Thorac cardiovasc Surg 2011; 59(5): 259-267
DOI: 10.1055/s-0030-1271191
Special Reports

© Georg Thieme Verlag KG Stuttgart · New York

Cardiac Surgery in Germany during 2010: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

J. F. Gummert1 , A. K. Funkat2 , A. Beckmann3 , M. Ernst4 , K. Hekmat5 , F. Beyersdorf6 , W. Schiller7
  • 1Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
  • 2Department of Cardiac Surgery, University Leipzig, Heartcenter, Leipzig, Germany
  • 3German Society for Thoracic and Cardiovascular Surgery, Berlin, Germany
  • 4Department of Thoracic and Cardiovascular Surgery, University Kiel, Kiel, Germany
  • 5Department of Cardiac and Thoracic Surgery, Friedrich Schiller University Jena, Jena, Germany
  • 6Department of Cardiovascular Surgery, University Medical Center Freiburg, Freiburg, Germany
  • 7Department of Cardiac Surgery, University Bonn, Bonn, Germany
Further Information

Prof. Dr. med. J. Gummert

Herz- und Diabeteszentrum Nordrhein-Westfalen
Universitätsklinik der Ruhr
Universität Bochum

Georgstraße 11

32545 Bad Oeynhausen

Germany

Phone: +49 57 31 97 13 31

Fax: +49 57 31 97 18 20

Email: jgummert@hdz-nrw.de

Publication History

received May 15, 2011

accepted May 16, 2011

Publication Date:
10 June 2011 (eFirst)

Table of Contents #

Abstract

All cardiac surgical procedures performed in 79 German cardiac surgical units throughout the year 2010 are presented in this report, based on a voluntary registry which is organized by the German Society for Thoracic and Cardiovascular Surgery. In 2010 a total of 95 734 cardiac surgical procedures (ICD and pacemaker procedures excluded) have been collected in this registry. More than 12.4 % of the patients were older than 80 years compared to 11.8 % in 2009. Hospital mortality in 42 804 isolated CABG procedures (14.2 % off-pump procedures) was 2.8 %. In 25 127 isolated valve procedures (including 3660 transcatheter-valve implantations) a mortality of 4.9 % has been observed. This voluntary registry of the German Society for Thoracic and Cardiovascular Surgery will continue to be an important tool enabling quality control and illustrating the development of cardiac surgery in Germany.

#

Introduction

Increasing demands for quality assurance in medicine – by patients, relatives, insurance companies and authorities all over the world – have stimulated the development of a wide range of registries and other tools [1], [2], [3], [4], [5], [6] to answer those needs. As early as in 1978 the German Society for Thoracic and Cardiovascular Surgery decided to set up a voluntary registry for cardiac surgical procedures. The aim of this registry continues to illustrate the development of cardiac surgery in Germany and to allow each individual cardiac surgical unit to compare its own results to the nationwide results.

Innovative technologies as minimal invasive mitral valve surgery, off-pump surgery and transapical or transvascular aortic valve replacement ([Table V2]) have been included in the registry to monitor the development in these fields, important for the future of our speciality.

The registry data have been published since 1989 [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. The following report contains the collected data for the year 2010.

#

Material and Methods

Since 2004 the standardized questionnaire asks for detailed information about each individual procedure exactly defined by one or more operation codes (OPS).

All centers were asked to complete the questionnaire until January 21, 2011 asking for all performed procedures and associated hospital mortality in each institution. The questionnaires were sent to the German Society of Thoracic and Cardiovascular Surgery, evaluated for completeness and compiled for further analysis thus ensuring anonymity for the individual center. This compilation algorithm guaranties a high compliance for submission of the complete data set, as demonstrated by a 100 % completeness each year.

Inclusion criteria for the registry 2010 were all individual surgical procedures performed between January 1, 2010 and December 31, 2010, unrelated to admission or discharge dates as compared to other registries.

