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Vol. 75. Issue 1.
Pages 95-98 (January 2022)
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Vol. 75. Issue 1.
Pages 95-98 (January 2022)
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Aorta Code: a pilot study of a health care network for patients with acute aortic syndrome
Código Aorta: proyecto piloto de una red asistencial para la atención al paciente con síndrome aórtico agudo
Carlos Ferreraa,
Corresponding author

Corresponding author:
, Isidre Vilacostaa, Pablo Buscab, Alfonso Martín Martínezc, Francisco Javier Serranod, Luis Carlos Maroto Castellanose, on behalf of the Multidisciplinary Aorta Code CardioRed1 Group
a Servicio de Cardiología, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
b Servicio de Urgencias Médicas de Madrid, SUMMA-112, Madrid, Spain
c Servicio de Urgencias, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain
d Servicio de Cirugía Vascular, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
e Servicio de Cirugía Cardiaca, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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Tables (2)
Table 1. Baseline and presenting characteristics of patients with acute aortic syndrome during care-as-usual and after implementation of the Aorta Code project
Table 2. Treatment and prognosis of patients with acute aortic syndrome during care-as-usual and after implementation of the Aorta Code project
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To the Editor,

Acute aortic syndrome (AAS) is a rare condition associated with high mortality.1

The Aorta Code project was designed to create a dedicated health care network for patients with AAS. The project had 3 main goals: to increase vigilance and improve the diagnosis of AAS, to expedite the transfer of patients to the network's aortic referral center, and to provide optimal treatment through a highly specialized team.

The Aorta Code network is formed by 4 hospitals from the autonomous community of Madrid and the area's medical emergency response service (SUMMA-112). It provides coverage to a population of 1.04 million inhabitants.

The project set-up included specialized training at the hospitals’ emergency departments and SUMMA-112 and the development of a diagnostic and a treatment algorithm based on clinical practice guidelines.2 A highly specialized AAS care team formed by 2 cardiologists, 2 cardiac surgeons, and 2 vascular surgeons (the Aorta Team) was created to take responsibility for decisions on incoming patients and their treatment. The project was approved by the relevant health authorities in Madrid and the local ethics committee at Hospital Clínico San Carlos. Informed consent was obtained from all patients involved.

The full Aorta Code protocol has been published elsewhere.2 In brief, as soon as a patient is diagnosed with AAS, the emergency responders activate the Aorta Code via a dedicated telephone line. The coordination committee at SUMMA-112 dispatches a unit for the urgent transfer of the patient to the referral hospital, where their case is assessed by the members of the Aorta Team, who decide on the definitive treatment.

To evaluate the Aorta Code project, we compared outcomes from the 18 months before the project was implemented (care-as-usual period) with outcomes from the first 2 years of its implementation (March 15, 2019 to March 15, 2021).

Categorical variables are expressed as number and percentage and were compared using the chi-square or Fisher exact test. Quantitative variables are expressed as mean±standard deviation or median [interquartile range] and were compared using the t test. Statistical significance was set at P < .05 and the statistical analyses were performed in STATA (version 12.0).

The AAS code was activated 59 times during the 2 years analyzed (this included a 3-month period in which the service was interrupted due to the COVID-19 pandemic). AAS was confirmed in 42 patients (table 1); 5 patients did not have aortic disease, 8 had nonacute aortic disease, and 4 had a ruptured abdominal aortic aneurysm.

Table 1.

Baseline and presenting characteristics of patients with acute aortic syndrome during care-as-usual and after implementation of the Aorta Code project

