Thorac cardiovasc Surg 2012; 60(06): 371-382
DOI: 10.1055/s-0032-1326724
Special Report
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cardiac Surgery in Germany during 2011: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

Anne-Kathrin Funkat
1  Department of Cardiac Surgery, Herzzentrum, University of Leipzig, Leipzig, Germany
,
Andreas Beckmann
2  German Society for Thoracic and Cardiovascular Surgery, Berlin, Germany
,
Jana Lewandowski
2  German Society for Thoracic and Cardiovascular Surgery, Berlin, Germany
,
Michael Frie
3  FOM Hochschule fuer Oekonomie & Management, Essen, Germany
,
Wolfgang Schiller
4  Department of Cardiac Surgery, University Bonn, Bonn, Germany
,
Markus Ernst
5  Department of Thoracic and Cardiovascular Surgery, University Kiel, Kiel, Germany
,
Khosro Hekmat
6  Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
› Author Affiliations
Further Information

Address for correspondence and reprint requests

Anne-Kathrin Funkat, Ph.D.
Department of Cardiac Surgery, Herzzentrum, University of Leipzig
Strümpellstr. 39, Leipzig 04289
Germany   

Publication History

27 July 2012

27 July 2012

Publication Date:
03 September 2012 (eFirst)

 

Abstract

All cardiac surgical procedures performed in 78 German cardiac surgical units throughout the year 2011 are presented in this report, based on a voluntary registry which is organized by the German Society for Thoracic and Cardiovascular Surgery. In 2011, a total of 100,291 cardiac surgical procedures (implantable cardioverter defibrillator and pacemakers procedures excluded) have been collected in this registry. More than 13.4% of the patients were older than 80 years compared with 12.4% in 2010. Hospital mortality in 41,976 isolated coronary artery bypass graft procedures (14.7% off-pump) was 2.9%. In 26,972 isolated valve procedures (including 5,210 catheter-based procedures), an in-hospital mortality of 5.2% 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 current facts and the development of cardiac surgery in Germany.


#

Introduction

Increasing demands for quality control 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 to answer those needs. As early as in 1978, the German Society for Thoracic and Cardiovascular Surgery (www.dgthg.de) 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 still experimental procedures such as transcatheter (transapical or transvascular) aortic valve implantation (TAVI) ([Table V1]) have been included in the registry to monitor the development in this field, important for the future of patient care.

The registry data are published once a year since 1989.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] The following report contains the assorted data for the year 2011.


#

Materials and Methods

Since 2004, the standardized questionnaire asks for detailed information about each individual procedure exactly defined by one or more operation codes (German Operationen- und Prozedurenschlüssel [OPS]).

All centers had to complete the questionnaire until January 20, 2012, asking for all performed procedures and associated hospital mortality in each institution. The completed questionnaires were sent to the office of the German Society for Thoracic and Cardiovascular Surgery in Berlin, and were evaluated for completeness and compiled for further analysis, thus ensuring anonymity for the individual center. The compilation algorithm guaranties a high compliance for submission of the complete dataset.

Inclusion criteria for the registry 2011 were all individual surgical procedures performed between January 1, 2011 and December 31, 2011, unrelated to admission or discharge dates as compared with other registries.

Alike to all previous reports, the number of procedures was counted, not individual patients, for example, 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. As per the definition, the observed mortality was attributed to the first heart surgical procedure, for example, the death of a patient requiring additional coronary artery bypass grafting (CABG) due to a complication after aortic valve replacement during the same admission would be attributed only to the aortic valve 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 counting the number of the treated patients. Another reason was to simplify the process of data acquisition thus enabling all cardiac surgery units in Germany, the submission of a complete dataset, regardless of their existing hardware and software.

In 2011, a total of 79 units performed heart surgery, 78 units answered the questionnaire and delivered a complete dataset for the year 2011 including hospital mortality rates. Due to technical reasons, one unit with ~200 cases could not deliver the data.