Alike to all previous years the number of procedures was counted, not individual patients, e.g., a patient requiring additional coronary surgery due to a complication after aortic valve replacement during the same admission would be counted in the category “aortic valve replacement” and in the category “coronary surgery”. Thus the registry contains more procedures than the actual number of patients operated on.

Mortality was defined as in-hospital mortality. Per definition the observed mortality was attributed to the first cardiac surgery procedure, e.g., the death of a patient requiring additional coronary surgery due to a complication after aortic valve replacement during the same admission would be attributed only to the aortic valve group, but not to the coronary surgery group.

The main reason for this structural setup of the registry – like in previous years – was getting detailed information on all performed procedures and not only the number of treated patients. Another reason was to simplify the process of data acquisition thus enabling all cardiac surgery units in Germany – regardless of the existing hard- and software used for data management in individual units – to submit a complete data set.

As in previous years (except for 2008) all units answered the questionnaire and delivered a complete data set for the year 2010 including hospital mortality rates. In 2010 the total number of units has decreased from 80 to 79.

#

Registry 2010

[Table 1] demonstrates the development of procedures using cardiopulmonary bypass (CPB) over the past 30 years in Germany. The number of heart surgery procedures has stabilized.

Table 1 Development of frequency in open heart procedures with CPB in Germany from 1978 to 2010 (1978–1985: Federal Republic of Germany [West Germany] only).

Year

1978

1980

1985

1990

1995

2002

2005

2006

2007

2008

2009

2010

Total number of units

21

21

33

46

76

79

79

80

80

79

80

79

Total number of operations

8 365

10 680

21 705

38 783

78 184

96 194

91 967

91 057

91 618

89 773

86 916

84 686

Average per unit

398

509

658

843

1 029

1 218

1 164

1 138

1 145

1 136

1 086

1 072

Overall, 166 621 procedures were reported to the registry for the year 2010, an increase of 2.6 % (2009: 162 417 procedures). A total of 98 577 cardiac surgical procedures (excluded: ICD, pacemakers and miscellaneous procedures without CPB) displayed a decrease of 0.01 % (n = 14) compared to the year 2009 (98 563 procedures) ([Table 2]). The following tables and figures ([Tables 3]–[6], [Tables V1], [V2], [V3], [V4], [V5], [V6], [V7], [Tables C1], [C2], [C3], [C4], [Tables Con1] and [Con2], [Tables Mis1], [Mis2], [Mis3], [Mis4], [Mis5] and [Figs. 1], [2], [3], [4], [5], [6], [7], [8], [9]) represent the compiled data of the registry 2010 for the various subcategories.

Table 2 Total results of all 79 units performing cardiac surgery in 2010. The % indicates changes compared to 2009.

Category

With CPB

Without CPB

Total

% Change

Valve procedures

21 554

3 573

25 127

+6.7 %

Coronary surgery

49 549

6 444

55 993

−4.3 %

Congenital lesion

4 691

1 031

5 722

+7.6 %

Surgery of thoracic aorta

6 342

426

6 768

+7.5 %

Other cardiac surgery

1 398

1 182

2 580

−10.2 %

Assist devices

689

1 235

1 924

+31.2 %

Pacemaker and ICD

71

24 784

24 855

+4.7 %

Extracardiac surgery

392

43 260

43 652

+7.3 %

Total

84 686

81 935

166 621

+2.6 %

Table 3 Distribution of individual units according to the number of cardiac surgery procedures with or without CPB.

Number of operations

< 500

500–999*

1 000–1 499

1 500–1 999

2 000–5 000

Number of units

9

21

29

13

7

Average per unit

353

773

1 156

1 722

2 916

Min-max

167–479

518–986

1 003–1 482

1 571–1 932

2 186–3 865

* One unit performs pediatric cardiac surgery only

Table 4 Distribution of units according to surgical profiles in 2010.