Variable  Aorta Code (n=42)  Care-as-usual (n=18)  P 
Age, y  67.1±2.2  63.4±4.3  .403 
Male sex  57.1% (24)  77.8% (14)  .129 
Aortic dissection  80.9% (34)  77.8% (14)  .720 
Hypertension  17.1% (7)  22.2% (4)   
DTTA rupture  2.4% (1)   
73.8% (31)  77.8% (14)  .745 
26.8% (10)  22.2% (4)   
Risk factors
Hypertension  76.2% (32)  55.6% (10)  .169 
Diabetes mellitus  7.2% (3)  5.6% (1)  .821 
Hypercholesterolemia  45.2% (19)  22.2% (4)  .172 
Smoking  28.6% (12)  27.8% (5)  .950 
COPD  11.9% (5)  5.6% (1)  .453 
Chronic kidney failure  2.4% (1)  5.6% (1)  .530 
Aortic aneurysm  5.4% (2)  11.1% (2)  .445 
Signs, symptoms, and complications on admission
SBP, mmHg  134.6±6.5  132.3±8.8  .840 
Chest pain  80.5% (33)  88.9% (16)  .428 
Syncope  19.1% (8)  11.1% (2)  .450 
Neurological deficit  16.7% (7)  27.8% (5)  .324 
Pulse deficit  19.1% (8)  22.2% (4)  .778 
Peripheral ischemia  12.8% (5)  27.8% (5)  .168 
Acute kidney failure  15.8% (6)  22.2% (4)  .557 
Myocardial infarction  12.8% (5)  11.1% (2)  .855 
Shock  23.1% (9)  16.7% (3)  .581 
Tamponade  19.5% (8)  16.7% (3)  .796 
Need for intubation  7.5% (3)  5.6% (1)  .787 
Other studies
Normal electrocardiogram  52.4% (22)  61.1% (11)  .533 
Normal chest radiograph  7.3% (3)  5.88% (1)  .844 
Hemopericardium  28.6% (12)  33.3% (6)  .712 
Pleural effusion  23.8% (10)  23.5% (4)  .982 
Hemomediastinum  14.3% (6)  18.8% (3)  .675 
Hemothorax  7.2% (3)  0% (0)  .550 
Periaortic hematoma  31% (13)  29.4% (5)  .907 
Supraortic branch involvement  48.8% (20)  58.8% (10)  .486 
True lumen compression  60% (21)  43.8% (7)  .279 
Renal artery involvement  48.8% (20)  35.3% (6)  .347 
D-dimer level, ng/mL  7187 (4230-54 411)  6817 (2390-49 739)  .871 
Maximal aortic diameter, mm  50.3±51±3.3  .836 
Maximal AIH thickness, mm  12±1.4  17.4±4.9  .197 

AIH, aortic intramural hematoma; COPD, chronic obstructive pulmonary disease; DTAA, descending thoracic aortic aneurysm; SBP, systolic blood pressure.

Following the implementation of the Aorta Code project, the number of patients diagnosed with AAS doubled (from a mean of 1 patient a month to 2 patients a month). No significant differences were observed between the groups for the presence of risk factors, imaging findings, or clinical presentations (table 1). Transfer times to the hospital were also significantly reduced (table 2). There were no significant differences between the groups for time from first symptom to diagnosis or time from diagnosis to surgery. Preoperative AAS complication rates also decreased (table 2).

Table 2.

Treatment and prognosis of patients with acute aortic syndrome during care-as-usual and after implementation of the Aorta Code project

Variable  Aorta Code (n=42)  Care-as-usual (n=18)  P 
Time from symptoms to diagnosis, h  4.2 (1.01-8.9)  5.8 (2.5-9.6)  .508 
Transfer time, min  150 (114-196)  259 (180-273)  .046 
Medical  26.2% (11)  22.2% (4)  .745 
Surgical  64.3% (27)  77.8% (14)  .303 
Endovascular  14.3% (6)  0% (0)  .091 
Complicated AAS before surgery  40.7% (11)  76.9% (10)  .046 
Type A AAS surgery  87.1% (27)  92.8% (13)  .569 
Surgery (segments)
Valve  40.7% (11)  30.8% (4)  .542 
Root  70.4% (19)  38.5% (5)  .054 
Ascending aorta  92.6% (24)  92.3% (12)  .974 
Hemiarch  9.5% (2)  30.8% (4)  .114 
Complete arch in type 1 AAS  72.2% (13)  40% (4)  .094 
Time in cardiocirculatory arrest, min  27.8±2.9  30.7±4.9  .593 
Preoperative complications
Kidney failure  55.6% (15)  53.9% (7)  .919 
Mesenteric ischemia  11.1% (3)  15.4% (2)  .702 
Peripheral ischemia  7.4% (2)  > .999 
Tamponade  11.1% (3)  7.7% (1)  .736 
Myocardial infarction  7.4% (2)  .314 
Neurological complications  37.1% (10)  30.8% (4)  .697 
Reoperation  29.6% (8)  23.1% (3)  .664 
Overall mortality  23.8% (10)  22.2% (4)  .894 
Surgical mortality  22.2% (6)  30.8% (4)  .559 

AAS, acute aortic syndrome.

Complicated AAS: occurrence of any of the following complications before surgery for AAS: poor perfusion, kidney failure, myocardial infarction, tamponade, shock, and neurological complications.

