# A Type-Entry-Malperfusion-Based Propensity Score Matched Analysis Depending on Surgical Expertise in Patients Without Malperfusion Undergoing Surgery for Acute Type A Aortic Dissection

## TL;DR

This study compares surgical outcomes for aortic dissection patients based on surgeon expertise, finding no significant difference in survival but more extensive repairs by specialized aortic surgeons.

## Contribution

The study introduces a surgeon expertise-based analysis using propensity score matching in aortic dissection surgery, focusing on patients without malperfusion.

## Key findings

- Specialized aortic surgeons performed more extensive aortic repairs, such as Bentall and frozen elephant trunk procedures.
- There was no significant difference in 30-day mortality or stroke rates between the two surgeon groups.
- Five-year survival rates did not differ significantly between the groups.

## Abstract

This study investigates differences in short- and mid-term outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons.

Patients who underwent surgery for acute type A aortic dissection between 2013 and 2023 defined as M0 (no malperfusion) according to the type-entry-malperfusion classification were included and divided into 2 groups according to the surgeon’s expertise: aortic surgeon vs 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 30-day mortality and/or CT-confirmed stroke.

The matched cohort comprised 2 balanced groups with 234 patients (117 in 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 = .007; odds ratio [OR] 1.18 [CI, 1.05-1.32]), valve-sparing root replacement (David) (P = .013; OR 1.05 [CI, 1.01-1.10]), and frozen elephant trunk implantation (P < .001; OR 1.18 (CI, 1.09-1.27]). The combined end-point of 30-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (P = .54; OR 0.97 [CI, 0.86-1.08]). Further clinical outcomes, including 5-year survival, did not differ significantly (P = .170).

Patients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and mid-term 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 frozen elephant trunk technique and may advocate for call coverage by an aortic surgeon for type A repair at high-volume centres.

Acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality, demanding urgent surgical repair according to current guidelines.