Type of surgery performed

Number of units

Coronary surgery

78

Valve surgery

78

Surgery of congenital heart diseases with CPB in children < 1 year

26*

Heart transplantation

24**

Heart-lung transplantation

5

* Surgery of congenital heart disease with CPB in children < 1 year (n = 1 975); thereof: 3–6 operations in 3 units, 20–46 operations in 8 units, 54–97 operations in 8 units, 126–262 operations in 7 units; ** Heart transplantations (n = 379): 78 % of the total annual heart transplantations are performed by 10 of 24 units with > = 15 HTx per year; thereof: 1–4 transplants in 6 units, 6–9 transplants in 5 units, 10–18 transplants in 7 units, 22–63 transplants in 6 units

Table 5 Additional demographic data of procedures with CPB in 2010 and 2009. The numbers in each category reflect procedures and not individual patients.

Demographic data

2010

2009

Emergency operations

11 850

12.0 %

11 414

11.6 %

Redo procedures

8 458

8.6 %

8 584

8.7 %

Age > 69 years*

93 646

52.2 %

93 288

50.8 %

Table 6 Gender distribution. All coronary surgery (49 549 on-pump and 6 444 off-pump procedures) and all congenital surgery procedures are included in this table.

Male/female ratio among cardiac procedures

Valve procedures

56 %

44 %

Coronary surgery

75 %

25 %

Congenital surgery

54 %

46 %

Surgery of thoracic aorta

68 %

32 %

Other cardiac surgery

45 %

55 %

Assist devices

71 %

29 %

Pacemaker and ICD

64 %

36 %

Extracardiac surgery

64 %

36 %

Total

66 %

34 %

Table V1 Isolated valve procedures. Combination procedures (CABG and aortic surgery) are not included. Transcatheter access: 3 629 aortic valve implantations; 6 mitral valve implantations; 23 mitral valve annuloplasties; 1 double aortic and mitral valve procedure;1 pulmonary valve implantation.

Procedures

n

Deaths

%

Single

17 545

612

3.5

Double

3 466

273

7.9

Triple

344

42

12.2

Transcatheter access

3 660

284

7.8

Not specified

112

8

7.1

Total

25 127

935

3.7

Table V2 Single valve procedures. 2 062 (38.6 %) mitral valve procedures were done using a minimally invasive access. The number of isolated aortic valve procedures by sternotomy decreased from 11 981 procedures in 2009 to 11 689 in 2010, perhaps as an effect of the increase in catheter-based valve implantations (2010: n = 3 629, 2009: n = 2 198).

Position

n

Deaths

%

Aortic sternotomy

10 225

319

3.1

Aortic part. sternotomy

1 464

33

2.3

Aortic transvascular

1 450

111

7.7

Aortic transapical

2 179

173

7.9

Mitral sternotomy

3 279

178

5.4

Mitral mic

2 062

38

1.8

Mitral transcatheter

29

0

0.0

Tricuspidal sternotomy

388

35

9.0

Tricuspidal mic

83

8

9.6

Pulmonary sternotomy

44

1

2.3

Pulmonary mic

0

Pulmonary transcatheter

1

0

0.0

Total

21 204

896

4.2

Table V3 Isolated aortic valve procedures. Out of 11 689 procedures, 1 464 (12.5 %) were done by a partial sternotomy access. Transcatheter procedures are not included.

Type of valve

n

Deaths

%

Prosthesis

1 840

27

1.5

Xenograft

9 704

323

3.3

Homograft

38

1

2.6

Reconstruction

107

1

0.9

Total

11 689

352

3.0

Table V4 Isolated mitral valve procedures. Out of 5 341 procedures, 2 062 (38.6 %) were done using a minimally invasive access.

Type of valve

n

Deaths

%

Prosthesis

598

37

6.2

Xenograft

1 292

116

9.0

Homograft

11

2

18.2

Reconstruction

3 440

61

1.8

Total

5 341

216

4.0

Table V5 Multiple valve procedures. Transcatheter procedures are not included.

