Learning Curve of Aortic Arch Replacement Surgery in Chinese Mainland with Stanford Type A Aortic Dissection


  • Yuntian Sun Department of Cardiovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, 100853, Beijing, China
  • Yunlong Fan
  • Zhaorui Dong Department of Cardiovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, 100853, Beijing, China
  • Shixiong Wei Department of Cardiovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, 100853, Beijing, China
  • Chao Song Department of Cardiovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, 100853, Beijing, China




Stanford type A aortic dissection, CUSUM learning curve, hemi-arch replacement, total-arch replacement, Cardiovascular surgery


Background: Stanford type A aortic dissection (TAAD) is the most common cause of death caused by aortic disease in the Chinese mainland. Patients suffering TAAD need immediate surgical treatment [Pompilio 2001; Di Eusanio 2003; Ueda 2003; Li 2013; Afifi 2016; Zhou 2019; Zhou 2021]. Emergency aortic arch replacement is difficult and risky. The prognosis following surgery varies depending on the different surgical approaches [Pompilio 2001; Kazui 2002; Di Eusanio 2003; Ueda 2003; Moon 2009; Li 2013; Afifi 2016; Zhou 2019; Zhou 2021]. Aortic arch replacement includes total-arch replacement (Sun's operation) and hemi-arch replacement. The comparative analysis of learning curves between the two procedures has not been systematically studied. In this study, we studied and analyzed the learning curves of total-arch replacement and hemi-arch replacement using cumulative sum (CUSUM) analysis.

Methods: From January 2013 to December 2019, a total of 139 Stanford TAAD operations were performed by the same surgeon and two assistants, including 61 cases of hemi-arch replacement and 78 cases of total-arch replacement. Baseline information, including preoperative conditions, intraoperative related data and postoperative prognosis, were collected. Descriptive statistics and CUSUM were used to analyze the total operation time, cardiopulmonary bypass (CPB) time, aortic clamping (AC) time, operative mortality, incidence of postoperative complications, postoperative intensive care unit (ICU) time, hospital stay, and postoperative drainage volume.

Results: A total of 139 patients with TAAD (age 48.8 ± 12.3, male, 107, female, 32) underwent emergency aortic arch replacement. A total of 61 patients (43.9%) underwent hemi-arch replacement, and 78 patients (56.1%) underwent total-arch replacement. The total time, cardiopulmonary bypass (CPB) time, and aortic clamping (AC) time of hemi-arch operation were 434.2 ± 137.0 minutes, 243.3 ± 87.2 minutes, and 157.0 ± 60.2 minutes. The total, CPB, and AC times of total-arch operation were 747.8 ± 164.3 minutes, 476.4 ± 121.6 minutes, and 238.5 ± 67.6 minutes. The mortality of hemi-arch operation was 3.3%, and that of total-arch operation was 6.4%. The incidence of complications after hemi-arch operation was 11.3%, and that after total-arch operation was 46.2%. The ICU time and hospital stay after hemi-arch surgery were 7.3 ± 4.4 days and 27.2 ± 16.2 days, respectively, and the ICU time and total hospital stay after total-arch surgery were 7.2 ± 5.9 days and 24.0 ± 10.3 days, respectively. The total drainage volume after hemi-arch operation was 2182.4 ± 1236.4 ml, and that after total-arch operation was 2467.3 ± 1385.7 ml. According to CUSUM analysis, the same cardiovascular surgery team seems to have different learning curves in the time of two operations. CUSUM analysis of intraoperative and postoperative indicators shows that after a certain period of professional and systematic cardiovascular surgery training, aortic hemi-arch replacement has the characteristics of short learning cycle and easy to master for surgeons, while total-arch replacement requires a longer learning cycle.

Conclusions: Although the emergency operation of TAAD is difficult and risky, according to results the of CUSUM analysis, cardiovascular surgeons can achieve better learning results in hemi-arch replacement than total-arch replacement.


Afifi RO, Sandhu HK, Leake SS, Rice RD, Azizzadeh A, Charlton-Ouw KM, et al. 2016. Determinants of Operative Mortality in Patients With Ruptured Acute Type A Aortic Dissection. Ann Thorac Surg. 101(1):64-71.

Braca P, Gaglione D, Marano S, Millefiori LM, Willett P, Pattipati K. 2021. Quickest Detection of COVID-19 Pandemic Onset. IEEE Signal Process Lett. 28:683-687.

Braverman AC. 2011. Aortic dissection: prompt diagnosis and emergency treatment are critical. Cleve Clin J Med. 78(10):685-696.

DeBakey ME, Beall AC Jr, Cooley DA, Crawford ES, Morris GC Jr, Garrett HE, et al. 1966. Dissecting aneurysms of the aorta. Surg Clin North Am. 46(4):1045-1055.

DeBakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES, Beall AC Jr. 1965. Surgical Management of Dissecting Aneurysms of the Aorta. J Thorac Cardiovasc Surg. 49:130-149.

DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell J, Noon GP, et al. 1982. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery. 92(6):1118-1134.

Di Eusanio M, Tan ME, Schepens MA, Dossche KM, Di Bartolomeo R, Pierangeli A, et al. 2003. Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients. Ann Thorac Surg. 75(2):514-519.

He T, Sun X, Yang Y, Yuan M, Yang G, Cheng K, et al. 2021. Learning curve for total thoracoscopic lobectomy for treating pediatric patients with congenital lung malformation. Asian J Surg.

Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, et al. 1996. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation. 94(9 Suppl):II188-193.

Kazui T, Yamashita K, Washiyama N, Terada H, Bashar AH, Suzuki T, et al. 2002. Impact of an aggressive surgical approach on surgical outcome in type A aortic dissection. Ann Thorac Surg. 74(5):S1844-1847; discussion S1857-1863.