#

Registry Data 2011

[Table 1] demonstrates the development of procedures using cardiopulmonary bypass (CPB) over the past 30 years in Germany. The number of heart operations procedures with CPB remains on a stable level.

Table 1

Frequency in Open Heart Procedures in Germany from 1978 to 2011 (1978 to 1985: Federal Republic of Germany [West Germany] Only)

Year

1978

1980

1985

1990

1995

2005

2007

2008

2009

2010

2011

Total Number of Units

21

21

33

46

76

79

80

79

80

79

78

Total Number of Operations

8365

10680

21705

38783

78184

91967

91618

89773

86916

84686

84402

Average Per Unit

398

509

658

843

1029

1164

1145

1136

1086

1072

1082

Overall, 173,347 procedures were reported to the registry for the year 2011, an increase of 4.0% (2010: 166,621 procedures). A total of 100,291 cardiac surgical procedures (excluded: implantable cardioverter defibrillator (ICD), pacemakers, and miscellaneous procedures without CPB) display an increase of 1.74% (n = 1,714) compared with the year of 2010 (98,755 procedures) ([Table 2]). The following tables and figures ([Tables 3] to [6], [Tables V1] to [V7], [Tables C1] to [C3], [Tables Con1] and [Con2], [Tables Mis1] to [Mis5] and [Figs. 1] to [11]) represent the compiled registry data for 2011 classified in individual categories.

Table 2

Total Results of All 78 Units Performing Cardiac Surgery in 2011

Category

With CPB

Without CPB

Total

% Change

Valve Procedures

21887

5085

26972

+ 7.3

Coronary Surgery

48743

6556

55299

− 1.2

Congenital Heart Surgery

4609

990

5599

− 2.1

Surgery of Thoracic Aorta

6658

543

7201

+ 6.4

Other Cardiac Surgery

1300

1330

2630

+ 1.9

Assist Devices

724

1385

2109

+ 9.6

Pacemaker and ICD

76

25929

26005

+ 4.6

Extracardiac Surgery

405

47127

47532

+ 8.9

Total

84402

88945

173347

+ 4.0

ICD, implantable cardioverter defibrillator; CPB, cardiopulmonary bypass.


Note: The % indicates changes compared with 2010.


Table 3

Distribution of Individual Units According to the Number of Cardiac Surgery Procedures with or without CPB

Number of Operations

< 500

500–999[a]

1000–1499

1500–1999

2000–5000

Number of Units

5

25

26

13

9

Average Per Unit

396

777

1194

1742

2802

Minimum–Maximum

245–477

510–974

1002–1458

1516–1968

2075–3823

CPB, cardiopulmonary bypass.


a One unit is performing pediatric cardiac surgery only.


Table 4

Distribution of Units According to Surgical Profiles in 2011

Type of Surgery Performed

Number of Units

Coronary Surgery

77

Valve Surgery

77

Surgery of Congenital Heart Diseases With CPB in Children < 1 Year

26[a]

Heart Transplantation

22[b]

Heart–Lung Transplantation

5

CPB, cardiopulmonary bypass.


a Surgery for congenital heart disease with CPB in children < 1 year (n 2037); thereof: 2 to 18 operations in five units, 26–45 operations in five units, 52–84 operations in eight units, and 109–250 operations in eight units.


b Heart transplantations (n = 355): 70% of the total annual heart transplantations are performed by 8 of 22 units with ≥ 15 heart transplantation per year; thereof: 1–4 transplants in three units, 5–9 transplants in six units, 10–19 transplants in seven units, and 21–77 transplants in six units.


Table 5

Additional Demographic Data for Procedures with CPB in 2011 and 2010

Demographic Data

2011

2010

Emergency Operations

11911

11.9%

11850

12.0%

Redo Procedures

8511

8.5%

8458

8.6%

Age > 69 Years[a]

95456

53.6%

93646

52.2%

CPB, cardiopulmonary bypass.