Combination

n

Deaths

%

Aortic + mitral

1 770

132

7.5

Mitral + tricuspid

1 333

113

8.5

Aortic + tricuspid

211

22

10.4

Tricuspid + pulmonary

6

0

0.0

Aortic + pulmonary*

146

6

4.1

Aortic + mitral + tricuspid

344

42

12.2

Aortic + mitral + pulmonary

0

0

Total

3 810

315

8.3

* Including Ross procedures

Table V6 Mitral valve surgery – replacement vs. reconstruction.

Total

Replacement

Reconstruction

Mitral valve surgery

n

Deaths

% Death

% Reconstruction

n

Deaths

% death

n

Deaths

% Death

Isolated

5 341

216

4.0

64.4

1 901

155

8.2

3 440

61

1.8

MV +

  • aortic valve

1 770

132

7.5

61.1

688

94

13.7

1 082

38

3.5

  • tricuspid valve reconstruction*

1 296

109

8.4

61.0

483

56

11.6

813

53

6.5

  • CABG

2 588

252

9.7

68.5

816

103

12.6

1 772

149

8.4

  • CABG + aortic valve replacement

921

92

10.0

70.8

269

47

17.5

652

45

6.9

Total

11 916

801

6.7

64.9

4 157

455

10.9

7 759

346

4.5

* 37 procedures (not specified mitral valve + tricuspid valve surgery) excluded. Deaths %: 10.8 (4/37)

Table V7 Overview valve surgery.

Aortic valve replacement

26 208

Isolated valve surgery

11 544

Mechanical prosthesis

1 840

Xeno graft

9 704

Combination (valve)1

2 282

Combination (valve + CABG)1

8 753

Transfemoral

1 450

Transapical

2 179

Mitral valve surgery

11 873

Replacement

4 146

Mechanical prothesis

598

Xeno graft

1 292

Combination (valve)1

1 171

Combination (valve + CABG)1

1 085

Reconstruction

7 728

Isolated mitral valve surgery

3 440

Combination (valve)

1 864

Combination (valve + CABG)

2 424

Tricuspid valve surgery 2

1 961

Isolated replacement (xeno)

111

Isolated replacement (mechanical)

27

Reconstruction (isolated)

332

Reconstruction (combined – valve)

1 491

1 Currently it is not possible to distinguish between mechanical prosthesis and xenografts in combination procedures. 2 Currently it is not possible to separate combined CABG and tricuspid valve procedures

Table C1 Isolated CABG surgery with CPB and combined procedures with CPB.

Procedures

n

Deaths

%

CABG

42 804

1 212

2.8

CABG +

TMLR

41

2

4.9

  • aneurysma resection

224

12

5.4

  • aortic valve replacement

7 832

436

5.6

  • transcatheter aortic valve implantation

18

7

38.9

  • mitral valve replacement

816

103

12.6

  • mitral valve repair

1 772

149

8.4

  • aortic + mitral valve replacement

269

47

17.5

  • aortic valve replacement + mitral valve repair

652

45

6.9

  • other

1 565

108

6.9

Total

55 993

2 121

3.8

Table C2 Isolated CABG surgery with CPB.

Number of grafts

n

Deaths

%

Single

1 227

72

5.9

Double

7 985

282

3.5

Triple

15 752

469

3.0

Quadruple

8 812

227

2.6

Quintuple + more

2 935

58

2.0

Total

36 711

1 108

3.0

Table C3 Off-pump Isolated CABG surgery.

Number of grafts

n

Deaths

%

Single

1 502

31

2.1

Double

1 842

35

1.9

Triple

1 987

31

1.6

Quadruple

533

7

1.3

Quintuple + more

229

0

0.0

Total

6 093

104

1.7

Table C4 Transmyocardial laser revascularization (TMRL).