Kim JB, Chung CH, Moon DH, Ha GJ, Lee TY, Jung SH, et al. 2011. Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection. Eur J Cardiothorac Surg. 40(4):881-887.

Kudsi OY, Gokcal F, Bou-Ayash N, Crawford AS. 2021. Learning curve of robotic transversus abdominis release in ventral hernia repair: a cumulative sum (CUSUM) analysis. Surg Endosc.

Lee D, Kang ML, Christie L, Lim WW, Tay DX, Patel S, et al. 2021. Improving trauma care in exsanguinating patients with CHOP (critical haemorrhage to operating-room patient) resuscitation protocol-A cumulative summation (CUSUM) analysis. Injury. 52(9):2508-2514.

Lenfant L, Corrigan D, Beksac AT, Schwen Z, Kaouk J. 2021. Learning curve analysis of single-port robot-assisted extraperitoneal prostatectomy using the cumulative sum (CUSUM) method. BJU Int.

Li F, Liu N, Dong P, Hou XT. 2013. [Analysis of factors related to acute renal failure post deep hypothermia circulatory arrest surgery of type A aorta dissection surgery]. Zhonghua Wai Ke Za Zhi. 51(12):1094-1098.

Li Y, Zhang N, Xu S, Fan Z, Zhu J, Huang L, et al. 2020. Acute type A aortic intramural hematoma and type A aortic dissection: correlation between the intimal tear features and pathogenesis. Quant Imaging Med Surg. 10(7):1504-1514.

Liu H, Liu S, Zaki A, Wang X, Cong S, Yang Y, et al. 2020. Quantifying the learning curve of emergent total arch replacement in acute type A aortic dissection. J Thorac Dis. 12(8):4070-4081.

Luo C, Qi R, Zhong Y, Chen S, Liu H, Guo R, et al. 2021. Early and Long-Term Follow-Up for Chronic Type B and Type Non-A Non-B Aortic Dissection Using the Frozen Elephant Trunk Technique. Front Cardiovasc Med. 8:714638.

Ma WG, Zhu JM, Zheng J, Liu YM, Ziganshin BA, Elefteriades JA, et al. 2013. Sun's procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg. 2(5):642-648.

Moon MR. 2009. Approach to the treatment of aortic dissection. Surg Clin North Am. 89(4):869-893, ix.

Pompilio G, Spirito R, Alamanni F, Agrifoglio M, Polvani G, Porqueddu M, et al. 2001. Determinants of early and late outcome after surgery for type A aortic dissection. World J Surg. 25(12):1500-1506.

Poon SS, Theologou T, Harrington D, Kuduvalli M, Oo A, Field M. 2016. Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis. Ann Cardiothorac Surg. 5(3):156-173.

Sherifova S, Holzapfel GA. 2019. Biomechanics of aortic wall failure with a focus on dissection and aneurysm: A review. Acta Biomater. 99:1-17.

Sun L, Qi R, Zhu J, Liu Y, Zheng J. 2011. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch. Circulation. 123(9):971-978.

Szymczak P, Grzybowska ME, Sawicki S, Wydra DG. 2021. Laparoscopic Pectopexy-CUSUM Learning Curve and Perioperative Complications Analysis. J Clin Med. 10(5).

Tamai K, Hori D, Yuri K, Yamaguchi A. 2020. Additional frozen elephant trunk as a bailout for a misdeployed frozen elephant trunk in the false lumen in a patient with acute aortic dissection. Eur J Cardiothorac Surg. 57(2):399-401.

Toennesen LL, Vindum HH, Risom E, Pulga A, Nessar RM, Arshad A, et al. 2021. Learning Curves for Electromagnetic Navigation Bronchoscopy Using CUSUM Analysis. J Bronchology Interv Pulmonol.

Ueda T, Shimizu H, Hashizume K, Koizumi K, Mori M, Shin H, et al. 2003. Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion. Ann Thorac Surg. 76(6):1951-1956.

Verhaeghe C, El Hachem H, Inchboard L, Corroenne R, Dreux C, Jeanneteau P, et al. 2021. Assessment of operator performance during oocyte retrievals: residents' learning curve and continuous monitoring of senior physicians. BMC Med Educ. 21(1):193.

Wang Z, Ge M, Chen C, Lu L, Zhang L, Wang D. 2021. Hepatic dysfunction in patients who received acute DeBakey type I aortic dissection repair surgery: incidence, risk factors, and long-term outcomes. J Cardiothorac Surg. 16(1):296.

Wang Z, Zhuang X, Chen B, Wen J, Peng F, Liu X, et al. 2020. 99-Case Study of Sporadic Aortic Dissection by Whole Exome Sequencing Indicated Novel Disease-Associated Genes and Variants in Chinese Population. Biomed Res Int. 2020:7857043.

Zhou C, Li Y, Yan Y, Feng D, Wei M, Wen J. 2021. Changes in Coagulation and Fibrinolysis Systems During the Perioperative Period of Acute Type A Aortic Dissection. Heart Surg Forum. 24(2):E223-E230.

Zhou X, Krishnan A, Hsu J, Burns A, Mandal K. 2019. Delayed Surgical Management of Type A Intramural Hematoma Is Not Associated with Worse Outcomes Than Emergent Operation. Heart Surg Forum. 22(2):E103-E106.



How to Cite

Sun, Y., Fan, Y., Dong, zhaorui, Wei, S., & Song, C. (2022). Learning Curve of Aortic Arch Replacement Surgery in Chinese Mainland with Stanford Type A Aortic Dissection. The Heart Surgery Forum, 25(1), E088-E096. https://doi.org/10.1532/hsf.4399