Aortic Dissection Awareness UK

I'm going to talk about surgical teams, but because it's quite a mixed audience, I thought we'd just go through a few details so we're all on the same page about aortic dissection. So this is the aorta, this is the ascending aorta, and this is what we call the aortic arch because it looks like an arch. Three blood vessels come off and go to the head and the arms and then it comes around the back of the heart through the chest down into the tummy and there are four important branches in the tummy. Two go off to the liver, spleen and bowel and things like that and then two go to the kidneys and then it goes down to the legs. So that's the ABC of the aorta. So what is a type A dissection? So type A dissection just as on some of the banners around here it's just a split in the wall of the aorta and it splits longitudinally and a type A dissection which you'll have heard of is simply a dissection that involves the ascending aorta just above the heart here. The split can go all the way around but any dissection that involves the ascending is called a type A and that's the most important thing because that's immediate surgical management and the reason for that is the tear in simple terms can dissect back into the heart and cause some mischief with the coronary arteries and the aortic valve and cause rupture and that's life threatening. So type A straight to theatre as soon as you can with as good a surgeon as you can find. Type B starts usually just beyond this artery here called the left subclavian which goes to the left arm and it splits all the way down usually to the legs and it's been shown quite clearly that type B dissection, a simple type B dissection, should be treated medically with blood pressure control. There are some more complex type B dissections that will need some sort of intervention, either a stent or even surgery. So that's the basics of type A and type B. This is my only graph which you've probably already seen and what it shows in simple terms is that if you try to treat a type A dissection medically without surgery the outcomes are not very good and that's where the 1% mortality per hour comes from over the first two days. After that the mortality curve sort of flattens off a little bit and what it shows is that if you try to treat at these square blocks down here if you try to treat it surgically then the outcomes are obviously much better. So, if you have a type A, find a surgeon. So the treatments, there are various different types of treatment. So this is the simplest form of treatment, which is just to replace the ascending aorta. And it looks very simple, you just replace this bit in the middle here, and the graft is usually about 3 or 4 centimetres long, and you wonder what all the fuss is about. But to do that is probably a 10 or 12 hour operation involving the heart-lung machine and cooling your body down and switching the circulation off and trying to re-approximate those torn layers and put it all back together again. So it's a very high risk operation even just to do that. But that's the least that you can do. If there are problems with the coronary arteries or there are problems with the aortic valve then you need to do a little bit more and this is called an aortic root replacement. So you can see the graft's gone down a little bit more, right into the root of the aorta, sorry, in root of the heart. And you see a little coronary artery here is being reattached, and there's another one on the other side, and the valve has most likely been replaced inside that. So that's called an aortic root replacement, and we've also replaced the ascending aorta. So that's more complex operation, and that will come with a higher risk profile. And then this is the most extensive operation that you can do in a type A where you've basically replaced the whole of the root, the acing aorta, the total arch, and we've re-implanted these blood vessels to the brain and then we've done some stitching called an anastomosis over here beyond the artery to the left arm and then deployed a stent down into the descending thoracic aorta. And this is a Thoraflex device, it's made by Vascular Tech you've heard about and you should have the opportunity to see one of these devices later on. very very extensive operation and there's current debate about whether we should be doing that routinely or whether we should do it only when indicated. So there are various forms of treatment. So how can we improve the outcomes for this sort of operation? So Debbie's going to speak after me in a little bit more detail about how we can screen patients in A&E and how we can make quicker diagnosis and that's all around biomarkers, CT scanning and education in A&E where there's very high turnover every six months the junior doctors change over so there's a continuing problem with education of junior doctors in A&E and thinking about the diagnosis of dissection. Debbie will talk about that and she's also going to talk about how we can optimize early medical management which is blood pressure control and monitoring and then and how we can transfer patients quicker to a center where they can do a good operation. And then I'll talk about specialist surgical teams. So at the moment, what happens is basically the hospitals, the country's vaguely split up into regions. In each region, there will be a couple of cardiac surgery centers. So if you have your dissection in the Northwest, you'll be taken to the local hospital, which will usually either be Liverpool or Blackpool, it may be Manchester. So basically you will go to your