Procedures

n

Deaths

%

TMLR with ACB

28

1

3.6

TMLR without ACB

13

1

7.7

Total

41

2

4.9

Table Con1 Age distribution among procedures for the correction of congenital heart defects.

Age

n

Deaths

%

A) Without CPB

  • over 18 years

82

1

1.2

  • 1–17 years

172

1

0.6

  • under 1 year

777

23

3.0

Total A

1 031

25

2.4

B) With CPB

  • over 18 years

936

23

2.5

  • 1–17 years

1 780

19

1.1

  • under 1 year

1 975

82

4.2

Total B

4 691

124

2.6

Table Con2 Procedures for the correction of congenital heart defects with and without CPB.

Age < 1 year

Age 1 to under 18 years

Age > = 18 years

Lesion

n

Deaths

%

n

Deaths

%

n

Deaths

%

ASD

63

0

0.0

303

0

0.0

246

4

1.6

Complete AV-canal

168

1

0.6

65

1

1.5

15

0

0.0

VSD

362

2

0.6

136

0

0.0

36

1

2.8

Fallot's tetralogy

169

3

1.8

28

0

0.0

1

0

0.0

DORV

63

1

1.6

15

0

0.0

1

0

0.0

TGA

119

3

2.5

11

0

0.0

0

0

TGA + VSD

62

1

1.6

4

0

0.0

0

0

Truncus arteriosus

29

2

6.9

10

0

0.0

1

0

0.0

Fontan

1

0

0.0

246

4

1.6

14

2

14.3

Norwood

146

16

11.0

2

1

50.0

0

0

Pulmonary valve

63

3

4.8

219

3

1.4

81

1

1.2

Transcatheter pulmonary valve implantation

0

0

1

0

0.0

7

0

0.0

Aortic valve

48

2

4.2

195

1

0.5

315

5

1.6

Ross procedure

13

4

30.8

30

0

0.0

43

0

0.0

Mitral valve

26

0

0.0

107

0

0.0

57

3

5.3

Tricuspid valve

60

1

1.7

68

1

1.5

60

7

11.7

PDA

329

15

4.6

20

1

5.0

9

0

0.0

Coarctation

198

1

0.5

33

0

0.0

10

0

0.0

Transpl. heart

8

2

25.0

34

1

2.9

0

0

Transpl. heart + lung

0

0

2

0

0.0

0

0

Transpl. lung

0

0

11

1

9.1

0

0

Others

825

52

6.3

412

13

3.2

122

1

0.8

Total

2 752

109

4.0

1 952

27

1.4

1 018

24

2.4

Table Mis1 Development of Ross procedures in various age groups.

Autologous aortic valve replacement (ROSS procedure)

n (2010)

n (2009)

n (2008)

n (2007)

n (2006)

n (2005)

n (2004)

n (2003)

n (2002)

n (2001)

In patients > = 18 years

184

175

207

261

228

235

250

170

163

140

In patients < 18 years

43

54

42

34

50

46

50

37

61

41

Total

227

229

249

295

278

281

300

207

224

181

Table Mis2 Transplantation. All pediatric transplantations (demonstrated in [Table Con2]) are included in this table. Eurotransplant (ET) has reported for the same period 368 heart transplantations (HTx), 6 heart + kidney transplantations, 1 heart + liver transplantations, 15 heart-lung transplantations (HLTx), 237 double lung (DLTx), 44 single-lung transplantations (SLTx), 1 lung + kidney transplantations and 0 lung + liver transplantations. The differences (ET: − 11 LTx, − 3 HTx) may be explained by different inclusion criteria (time of transplantation) for the registry and the ET database.

Transplantation

With CPB

Without CPB

n

Deaths

%

n

Deaths

%

Heart

379

44

11.6

Heart + lung

16

3

18.8

Lung

83

18

21.7

183

11

6.0

Table Mis3 Aortic Surgery. All procedures involving aortic surgery are included in this table. Isolated aortic surgery as well as all possible combination procedures (e.g., additional coronary surgery) are summarized in this category.

