outcomes foraortic root replacement in North America. J Thorac Cardiovasc Surg 145: 166-170.
- Knipp BS, Deeb GM, Prager RL, Williams CY, Upchurch GR, et al. (2007) A contemporary analysis of outcomes for operative repair of type A aortic dissection in the United States. Surgery 142: 524-8.
- Kazui T, Osada H, Fujita H (2007) An attempt to analyze the relation between hospital surgical volume and clinical outcome. Gen Thorac Cardiovasc Surg 55: 483-492.
- Sakata R, Kuwano H, YokomiseH (2012) Hospital volume and outcomes of cardiothoracic surgery in Japan: 2005–2009 national survey. Gen Thorac Cardiovasc Surg 60: 625-638.
- Chikwe J, Cavallaro P, Itagaki S, Seigerman M, DiLuozzo G, et al. (2013) National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality. Ann Thorac Surg 95: 1563–1569.
- Andersen ND, Ganapathi AM, Hanna JM, Williams JB, Gaca JG, et al. (2014) Outcomes of acute type A dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program. JACC 63: 1796-1803.