The number of surgeons treating patients diagnosed with AAS fell from 13 (7 cardiac and 6 vascular surgeons) during care-as-usual to 4 (2 cardiac and 2 vascular surgeons) during the project. Sixty percent of patients with type A AAS were treated with the Bentall-De Bono procedure during the care-as-usual period. This percentage fell to 42% after implementation of the project, as 58% were treated with aortic root repair surgery. There was also a relative increase of 80% in the number of complete aortic arch procedures performed (P=.09) (table 2). The project achieved a relative reduction of 28% in surgery mortality rates compared with care-as-usual, although the difference was nonsignificant (risk difference, 8.5%; odds ratio=0.64; 95% confidence interval, 0.15-2.6; P=.559). There were no differences between the groups in overall mortality.

The clinical presentation of AAS is variable and often leads to diagnostic errors.3 Implementation of the Aorta Code project improved the knowledge and skills of emergency service physicians and increased the number of AAS diagnoses. Although management of acute aortic disease by a small team of dedicated surgeons at a limited number of specialized centers has been found to improve survival outcomes,4 our project is the first of its kind to be implemented in Spain. The Aorta Code project has had 2 main effects: a) it has increased the complexity of surgical procedures (by assigning all interventions to just 2 surgeons) and b) it has reduced surgical mortality rates, although the difference with care-as-usual was not significant due to the small sample. Extending surgical repair to include the aortic arch and root increases complexity, but performance of this surgery by an expert team of surgeons in carefully selected patients does not increase in-hospital morbidity or mortality and reduces the need for reoperation in the mid- to long-term, thereby improving prognosis.5

In conclusion, a) the creation of a health care network for patients with AAS is feasible and requires the extensive involvement of emergency departments and response services and the creation of a team of experts in aortic conditions, b) the Aorta Code project has improved the diagnosis of AAS and shortened transfer times to the referral hospital, and c) the performance of AAS surgery by a small team of highly specialized surgeons has improved outcomes.


No funding was received for this study.


C. Ferrera, I. Vilacosta, P. Busca, A. Martín Martínez, F.J. Serrano, and L. Maroto Castellanos contributed significantly to the collection and interpretation of data. C. Ferrera analyzed the data. C. Ferrera and I. Vilacosta wrote the first version of the manuscript. All the authors revised the full manuscript and approved its final version. All the authors agree on the content of the article and guarantee the veracity and accuracy of all parts of this study. The authors declare that they are responsible for the content of this study.

Conflicts of Interest



Julián Pérez Villacastín, Marian Bas, Christian Bengoa, Ana Cortés Martínez, J. Alberto García Lledó, Inmaculada Fernández Rozas, Alejandro Curcio, and Carlos Macaya.

Appendix A
APPENDIX. Researchers from the Multidisciplinary Aorta Code CardioRed1 Group

Carlos Ferrera, Ana Carrero, Alfonso Martín, Francisco Javier Martín Sánchez, María Jesús Domínguez García, Pablo Busca, Fátima Fernández Salgado, Isaac Martínez, Javier Cobiella, Francisco Javier Noriega, Ana Viana Tejedor, Francisco Javier Serrano Hernando, Luis Carlos Maroto Castellanos, Isidre Vilacosta.

A. Evangelista, J.M. Rabasa, V.X. Mosquera, et al.
Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).
Eur Heart J Acute Cardiovasc Care., 7 (2018), pp. 602-608
I. Vilacosta, C. Ferrera, L.C. Maroto Castellanos, J. Pérez-Villacastín, M. Bas Villalobos, C. Bengoa.
Código Aorta Planificación/Ejecución/Resultados [internet].
Fundación Interhospitalaria Investigación Cardiovascular (FIC) y Fundación Para la Investigación Biomédica del Hospital Clínico San Carlos (FIB), Madrid (España), (2020),
L. Zaschke, H. Habazettl, J. Thurau, et al.
Acute type A aortic dissection: Aortic Dissection Detection Risk Score in emergency care — surgical delay because of initial misdiagnosis.
Eur Heart J Acute Cardiovasc Care., 9 (2020), pp. S40-S47
N.D. Andersen, A.M. Ganapathi, J.M. Hanna, J.B. Williams, J.G. Gaca, G.C. Hughes.
Outcomes of acute type a dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program.
J Am Coll Cardiol., 63 (2014), pp. 1796-1803
M. Czearny, J. Schmidli, S. Adler, et al.
Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS).
Eur J Cardiothorac Surg., 55 (2019), pp. 133-162

See the Appendix for the full list of researchers from the Multidisciplinary Aorta Code CardioRed1 Group.

Copyright © 2021. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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