Aortic surgery*

With CPB

Without CPB

n

Deaths

%

n

Deaths

%

Supracoronary ascending

1 483

115

7.8

Infracoronary ascending

  • mechanical valve conduits

626

45

7.2

  • biological valve conduits

678

72

10.6

  • David

476

10

2.1

  • Yacoub

125

5

4.0

  • other

275

23

8.4

Supracoronary ascending + aortic valve replacement

1 166

60

5.1

Aortic arch replacement**

1 316

140

10.6

Descending

99

10

10.1

15

3

20.0

Thoracoabdominal

91

10

11.0

55

11

20.0

Endostent descending

7

1

14.3

356

25

7.0

Total

6 342

491

7.7

426

39

9.2

*Abdominal aortic surgery is not included: 617 abdominal and 389 endostent abdominal. ** All possible combined procedures are included in this category; the only common denominator is aortic arch surgery

Table Mis4 Pacemaker and ICD implantation.

Pacemaker and ICD

With CPB

Without CPB

Total

Deaths

Death %

n

Deaths

n

Deaths

Pacemaker: implantation

9 223

59

0.6

3

0

9 220

59

Pacemaker: battery exchange

1 974

2

0.1

3

0

1 971

2

Pacemaker: revision

2 828

12

0.4

39

0

2 789

12

ICD: implantation

5 380

14

0.3

2

0

5 378

14

ICD: battery exchange

1 946

3

0.2

0

0

1 946

3

ICD: revision

2 853

23

0.8

22

2

2 831

21

Miscellaneous

651

2

0.3

2

0

649

2

Total

24 855

115

0.5

71

2

24 784

113

Table Mis5 Surgical atrial ablation. Included in this table are all isolated ablation procedures and all possible combination procedures (e.g., CABG + ablation). Total of n = 343 procedures are not specified with regard to endocardiac/epicardiac ablation.

Energy

Total

Endocardiac ablation (n)

Endocardiac ablation (n)

unipolar radiofrequency

315

283

32

unipolar cryo-radiofrequency

532

327

205

bipolar radiofrequency

1 621

193

1 428

Cryothermy

1 494

1 136

358

Microwave

56

8

48

Focused ultrasound

465

48

417

Laser

0

0

0

other

19

1

18

Total

4 502

1 996

2 506

Zoom Image

Fig. 1 Development of cardiac surgery in Germany between 1994 and 2010. 1) Coronary surgery and combined procedures include all types of isolated coronary surgery with or without CPB and any combined procedures. 2) Valve procedures include all types of isolated valvular surgery. Combinations of aortic surgery and valve procedures are summarized in the miscellaneous group. 3) Congenital surgery includes all types of procedures with or without CPB. ASD repair in adults in combination with coronary or valve surgery are summarized in the coronary or valve surgery group. 4) Miscellaneous includes all other types of procedures with CPB.

Zoom Image

Fig. 2 The number of coronary artery bypass procedures is continuously declining since the year 2000. The proportion of off-pump procedures has slightly increased compared to previous years but still has not reached the percentage as in other comparable countries.

Zoom Image

Fig. 3 Isolated aortic valve replacement between 1994 and 2010 in Germany. The number of xenovalve replacements is steadily increasing. There is a marked difference in mortality which is probably age related. Ross procedures, homograft procedures and transcatheter valve implantations are excluded in this overview.

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Fig. 4 Isolated aortic valve replacement via sternotomy or catheter-based procedures. The figure shows the significant increase in catheter-based procedures. In 2010 more than 23 % of isolated aortic valve procedure were performed using a vascular or transapical approach. This development underlines that the new found national aortic valve registry is mandatory to get valid information to further evaluate this development.

