Quantifying the learning curve of emergent total arch replacement in acute type A aortic dissection
Quantifying the learning curve of emergent total arch replacement in acute type A aortic dissection
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量化急性 A 型主动脉夹层紧急全弓置换术的学习曲线
DOI：
10.21037/jtd-20-912
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发表时间：
2020-08-01
影响因子：
2.5
通讯作者：
Wang, Chunsheng
中科院分区：
文献类型：
--
作者：
Liu, Huan;Liu, Shun;Wang, Chunsheng
急性A型主动脉夹层累及主动脉弓是一种危及生命的疾病，需要立即手术治疗。紧急全牙弓置换和牙根重建是一项技术要求很高的手术，根据外科医生的经验，结果各不相同。急诊全牙弓置换术中的人为因素从未被系统地研究过。目前尚不清楚低手术量的外科医生在启动阶段取得可接受结果的能力。方法2013年1月至2016年12月，我院收治的急性A型主动脉夹层患者，由3名外科医生行急诊全主动脉弓置换术。收集基本特征、手术和术后结局。关键手术步骤的时间和手术死亡率采用描述性统计和累积SUM（CAMUM）分析计算。结果300例急性A型主动脉夹层患者（年龄53.8±11.5岁，女性63例，占21.0%）行急诊全弓置换术。219例（73.0%）患者接受了牙根加固，295例（98.3%）患者接受了冷冻象鼻修复。平均停循环时间和阻断时间分别为29.8±9.8和112.3±32.1 min。手术死亡率为6.7%，脑卒中发生率为4.0%。术后ICU和住院时间分别为8.4±10.6和18.0±12.2天。根据AQUIUM的解释，外科医生在手术时间方面似乎有不同的学习曲线。通过对手术死亡率的CIMUM失败分析，两位新任命的外科医生在他们的启动阶段保持在可接受的范围内，而一位具有较高手术量的资深外科医生的结局和性能更好。结论虽然急性A型夹层的急诊全弓置换术是一个复杂的情况下，训练有素的外科医生在成人心脏手术能够在他们的启动阶段取得可接受的结果。
Background Acute type A aortic dissection with arch involvement is a life-threatening condition, which requires immediate surgical attention. Emergent total arch replacement and root reconstruction is a technically demanding operation with varying outcomes based on surgeon experience. The human factors in total arch replacement in the emergent setting have never been systematically investigated. The ability of surgeons with low volumes to achieve acceptable results in their start-up period is not known. Methods From January 2013 to December 2016, patients with acute type A aortic dissection who underwent emergent total arch replacement with three surgeons were enrolled. Basic characteristics, procedural and postoperative outcomes were collected. The time of critical surgical steps and operative mortality were calculated using descriptive statistics and cumulative SUM (CUSUM) analysis. Results A total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent emergent total arch replacement. A total of 219 patients (73.0%) had root reinforcement, 295 patients (98.3%) underwent frozen elephant trunk repair. Mean circulatory arrest and cross-clamp times were 29.8±9.8 and 112.3±32.1 min, respectively. The operative mortality was 6.7%, the stroke rate was 4.0%. The mean length of postoperative ICU and hospital stays were 8.4±10.6 and 18.0±12.2 days, respectively. By CUSUM depictions, surgeons appeared to have different learning curves with regards to operative time. By CUSUM failure analysis on operative mortality, two newly appointed surgeons in their start-up period stayed in an acceptable range, while one senior surgeon with higher volumes experienced superior outcomes and better performance. Conclusions Although emergent total arch replacement for acute type A dissection is a complex scenario, surgeons well-trained in adult cardiac surgery are able to achieve acceptable results in their start-up period.