Note: The numbers in each category reflect procedures and not individual patients.


a Without patients younger than 20 years.


Table 6

Gender Distribution

Male/Female Ratio among Cardiac Procedures

Heart Valve Procedures

55%

45%

Coronary Surgery

75%

25%

Congenital Heart Surgery

52%

48%

Surgery of Thoracic Aorta

68%

32%

Other Cardiac Surgery

44%

56%

Assist Devices

71%

29%

Pacemaker and ICD

59%

41%

Extracardiac Surgery

63%

37%

Total

65%

35%

ICD, implantable cardioverter defibrillator.


Note: All coronary surgery (48743 on-pump and 6556 off-pump procedures) and all congenital surgery procedures are included in this table.


Table V1

Single Heart Valve Procedures

Position

n

Deaths

%

Aortic Sternotomy

9874

331

3.4

Aortic Part. Sternotomy

1794

49

2.7

Aortic Endovascular

2306

117

5.1

Aortic Transapical

2777

241

8.7

Mitral Sternotomy

3231

193

6.0

Mitral Mic

2280

56

2.5

Mitral Transcatheter

120

5

4.2

Tricuspidal Sternotomy

363

38

10.5

Tricuspidal Mic

92

5

5.4

Pulmonary Sternotomy

42

1

2.4

Pulmonary Mic

0

Pulmonary Transcatheter

1

0

0.0

Total

22880

1036

4.5

part., partial; mic, minimally invasive surgery.


Note: A total of 2280 (41%) mitral valve procedures were done using a minimally invasive access. The number of isolated conventional aortic valve replacement showed no difference from 2010 to 2011 (2010: 11689 and 2011:11668 procedures).


Table V2

Isolated Aortic Valve Procedures

Type of Valve

n

Deaths

%

Prosthesis

1689

41

2.4

Xenograft

9846

334

3.4

Homograft

37

2

5.4

Reconstruction

96

3

3.1

Total

11668

380

3.3

transcatheter aortic valve implantation.


Note: Out of 11668 procedures, 1794 (15%) were done by a partial sternotomy access. TAVI excluded.


Table V3

Isolated Heart Valve Procedures

Procedures

n

Deaths

%

Single

17676

673

3.8

Double

3600

299

8.3

Triple

362

53

14.6

Transcatheter Access

5210

363

7.0

Not Specified

124

10

8.1

Total

26972

1398

5.2

Note: Combined procedures (coronary artery bypass graft and aortic surgery) are not included.


Table V4

Isolated Mitral Valve Procedures

Type of Valve

n

Deaths

%

Prosthesis

579

28

4.8

Xenograft

1334

152

11.4

Homograft

11

3

27.3

Reconstruction

3587

66

1.8

Total

5511

249

4.5

Note: Out of 5511 procedures, 2280 (41%) were done using a minimally invasive access. Transcatheter procedures excluded.


Table V5

Multiple heart Valve Procedures

Combination

n

Deaths

%

Aortic + Mitral

1854

153

8.3

Mitral + Tricuspid

1419

110

7.8

Aortic + Tricuspid

188

33

17.6

Tricuspid + Pulmonary

17

2

11.8

Aortic + Pulmonary[a]

122

1

0.8

Aortic + Mitral + Tricuspid

357

50

14.0

Aortic + Mitral + Pulmonary

5

3

60.0

Total

3962

352

8.9

Note: Transcatheter procedures are not included.


a Including Ross procedures.