Several figures highlight important developments of cardiac surgery in Germany over the last decade. Remarkable is the development of age distribution over the last 15 years ([Fig. 5]) with presently 52.2 % of the cardiac procedures in patients 70 years or older and 12.4 % in patients 80 years or older. However, mortality has been the same or even decreased slightly over the past 15 years (e.g,, isolated aortic valve replacement 4.1 % in 1994, 2.9 % in 2009, 3.0 % in 2010, isolated CABG 3.1 % in 1994, 2.8 % in 2009 and in 2010). The proportion of off-pump coronary bypass procedures has increased to 14.2 % (2009: 13.1 %).

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Fig. 5 Age distribution of cardiac procedures (without ICD and pacemaker) over the last 15 years. Currently more than 50 % of the patients are older than 70 years. Patients younger than 20 years are excluded.

Another remarkable evolution is the steady increase of mitral valve reconstruction over the last 16 years. Since 2004 more than 50 % of isolated mitral valve procedures are reconstructions, in 2010 mitral valves could be reconstructed in more than 64 % ([Fig. 7]). It is important for the interpretation of this figure that due to the data collection method (OPS) all isolated mitral valve procedures including all patients with mitral valve stenosis, valve calcification, endocarditis and emergency procedures are included. Operation codes give no information about the underlying disease. The reconstruction rate is certainly higher if only patients are included where a reconstruction would be feasible. In other publications, e.g., Gammie et al. [27] the reconstruction rate must be interpreted with caution compared to this data since patients with mitral valve stenosis, endocarditis and emergency procedures were excluded.

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Fig. 6 Distribution of urgency 1994 and 2010. The incidence of emergency procedures has not changed significantly.

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Fig. 7 Isolated mitral valve surgery over the last 15 years. More reconstructions (64 %) than replacements (36 %) were performed. In 1994 the percentage of reconstructions was only 21 %. It is important for the interpretation of this figure that due to the data collection method all isolated mitral valve procedures including all patients with mitral valve stenosis, valve calcification, endocarditis and emergency procedures are included. The reconstruction rate is certainly higher if only patients where a reconstruction would be feasible were included. In other publications, e.g. Gammie et al. the reconstruction rate must be interpreted with caution compared to this data since patients with mitral valve stenosis, endocarditis and emergency procedures were excluded.

The increase of left ventricular assist device implantation ([Fig. 9]) emphasizes the increasing relevance of mechanical circulatory support.

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Fig. 8 Development of congenital surgery in Germany over the last 14 years. The downward tendency in the age groups below 18 years reached in 2006 its lowest point. In these age groups the number of surgical procedures is slightly increasing since then. In patients older than 17 years there may be a bias since not all procedures are necessarily counted as congenital surgery (e.g., aortic valve surgery).

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Fig. 9 Development of mechanical circulatory support in Germany over the last 7 years. There is a significant increase in left ventricular assist devices (LVAD). However, the number of paracorporal biventricular support systems (BVAD) is only slowly growing and the number of total artificial hearts (TAH) has decreased.

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Discussion

This report enables a comprehensive overview of all cardiac surgical procedures performed in Germany in 2010. The accuracy of this registry is thought to be high due to the implemented compilation algorithm using operation codes (OPS). This is supported by other authors who could demonstrate a high accuracy for major outcome parameters in unaudited registries [28]. Alike to previous years we can conclude that cardiac surgery is performed on a high level with a low in hospital mortality compared to other international registries. This observation is important in an era of continuously increasing patient age and comorbidities, both leading to a higher perioperative risk profile.

Compared to 2009 the number of cardiac surgery procedures has stabilized due to the high volume of transcatheter aortic valve implantations.

Further improvements for the structure of the registry are necessary to allow a more detailed and risk adjusted analysis of the data. However, significant structural changes of the registry have to ensure data compatibility to allow further longitudinal data analysis.

The future of this voluntary registry as well as its further development will depend on continuous efforts of each individual cardiac surgical unit. This will be of outstanding importance to guarantee the ongoing high quality of cardiac surgery in Germany.