local cardiac centre and so it's a proximity-based referral system. When you get there some of those surgeons may be aortic surgeons some of them may be cardiac surgeons and so some of them may have a huge volume of elective practice in aortic surgery and be doing it on a daily basis some may have an interest in mitral surgery or coronary surgery and do very little aortic work. So in a way you're sort of susceptible to who's on call that day when you arrive in that hospital. There will be some redirection for patients so we may get a call in the night from say Manchester that says well we have this complicated patient that's had previous surgery or needs a total arch replacement, can you take him on and then the patient may come from Manchester over to here or Blackpool and then there's maybe some issues with capacity so there may be no intensive care unit bed so we're lucky in Liverpool we almost always have an intensive care unit bed and then we'll take the patient because the other surgeons can't find a bed for them. So these are the mortalities taken from the society blue book a little bit out of date now and things are a little bit better but the overall mortality in the UK for a type A dissection is about 23 percent. And you can see here if you replace just the ascending you get 20.7 percent. If you do an aortic valve replacement and ascending mortality is much lower, but if you do a root replacement the mortality there is really quite high at 30 percent, so one in three risk of dying if you have a root replacement. And that's not to mention if you're replacing the root total arch and doing a frozen elephant trunk You can imagine those mortality statistics are quite high. So this is some data from around the different regions that we've got from our society. And what it shows is that there's quite a lot of variation from region to region in terms of the mortality for an operation on a type A dissection. And it varies from roughly 25% to 6.8%. And that variation, it may or may not be real in the sense that it may be that in the East Midlands mortality is 7%, it may be that the patients presenting there are low risk and patients in say Yorkshire and Humber are all high risk. So there's no risk adjustment for that mortality. Maybe if you could come up with a score and risk adjust them all, all the centres would have the same mortality but we don't know that. We also know, as I've said, that some of the high risk patients are transferred to specialist aortic centers, and so the risk may be just shifted to a different center. You have to be a bit careful of that data. But there is some variation by surgeon, by center, and there is some variation in surgeon outcomes. So if you look at this activity by a consultant, so in this consultant 292 here, the type A dissection he does in the middle of the night is 100% of his aortic practice over that period, so he never really does any aortic surgery apart apart from when he does a type A dissection. Whereas this surgeon down here, it's only a small percentage of his work, and he's doing a lot of aortic surgery in the daytime. So when his dissection arrives at night, he's used to doing these sorts of things, and you can expect him to have better outcomes. And it's the same by center. So if you look at center PP, it's all anonymized. Dissection is 40% of their activity, whereas down here in center LL, I don't think that's Liverpool actually, it's a small percentage of their activity, so that's important. This is some data published by Mr Ou, and what it shows is that there is a strong volume effect, and by that it just means that the more dissections you do, the better the outcomes are, and that makes sense to a layperson, but it takes some proving to surgeons around the country that this is a real effect and the number the magic number is four basically so if you do more than four dissections a year as a surgeon your outcomes will be much better so 19.3 percent versus 12.6 percent. It makes sense. Same thing they found in America this was a study published by Joanne Chikwe, she was trained in the UK and went to New York and the magic number in America was about five. So there's a strong volume effect. The more you do, the better your outcomes. And that's what we took advantage of in Liverpool. And Jane has shown that data, that our mortality dropped from nearly 30% down to 10% just by specialising instead of 16 surgeons doing the dissections, there were four doing the dissections. So our mortality dropped and all the morbidity around that, as Jane showed, has improved. And that's just two lines showing the mortality before and the mortality after. So just by concentrating all the expertise into a few people, your outcomes got better. And that's similar to, actually your slide was much better than mine, Jane, so I need to get that from you, and it's awful green as well. In London, as Jane said as well, following the results that we got, Professor Pepper introduced a new system that involved the Royal Brompton, Harefield and Hammersmith, so a North London rotation, and they had a single point of contact, so when the patient came to A&E, they could ring up a number and got direct contact with a consultant surgeon straight to theatre, and you can see their mortality dropped significantly from nearly 30% to 15%, and again with root surgery got less, total arch, not much difference, not surprisingly. So they took advantage of that volume effect in a different way, by just getting more hospitals involved. And the same thing happened in Minneapolis, that was a regional wide restructuring of services