Table V6

Mitral Valve Surgery—Implantation/Replacement Versus Reconstruction

Mitral Valve Surgery

Replacement

Reconstruction

n

Total Deaths

% Death

% Reconstruction

n

Deaths

% Death

n

Deaths

% Death

Isolated

5511

249

4.5

65.1

1924

183

9.5

3587

66

1.8

Mitral Valve +

Aortic Valve

1854

153

8.3

62.8

689

103

14.9

1165

50

4.3

Tricuspid Valve Reconstruction[a]

1390

104

7.5

64.3

496

55

11.1

894

49

5.5

CABG

2590

269

10.4

68.6

812

139

17.1

1778

130

7.3

CABG + Aortic Valve Replacement

957

114

11.9

70.7

280

52

18.6

677

62

9.2

Total

12302

889

7.2

65.9

4201

532

12.7

8101

357

4.4

CABG, coronary artery bypass graft.


a Twenty-nine procedures (not specified Mitral valve + tricuspid valve surgery) excluded. Deaths %: 20.7 (6/29).


Table V7

Transcatheter Heart Valve Procedures: 54.6% of TAVI were Done Using a Transapical Access

With CPB

Without CPB

Total

Deaths

Death %

n

Deaths

n

Deaths

Aortic Valve Implantation

5083

358

7.0

121

42

4962

316

 Transvascular Access[a]

2306

117

5.1

34

13

2272

104

 Transapical Access

2777

241

8.7

87

29

2690

212

Mitral Valve

120

5

4.2

2

0

118

5

 Repair

94

1

1.1

1

0

93

1

 Implantation[b]

26

4

15.4

1

0

25

4

Aortic Valve Implantation[b] + CABG

38

8

21.1

15

5

23

3

Total

10444

734

7.0

261

89

10183

645

TAVI, transcatheter aortic valve implantation; CPB, cardiopulmonary bypass; CABG, coronary artery bypass graft.


Note: Pulmonary valve implantation for the correction of congenital lesions are not included, one procedure was reported for adults without congenital lesion. With the use of CPB, 2.3% of TAVI procedures were performed. It has to be assumed that CPB was mostly used in emergency situations, which explains the lethality of 34.7% in this group. Nevertheless, this underlines the necessity of a fully equipped surrounding for TAVI procedures where CPB is on standby for urgent use.


a Femoral, subclavian or transaortic access.


b Endovascular and transapical access.


Table C1

Isolated CABG with CPB and Combined Procedures with CPB

Procedures

n

Deaths

%

CABG

41976

1217

2.9

CABG+

TMLR

4

0

0.0

Aneurysm Resection

230

18

7.8

Aortic Valve Replacement

8023

441

5.5

Transcatheter Aortic Valve Implantation

38

8

21.1

Mitral Valve Replacement

812

139

17.1

Mitral Valve Repair

1778

130

7.3

Aortic + Mitral Valve Replacement

280

52

18.6

Aortic Valve Replacement + Mitral Valve Repair

677

62

9.2

Other

1481

102

6.9

Total

55299

2169

3.9

CABG, coronary artery bypass graft; CPB, cardiopulmonary bypass.


Table C2

Isolated CABG with CPB

Number of Grafts

n

Deaths

%

Single

1126

66

5.9

Double

7748

226

2.9

Triple

15749

489

3.1

Quadruple

8767

236

2.7

Quintuple + more

2431

71

2.9

Total

35821

1088

3.0

CABG, coronary artery bypass graft; CPB, cardiopulmonary bypass.


Table C3

Off-Pump Isolated CABG

Number of Grafts

n

Deaths

%

Single

1514

34

2.2

Double

1807

53

2.9

Triple

2004

33

1.6

Quadruple

708

8

1.1

Quintuple + More

122

1

0.8

Total

6155

129

2.1

CABG, coronary artery bypass graft.


Table Con1

Age Distribution among Procedures for Congenital Heart Disease

Age

n

Deaths

%

Without CPB

Over 18 Years

79

2

2.5

1–17 Years

178

1

0.6

Under 1 Year

733

11

1.5

Total of A

990

14

1.4

With CPB

Over 18 Years

878

25

2.8

1–17 Years

1694

8

0.5

Under 1 Year

2037

73

3.6

Total of B

4609

106

2.3

CPB, cardiopulmonary bypass.