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Acknowledgement

On behalf of the German Society for Thoracic and Cardiovascular Surgery the authors would like to thank the chairmen and their coworkers of all cardiac surgery units in Germany for their continuous cooperation and support for realizing this registry report. The authors would like to thank Mrs. J. Lewandowski for her excellent support in data collection.

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References

Prof. Dr. med. J. Gummert

Herz- und Diabeteszentrum Nordrhein-Westfalen
Universitätsklinik der Ruhr
Universität Bochum

Georgstraße 11

32545 Bad Oeynhausen

Germany

Phone: +49 57 31 97 13 31

Fax: +49 57 31 97 18 20

Email: jgummert@hdz-nrw.de

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References

Prof. Dr. med. J. Gummert

Herz- und Diabeteszentrum Nordrhein-Westfalen
Universitätsklinik der Ruhr
Universität Bochum

Georgstraße 11

32545 Bad Oeynhausen

Germany

Phone: +49 57 31 97 13 31

Fax: +49 57 31 97 18 20

Email: jgummert@hdz-nrw.de

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Fig. 1 Development of cardiac surgery in Germany between 1994 and 2010. 1) Coronary surgery and combined procedures include all types of isolated coronary surgery with or without CPB and any combined procedures. 2) Valve procedures include all types of isolated valvular surgery. Combinations of aortic surgery and valve procedures are summarized in the miscellaneous group. 3) Congenital surgery includes all types of procedures with or without CPB. ASD repair in adults in combination with coronary or valve surgery are summarized in the coronary or valve surgery group. 4) Miscellaneous includes all other types of procedures with CPB.

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Fig. 2 The number of coronary artery bypass procedures is continuously declining since the year 2000. The proportion of off-pump procedures has slightly increased compared to previous years but still has not reached the percentage as in other comparable countries.

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Fig. 3 Isolated aortic valve replacement between 1994 and 2010 in Germany. The number of xenovalve replacements is steadily increasing. There is a marked difference in mortality which is probably age related. Ross procedures, homograft procedures and transcatheter valve implantations are excluded in this overview.

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Fig. 4 Isolated aortic valve replacement via sternotomy or catheter-based procedures. The figure shows the significant increase in catheter-based procedures. In 2010 more than 23 % of isolated aortic valve procedure were performed using a vascular or transapical approach. This development underlines that the new found national aortic valve registry is mandatory to get valid information to further evaluate this development.

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Fig. 5 Age distribution of cardiac procedures (without ICD and pacemaker) over the last 15 years. Currently more than 50 % of the patients are older than 70 years. Patients younger than 20 years are excluded.

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Fig. 6 Distribution of urgency 1994 and 2010. The incidence of emergency procedures has not changed significantly.

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Fig. 7 Isolated mitral valve surgery over the last 15 years. More reconstructions (64 %) than replacements (36 %) were performed. In 1994 the percentage of reconstructions was only 21 %. It is important for the interpretation of this figure that due to the data collection method all isolated mitral valve procedures including all patients with mitral valve stenosis, valve calcification, endocarditis and emergency procedures are included. The reconstruction rate is certainly higher if only patients where a reconstruction would be feasible were included. In other publications, e.g. Gammie et al. the reconstruction rate must be interpreted with caution compared to this data since patients with mitral valve stenosis, endocarditis and emergency procedures were excluded.

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Fig. 8 Development of congenital surgery in Germany over the last 14 years. The downward tendency in the age groups below 18 years reached in 2006 its lowest point. In these age groups the number of surgical procedures is slightly increasing since then. In patients older than 17 years there may be a bias since not all procedures are necessarily counted as congenital surgery (e.g., aortic valve surgery).

Zoom Image

Fig. 9 Development of mechanical circulatory support in Germany over the last 7 years. There is a significant increase in left ventricular assist devices (LVAD). However, the number of paracorporal biventricular support systems (BVAD) is only slowly growing and the number of total artificial hearts (TAH) has decreased.