and they engaged in education, they got better diagnosis, better referral patterns, better transfers, they introduced standard operating protocols for operative procedures and they showed that much of the quality markers that they were measuring improved. So there are different ways to take advantage of that volume effect. So does the UK need to change? Well, we've tried and it's difficult because of vested interests. So, from a surgical point of view, some surgeons are resistant to change because they want to keep doing aortic surgery in every centre and they don't want it taken away from them. The society, we've got Graham Cooper who's going to talk later here, is the president of the society, they've also tried to introduce some changes and service specification to try and improve the outcomes of type A dissection. And of course NHS England from a government point of view have also tried to, through commissioning groups, have tried to produce service specifications and that work is ongoing. But it's difficult to know whether it's something that's going to come through a bottom-up approach in that the surgeons decide to change things at the ground or whether it will come top-down basically from a society or a government diktat that that you guys need to change and take advantage of these volume effects that we've seen. Catherine was, obviously I met her last year and I was listening to her and I went and searched out her campaign. And when I first saw this, I was a little bit embarrassed to be honest, because this is one of the things that they recommend. One is about process and it's organization of emergency cardiac surgical services. And I just thought, well, why should this sort of thing come from a patient group? And it's embarrassing that this sort of thing we should be sorting out ourselves. But actually thinking about it, it's an important aspect is patient advocacy and getting surgeons to change and putting aside the politics of it all. And I think working together, we can produce change. So there are solutions. So we have a thing called a UK Aortic Forum where we meet up once a year, usually at the Belfry Hotel somewhere near Birmingham. Some surgeons play stereotypically around a golf, and the other surgeons sit down and talk about how to improve services. No names mentioned. And what we vaguely decided, there should be some regional accountability. So everyone, there will be local solutions. So what's worked in London may not work in Liverpool, may not work in Manchester. So instead of a top-down dick-tap telling people how to do things, we just make people accountable in their region for their outcomes. So we go to Yorkshire and we say, okay, you've got three centres in Yorkshire, you know, this is your dissection mortality, you guys need to reorganise and improve your mortality so it's similar to how it is in London or something like that. And so whether that's in a single centre, whether it's multiple centres, whether it's specialty surgeons. Whatever they want to do locally, they should just be accountable for their outcomes and justify what they're doing. And that way they can reorganise things as they like. And one of the benefits of that will be education, training, research and audit and producing standard pathways, which Jane has also talked about. The key really that came out of the meeting was some sort of local solution with regional accountability. And the drivers for change, well, Graham Cooper's going to speak about that really, but it's patient advocacy groups, it's service specification, commissioning groups, and of course the aortic surgeons. And just so I don't give surgeons a bad name, the surgeons from the UK aortic surgery group developed a WhatsApp group, and there are, I don't know, 20 or 30 surgeons, aortic surgeons throughout the UK on this WhatsApp group. And so this was a chat at 07.25 this morning when I awoke. And it was about a patient had been admitted somewhere, had some issues, and so the surgeon wasn't sure what to do. So he got on the WhatsApp group, he had a chat, and had the advice of multiple senior aortic surgeons from around the country almost instantaneously. And so that's the sort of level day-to-day input that's really important. And so there is a degree of communication and collegiateness amongst the surgeons and they enjoy, they're usually zealots, they enjoy doing aortic surgery and they like to talk about it. Shouldn't forget about type B because Dan is in the room. I've already talked about type A. Type B dissection is a complete nightmare because it falls between vascular surgery, general medicine, cardiology, cardiac surgery and type B, the management and pathways for type B dissection are even more of a mess and need to be dealt with soon after we sorted out type A dissection. So I'll finish there, basically we could talk about this during question and answer times later but we can talk about is the variation in UK activity and outcomes valid and are those outcomes acceptable and do we really need to reorganize things and what models should we implement and we can talk about one important issue which is patients with type A dissections bypassing a hospital so if we're on a rotor with Liverpool Blackpool and Manchester and we have a patient in North Wales with a type A dissection is it really valid for that patient to come in an ambulance drive past Liverpool and go all the way to to Manchester and waste another hour or two getting to Manchester. And so those are the issues that you run into once you talk about organizing services regionally. So thank you very much.