Table Con2

Procedures for Congenital Heart Disease with and without CPB

Lesion

Age < 1 Year

Age 1–17 Years

Age ≥ 18 Years

n

Deaths

%

n

Deaths

%

n

Deaths

%

ASD

74

0

0.0

279

0

0.0

271

6

2.2

Complete AV Canal

180

5

2.8

76

0

0.0

14

1

7.1

VSD

303

1

0.3

121

0

0.0

26

1

3.8

Fallot's Tetralogy

206

5

2.4

36

1

2.8

6

0

0.0

DORV

65

1

1.5

14

0

0.0

0

0

TGA

132

4

3.0

7

0

0.0

0

0

TGA + VSD

65

2

3.1

7

0

0.0

0

0

Truncus Arteriosus

27

2

7.4

8

0

0.0

0

0

Fontan

5

0

0.0

275

1

0.4

10

2

20.0

Norwood Type

162

21

13.0

4

1

25.0

0

0

Pulmonary Valve

70

1

1.4

238

1

0.4

75

2

2.7

Transcatheter Pulmonary Valve Implantation

0

0

7

1

14.3

7

0

0.0

Aortic Valve

55

4

7.3

185

1

0.5

305

5

1.6

Ross Procedure

12

2

16.7

28

0

0.0

25

1

4.0

Mitral Valve

39

4

10.3

77

0

0.0

74

7

9.5

Tricuspid Valve

66

0

0.0

47

0

0.0

44

0

0.0

PDA

282

5

1.8

20

0

0.0

5

0

0.0

Coarctation

184

2

1.1

45

0

0.0

4

0

0.0

Heart Transplantation

4

0

0.0

18

0

0.0

0

0

Heart–Lung Transplantation

0

0

0

0

0

0

Lung Transplantation

0

0

9

0

0.0

0

0

Others

839

30

3.6

371

11

3.0

91

2

2.2

Total

2770

89

3.2

1872

17

0.9

957

27

2.8

ASD, atrial septal defect; AV, atrioventricular; VSD, ventricular septal defect; DORV, double outlet right ventricle; TGA, transposition at the great arteries; PDA, patent ductus arteriosus.


Table Mis1

Development of Ross Procedures in Various Age Groups

Autologous Aortic Valve Replacement (Ross Procedure)

n (2002)

n (2003)

n (2004)

n (2005)

n (2006)

n (2007)

n (2008)

n (2009)

n (2010)

n (2011)

In Patients ≥ 18 Years

163

170

250

235

228

261

207

175

184

134

In Patients < 18 Years

61

37

50

46

50

34

42

54

43

40

Total

224

207

300

281

278

295

249

229

227

174

Table Mis2

Transplantation All Pediatric Transplantations (Demonstrated in Table Con2) Are Included in This Table

Transplantation

With CPB

Without CPB

n

Deaths

%

n

Deaths

%

Heart

355

36

10.1

Heart + Lung

10

0

0.0

Lung

61

8

13.1

238

13

5.5

Note: Eurotransplant (ET) has reported for the same period 341 heart transplantations (HTx), 13 heart + kidney transplantations, 2 heart + liver transplantations, 10 heart–lung transplantations, 268 double lung, 57 single lung transplantations (LuTx), 1 lung + kidney transplantations, and 1 lung + liver transplantations. The differences (ET: −28 LuTx, −1 HTx) may be explained by different inclusion criteria (time of transplantation) for the registry and the ET database.


CPB, cardiopulmonary bypass.


