Big Data in Aortic Surgery:
Update on the STS Aortic Database
Nimesh D. Desai MD PhDCo-Director, Penn Thoracic Aortic Surgery Associate Professor of Surgery University of Pennsylvania
Co-Chair - STS Aortic Task Force
Why did we need to Update the Aortic Component of the STS database?
8.4%
6.9%
9.6%
13.7%
15.9%
7.9%
6.5%
9.1%
13.1%
15.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Total-AllProcedures
Ascending Aorta Aortic Arch Descending Aorta ThoracoabdominalAorta
Procecdure Type
Mortality by Procedure Type, Years 2005-2014
Operative MortalityIn-Hosp Mortality
Aortic Surgery has the highest SERIOUS complication rates of any cardiac Surgical procedures
Endovascular Revolution is Here!
Key Functionality of STS National Database Aortic Component
• Clear identification of patient phenotype
• Implantation details/Device-specific information
• Accommodation for Concurrent and Staged Hybrid procedures
• Detailed perioprocedural/30 day outcomes
• Aortic-Specific long-term follow-up for post-marketing analyses
** DUE TO COMPLEXITY – SURGEON INPUT INTO DATA ELEMENTS **
Clear Definition of Patient Phenotype
Clear Definition of Patient Anatomy
Aneurysm Types
Anatomy ExamplesSievers Classification for Bicuspid AV Aorto-Annular Ectasia
Diverticulum of Kommerrell
Sinus of Valsalva Aneurysm
Aortic Dissection
Malperfusion Syndromes
Fixed Malperfusion
Dynamic Malperfusion
ENDOVASCULAR PROCEDURESSURGICAL PROCEDURES
HYBRID/ENDOVASCULAR PROCEDURESSURGICAL PROCEDURES
Examples ‘Standard’ open Aortic repairsZone 2 Arch
Zone 3 Arch
Hemi Arch
Zone 3 Arch Elephant trunk Zone 3 Arch FrozenElephant trunk
Ascending only
Aortic Valve Procedures
Ascending/valve resuspension
Root Remodelling (Yacoub) Root Reimplantation
Florida Sleeve Aortic Valve External ringComposite Root Replacement
HYBRID / ENDOVASCULAR PROCEDURESSURGICAL PROCEDURES
Zone 0 Landing: Hybrid Arches
Total Endovascular Examples
Single Branched Graft for Zone 2
Zone 3 TEVAR
Ascending TEVAR GraftZONE 0 Zone 0 Single branch with
double transpositionZone 1 Single Branch with C-S Bypass
Endo TAAA Examples
Hybrid Abdominal Repair
Fenestrated and Branched Grafts
Endoleaks
Aorta 2.9: First YEAR!July 1, 2017 to Jun 30, 2018
55%
38%
7%
YES NO UNKNOWN
DID SURGEON PROVIDE INPUT FOR AORTIC
SURGERY DATA ABSTRACTION?
Aorta 2.9: First YEAR!July 1, 2017 to Jun 30, 2018.
Aortic Procedures: 22014 cases in 12 mos7.3% of all Adult Cardiac Surgery
57.8%
25.4%
6.4%
0.4% 0.8%3.0% 1.1% 0.3%
4.8%
0
10
20
30
40
50
60
70
Aneurysm Dissection ValvularDysfunction
Obstruction IntramuralHematoma
Infection Stenosis Coarctation Unknown
Perc
enta
ge o
f Aor
tic C
ases
(%)
Primary Indication of Aortic Surgery
1985
8
1646
510
0
5000
10000
15000
20000
25000
OPEN ENDOVASCULAR HYBRID
NU
MBE
R O
F CA
SES
AORTIC PROCEDURE STRATEGIES
Aorta 2.9: First YEAR!July 1, 2017 to Jun 30, 2018.
