Acute type A aortic dissection remains one of the most critical scenarios faced by cardiac surgeons. This is not only due to the aggressiveness of the disease itself, but also because outcomes depend on multiple factors that extend far beyond surgical technique: rapid diagnosis, system organization, team experience, and decision-making under extreme conditions, often during night-time emergencies. For years, variability in outcomes has reflected organizational differences more than technical ones. Within this context, care models aimed at minimizing chance and ensuring true expertise have emerged, including specialist aortic on-call rotas and structured aortic emergency pathways.

The authors analyzed 406 patients who underwent surgery for acute type A aortic dissection between 2015 and 2023 at a tertiary referral center, comparing outcomes before and after the introduction in 2020 of a specialist aortic surgery on-call rota. Following its implementation, in-hospital mortality was significantly reduced (25% vs. 16%; p = .033), an association that remained significant after multivariable adjustment (adjusted OR 0.60; 95% CI 0.36–1.00; p = .049). This improvement was accompanied by a shift in surgical strategy toward more extensive repairs, including a higher rate of aortic root replacement and a trend toward greater use of total arch replacement and frozen elephant trunk techniques, without an associated increase in major complications or intraoperative mortality.

The authors conclude that the implementation of a specialist aortic surgery on-call rota is associated with a significant reduction in in-hospital mortality in acute type A aortic dissection and facilitates a more extensive and complex surgical approach while maintaining acceptable perioperative outcomes. They emphasize that these findings should be confirmed in multicenter studies with longer follow-up.

COMMENTARY:

This study delivers a very clear message: in acute type A aortic dissection, organization matters as much as surgical technique, and often more. The British model of an aortic rota is neither a regional emergency code nor a training program. Rota literally means an on-call schedule. In practice, it refers to a dedicated on-call system covered exclusively by a small group of expert surgeons. In this experience, expertise is concentrated at St Bartholomew’s Hospital (London), with 7 selected surgeons out of a total of 14, all required to meet a minimum annual volume of major aortic surgery and acute type A dissection repairs. There is no room for compromise or improvisation: dissections are operated on by surgeons who routinely manage dissections.

The clinical impact is difficult to ignore. The absolute reduction in in-hospital mortality approaches 9%, a striking figure in this setting. Most importantly, this improvement is not achieved by doing less surgery, but by doing better surgery. After implementation of the specialist rota, surgeons undertook more ambitious repairs, with higher rates of aortic root replacement and a greater tendency toward total arch replacement and frozen elephant trunk procedures, in line with a tear-oriented strategy. Operative times increased, but mortality did not. Experience absorbed complexity.

The study also reinforces a well-known principle in daily practice: early prognosis remains largely driven by the patient’s initial clinical severity. Shock and malperfusion continue to be the main determinants of early mortality, far outweighing the duration of cardiopulmonary bypass or the extent of reconstruction. Surgery begins long before the operating room, during that initial phase in which every minute counts. This does not diminish the value of surgical technique, but it does remind us that type A dissection is a race against time from the very first symptom.

At this point, comparison with the Aortic Code implemented within a defined hospital network in the Community of Madrid—previously discussed on this blog last year—is particularly illustrative. While the British model focuses on whooperates, the Madrid Aortic Code acts on the entire care pathway: early diagnosis, protocolized activation, immediate transfer, and treatment at a reference center by an experienced multidisciplinary team. It is not a region-wide code, but one designed for a specific hospital network. These are different models, but they share a common goal: reducing variability, shortening critical delays, and concentrating expertise.

Both experiences convey the same practical message, almost as a clinical aphorism: acute type A aortic dissection should never depend on the chance availability of the on-call surgeon. Surgical technique undoubtedly matters. But it is organization that often determines whether a patient reaches the operating room alive. Specialist on-call rotas and aortic emergency pathways are neither a luxury nor an organizational trend; they are, quite simply, clinical tools that save lives.

REFERENCE:

Pruna-Guillen R, Rojanathagoon T, Oo A, Adams B, Lall K, Yap J, Di Salvo C, et al. Impact of an on-call specialist aortic rota implementation in acute type A aortic dissection on outcomes and repair complexity: a retrospective cohort study. Interdiscip Cardiovasc Thorac Surg. 2025;40(12):ivaf262. doi:10.1093/icvts/ivaf262.