Table Mis3

Aortic Surgery

Aortic Surgery[a]

With CPB

Without CPB

n

Deaths

%

n

Deaths

%

Supracoronary Ascending

1523

88

5.8

Infracoronary Ascending

 Mechanical Valve Conduits

623

40

6.4

 Biological Valve Conduits

681

76

11.2

 David

477

7

1.5

 Yacoub

130

4

3.1

 Other

277

21

7.6

Supracoronary Ascending + Aortic Valve Replacement

1331

56

4.2

Aortic Arch Replacement[b]

1419

165

11.6

Descending

105

13

12.4

16

4

25.0

Thoracoabdominal

78

23

29.5

31

6

19.4

Endostent Descending

14

0

0.0

496

27

5.4

Total

6658

493

7.4

543

37

6.8

Note: All procedures involving aortic surgery are included in this table. Isolated aortic surgery as well as all possible combined procedures (e.g., additional CABG) are summarized in this category.


a Abdominal aortic surgery is not included: 580 abdominal and 467 endostent abdominal.


b All possible combined procedures are included in this category; the only common denominator is aortic arch surgery.


CPB, cardiopulmonary bypass; CABG, coronary artery bypass graft.


Table Mis4

Pacemaker and ICD Procedures

Pacemaker and ICD

With CPB

Without CPB

Total

Deaths

Death %

n

Deaths

n

Deaths

Pacemaker: Implantation

9223

59

0.6

3

0

9220

59

Pacemaker: Battery Exchange

1974

2

0.1

3

0

1971

2

Pacemaker: Revision

2828

12

0.4

39

0

2789

12

ICD: Implantation

5380

14

0.3

2

0

5378

14

ICD: Battery Exchange

1946

3

0.2

0

0

1946

3

ICD: Revision

2853

23

0.8

22

2

2831

21

Miscellaneous

651

2

0.3

2

0

649

2

Total

24855

115

0.5

71

2

24784

113

ICD, implantable cardioverter defibrillator; CPB, cardiopulmonary bypass.


Table Mis5

Surgical Ablation Procedures

Energy

Total

Endocardiac Ablation

Epicardiac Ablation

n

n

Unipolar Radiofrequency

315

283

32

Unipolar Cryo-Radiofrequency

532

327

205

Bipolar Radiofrequency

1621

193

1428

Cryothermy

1494

1136

358

Microwave

56

8

48

Focused Ultrasound

465

48

417

Laser

0

0

0

Other

19

1

18

Total

4502

1996

2506

Note: 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.


CABG, coronary artery bypass graft.


Zoom Image
Figure 1 Development of cardiac surgery in Germany from 1994 to 2011. Coronary surgery and combined procedures include all types of isolated coronary surgery with or without CPB and any combined procedure. Heart valve procedures include all types of isolated valve surgery. Combinations of aortic surgery and heart valve procedures are summarized in the miscellaneous group. Congenital heart surgery includes all types of procedures with or without CPB. ASD repair in adults in combination with coronary or heart valve surgery are summarized in the coronary or heart valve surgery group. Miscellaneous includes all other types of procedures with CPB. ASD, atrial septal defect; CPB, cardiopulmonary bypass.
Zoom Image
Figure 2 Development of cardiac surgery in Germany during the past 10 years.
Zoom Image
Figure 3 Development of mortality for selected procedures.
Zoom Image
Figure 4 Isolated coronary bypass surgery. The number of coronary artery bypass procedures declined since the year 2000. The percentage of off-pump procedures has slightly increased compared with previous years but still has not reached the quantity of other comparable countries.
Zoom Image
Figure 5 Isolated aortic valve replacement from 1994 to 2011 in Germany. The use of xenografts is steadily increasing. There is a remarkable difference in mortality which is probably age related. Ross or other homograft procedures and transcatheter valve implantations are excluded in this overview.
Zoom Image
Figure 6 Conventional isolated aortic valve replacement or catheter-based procedures. The figure shows a significant increase in catheter-based procedures. In 2011, more than 30% of isolated aortic valve procedures were performed using an endovascular or transapical approach. This development underlines the importance of the new founded national aortic valve registry to get valid information about this relatively new therapy.
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Figure 7 Age distribution of cardiac procedures (without ICD and pacemaker procedures) since 1994. Currently, more than 53% of the patients are older than 70 years. Patients younger than 20 years are excluded. ICD, implantable cardioverter defibrillator.
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Figure 8 Distribution of urgency 1994 and 2011.
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Figure 9 Isolated mitral valve surgery over the past 18 years. More reconstructions (64%) than replacements (36%) were performed. In 1994, the percentage of reconstructions was only 21%. Due to the data collection method which is based on procedure codes, all isolated mitral valve procedures regardless of diagnosis, morphology, or urgency type are included. The rate of valve reconstruction would certainly be higher if patients with mitral valve stenosis, severe calcification, or endocarditis would have been excluded as it has been done in other publications, for example, Gammie et al.
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Figure 10 Development of congenital heart surgery in Germany over the past 10 years. Numbers remain more or less stable across previous years. However, there may be a bias since not all procedures for congenital heart surgery are necessarily counted in patients older than 18 years (e.g., aortic valve surgery).
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Figure 11 Development of mechanical circulatory support in Germany over the past 8 years. There is a significant increase in implantations of left ventricular assist devices (LVAD). However, in 2011, the number of implanted paracorporal biventricular support systems (BVAD) was only 70% compared with the previous year. The number of total artificial heart implantations (TAH) is still low.