22014 cases in 12 mos
0
2000
4000
6000
8000
10000
12000
14000
16000
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Annualized Volume of Aortic Aneurysm Procedures
Aortic Aneurysm (Total) Ascending Aorta Aortic Arch Descending Aorta Thoracoabdominal Aorta
*
Aorta 2.9: First YEAR!July 1, 2017 to June 30, 2018
Aorta 2.9: First YEAR!July 1, 2017 to Dec 31, 2017
Num
ber
6072 Aneurysms
Aneurysm Location
Aorta 2.9: Roots for Aortic Insufficiency
5887
3444
2443
0
1000
2000
3000
4000
5000
6000
7000
T O T A L A O R T I C I N S U F F I C I E N T
N O N - A O R T I C I N S U F F I C I E N T
NU
MBE
R O
F CA
SES
VOLUME OF ROOT REPLACEMENT PROCEDURES (7/1/17-6/30/18)
3444
659
72
0
500
1000
1500
2000
2500
3000
3500
4000
AORTIC INSUFFICIENT
DAVID V YACOUB
NU
MBE
R O
F CA
SES
VOLUME OF VALVE SPARING ROOT REPLACEMENT FOR AI
(7/1/17-6/30/18)
Aorta 2.9: DissectionJuly 1, 2017 to Jun 30,
2018.
65%
13%
4%
11%
3%
5%
0
10
20
30
40
50
60
70
HYPERACUTE (<48 HRS)
ACUTE (48HRS-2WEEKS)
SUBACUTE (>2WEEKS-90
DAYS)
CHRONIC (>90 DAYS)
ACUTE ON CHRONIC
UNKNOWN
PERC
ENTA
GE
OF
CASE
S (%
)
AORTIC DISSECTION: TIMING5846 Aortic Dissections
21%
37%
13%
4% 4%
BELOW STJ STJ-MIDASCENDING MIDASCENDING TO DISTAL ASCENDING
ZONE 1 ZONE 2
PERC
ENTA
GE O
F CA
SES
(%)
AORTIC DISSECTION: PRIMARY TEAR LOCATION
20%
62%
18%
0
10
20
30
40
50
60
70
YES NO UNKNOWN
PERC
ENTA
GE O
F CA
SES
(%)
AORTIC DISSECTION: MALPERFUSION
204
264
183 32
9 534
352
932
880 954
1937
1735
780
0
500
1000
1500
2000
2500
CORONARY RIGHT COMMON CAROTID
LEFT COMMON CAROTID
VISCERAL RENAL ILIOFEMORAL
NU
MBE
R O
F CA
SES
AORTIC DISSECTION: MALPERFUSION BED
Yes No
DTA/ThoracoAbdominal Procedures
886
1646
0
200
400
600
800
1000
1200
1400
1600
1800
OPEN DESCENDING THORACIC AORTA
TEVAR
NU
MBE
R O
F CA
SES
VOLUME OF DESCENDING AORTIC PROCEDURES
Aorta 2.9: First YEAR!July 1, 2017 to June 30,2018
TEVAR 1647 cases Prox LZ
Distal LZ
Final Endovascular Frontiers: Arch and Ascending Aorta
157
115
42
020406080
100120140160180
TOTAL IDE STUDIES
OFF LABEL
NU
MBE
R O
F CA
SES
VOLUME OF ZONE 0 TEVAR PROCEDURES
• Circulatory arrest (both low/moderate and deep/profound) with no cerebral protection had significantly worse composite endpoint (mortality or poor neurologic outcome) [OR: 1.6; p<0.01]
• 60% more likely to have stroke/death if HCA only
Overall OP Mort: 12%Overall Neuro/OP MORT 23%
Future Directions: Quality Improvement in Arch Surgery
• Straight circulatory arrest with no cerebral perfusion strategy was the MOST commonly used strategy (36% of all cases)
Major area for Quality Improvement
HOWEVER…
2201
4
1002
7
4819
1793 30
67
0
5000
10000
15000
20000
25000
AORTIC PROCEDURES CIRCULATORY ARREST ANTEGRADE PERFUSION RETROGRADE PERFUSION
NO PERFUSION
NU
MBE
R O
F CA
SES
CIRCULATORY ARREST
Aorta 2.9: First YEAR!July 1, 2017 to Jun 30, 2018.
30.5%
Aortic Surgery Risk Model Development
• Proximal Aortic Repair Risk model –Star-Rating
• Volume Thresholds, Regionalization of Aortic care?
• NOW HAVE ENOUGH DATA TO START MODEL DEVELOPMENT
Mori, Geirsson et al ATS 2018
THANK YOU!