As in previous years, several important developments continued also in 2011. Over the past 18 years, the age distribution ([Fig. 6]) demonstrates a shift to the categories with older patients. Currently, 53.6% of the cardiac procedures are performed in patients 70 years or older and 13.4% in patients 80 years or older. However, mortality remains the same or even decreased slightly over the past 18 years (see [Fig. 2]). Although the number of CABG decreased while the number of off-pump procedures for coronary heart disease increased to 14.7% (2010: 14.2%) ([Fig. 3]).

Since 2004 more than 50% of isolated mitral valve procedures are reconstructions, in 2011 more than 65% of the patients with mitral valve disease received a mitral valve reconstruction ([Fig. 8]). For correct interpretation of [Fig. 8], it is important to assert that, due to the data collection method (German OPS), all patients with various mitral valve diseases such as mitral valve stenosis, valve calcification, endocarditis, and patients under emergent conditions are included. The operation codes by itself give no information about the underlying disease. The reconstruction rate would certainly be higher if only patients would be included where a reconstruction is feasible. In other publications, for example, Gammie et al,[22] the reconstruction rate must be interpreted very carefully compared with our registry data because in their publication, patients with mitral valve stenosis, endocarditis, and in emergent conditions are excluded.

The increase of left ventricular assist device implantation ([Fig. 10]) emphasizes the increasing relevance of mechanical circulatory support.

The most remarkable evolution is the extensive increase of TAVI over the past 6 years ([Fig. 5]), while the number of isolated aortic valve replacements by open surgery remains stable. Starting in 2006 with 78 procedures (0.67% of isolated aortic valve procedures), 5,083 TAVI are reported in 2011 (30.5%). However, it should be kept in mind that the 78 units which contribute at this registry are not the only sites which are performing TAVI in Germany. TAVI via transvascular access are also performed in cardiology units without availability of a heart surgical unit. With the use of CPB, 2.3% of TAVI procedures were performed. It has to be assumed that CPB was mostly used in emergency situations, which explains the lethality of 34.7% in this group. Nevertheless, this underlines the necessity of a fully equipped surrounding for TAVI procedures where CPB is on standby for urgent use.

In the context of TAVI, two other quality assurance initiatives in Germany will be of great interest: the German Aortic Valve Registry and the legal quality assurance (§137 SGB V), which the AQUA-Institute is responsible for.


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Discussion

This report enables a comprehensive overview of all cardiac surgical procedures performed in Germany in 2011. The accuracy of this registry is reliable due to the implemented compilation algorithm using operation codes. This assumption is supported by other authors who could demonstrate a high accuracy for major outcome parameters in unaudited registries.[23] Alike to previous reports, we can conclude that cardiac surgery is performed on a high level with a low in-hospital mortality compared with other international registries. This conclusion is important especially in the era of continuously increasing patient age combined with relevant comorbidities, both leading to a higher perioperative risk profile.

Compared with 2010, the number of cardiac surgical procedures has stabilized due to the high volume of TAVI.

Further improvements for the structure of the registry are necessary to allow a more detailed and risk adjusted analysis of the collected 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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Acknowledgments

On behalf of the German Society for Thoracic and Cardiovascular Surgery, the authors would like to thank the chairmen and their coworkers of all heart surgery units in Germany for their continuous cooperation and support for realizing this registry report.


Address for correspondence and reprint requests

Anne-Kathrin Funkat, Ph.D.
Department of Cardiac Surgery, Herzzentrum, University of Leipzig
Strümpellstr. 39, Leipzig 04289
Germany   


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Figure 1 Development of cardiac surgery in Germany from 1994 to 2011. Coronary surgery and combined procedures include all types of isolated coronary surgery with or without CPB and any combined procedure. Heart valve procedures include all types of isolated valve surgery. Combinations of aortic surgery and heart valve procedures are summarized in the miscellaneous group. Congenital heart surgery includes all types of procedures with or without CPB. ASD repair in adults in combination with coronary or heart valve surgery are summarized in the coronary or heart valve surgery group. Miscellaneous includes all other types of procedures with CPB. ASD, atrial septal defect; CPB, cardiopulmonary bypass.
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Figure 2 Development of cardiac surgery in Germany during the past 10 years.
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Figure 3 Development of mortality for selected procedures.
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Figure 4 Isolated coronary bypass surgery. The number of coronary artery bypass procedures declined since the year 2000. The percentage of off-pump procedures has slightly increased compared with previous years but still has not reached the quantity of other comparable countries.
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Figure 5 Isolated aortic valve replacement from 1994 to 2011 in Germany. The use of xenografts is steadily increasing. There is a remarkable difference in mortality which is probably age related. Ross or other homograft procedures and transcatheter valve implantations are excluded in this overview.
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Figure 6 Conventional isolated aortic valve replacement or catheter-based procedures. The figure shows a significant increase in catheter-based procedures. In 2011, more than 30% of isolated aortic valve procedures were performed using an endovascular or transapical approach. This development underlines the importance of the new founded national aortic valve registry to get valid information about this relatively new therapy.
Zoom Image
Figure 7 Age distribution of cardiac procedures (without ICD and pacemaker procedures) since 1994. Currently, more than 53% of the patients are older than 70 years. Patients younger than 20 years are excluded. ICD, implantable cardioverter defibrillator.
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Figure 8 Distribution of urgency 1994 and 2011.
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Figure 9 Isolated mitral valve surgery over the past 18 years. More reconstructions (64%) than replacements (36%) were performed. In 1994, the percentage of reconstructions was only 21%. Due to the data collection method which is based on procedure codes, all isolated mitral valve procedures regardless of diagnosis, morphology, or urgency type are included. The rate of valve reconstruction would certainly be higher if patients with mitral valve stenosis, severe calcification, or endocarditis would have been excluded as it has been done in other publications, for example, Gammie et al.
Zoom Image
Figure 10 Development of congenital heart surgery in Germany over the past 10 years. Numbers remain more or less stable across previous years. However, there may be a bias since not all procedures for congenital heart surgery are necessarily counted in patients older than 18 years (e.g., aortic valve surgery).
Zoom Image
Figure 11 Development of mechanical circulatory support in Germany over the past 8 years. There is a significant increase in implantations of left ventricular assist devices (LVAD). However, in 2011, the number of implanted paracorporal biventricular support systems (BVAD) was only 70% compared with the previous year. The number of total artificial heart implantations (TAH) is still low.