Thorac cardiovasc Surg 2014; 62(01): 005-017
DOI: 10.1055/s-0033-1361953
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Cardiac Surgery in Germany during 2012: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

Andreas Beckmann
1  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Anne-Kathrin Funkat
2  Department of Cardiac Surgery, Herzzentrum, University of Leipzig, Leipzig, Germany
,
Jana Lewandowski
1  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Michael Frie
3  FOM Hochschule fuer Oekonomie and Management, Essen, Germany
,
Wolfgang Schiller
4  Department of Cardiac Surgery, University Bonn, Bonn, Germany
,
Khosro Hekmat
5  Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
,
Jan F. Gummert
6  Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
,
Friedrich Wilhelm Mohr
2  Department of Cardiac Surgery, Herzzentrum, University of Leipzig, Leipzig, Germany
› Author Affiliations
Further Information

Address for correspondence

Dr. Andreas Beckmann
Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie [DGTHG]
Langenbeck-Virchow-Haus, Luisenstr. 58-59, 10117 Berlin
Germany   

Publication History

18 October 2013

21 October 2013

Publication Date:
09 December 2013 (online)

 

Abstract

On the basis of a voluntary registry of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), data of all cardiac surgical procedures performed in 79 German cardiac surgical units during the year 2012 are presented. In 2012, a total of 98,792 cardiac surgical procedures (ICD and pacemaker procedures excluded) were submitted to the registry. More than 13.8% of the patients were older than 80 years, which is a further increase in comparison to previous years. In-hospital mortality in 42,060 isolated coronary artery bypass grafting procedures (84.6% on-pump and 15.4% off-pump) was 2.9%. In 28,521 isolated valve procedures (including 6,804 catheter-based procedures), an in-hospital mortality of 4.8% was observed. This long-lasting registry of the GSTCVS will continue to be an important tool for quality control and voluntary public reporting by illustrating current facts and developments 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 to answer those needs. As early as in 1978, the board of directors of the German Society for Thoracic and Cardiovascular Surgery (www.dgthg.de) decided to set up an annually updated database of all cardiac surgical procedures in terms of a voluntary registry. Since 1989, the updated data of the registry are published annually.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] The aim of this registry continues to illustrate developments and trends in cardiac surgery in Germany and it enables each participating cardiac surgical unit to compare its own results with the nationwide achievements.

For monitoring actual conditions as well as the development in cardiac medicine, the registry includes particular techniques such as off-pump cardiac surgery or minimal invasive mitral valve operations and also innovative technologies such as transapical or transvascular aortic valve implantation (TAVI) (see [Table V3]). Thereby important findings for present patient safety and the future of patient care may be collected and evaluated.

The data presented in this report comprehend assorted data of the year 2012.


#

Materials and Methods

Since 2004, a standardized questionnaire gathers detailed information about each individual procedure exactly defined by a German adaption of the International Classification of Procedures in Medicine called operation code (Operationen- und Prozedurenschlüssel).

All participants were requested to complete the structured questionnaire until January 21, 2013, asking for all performed procedures and associated in-hospital mortality. The completed questionnaire had to be sent to the office of the GSTCVS, where they were evaluated for completeness and compiled for further analysis, thus ensuring anonymity for each individual institution. This compilation algorithm guarantees a high compliance for submission of complete datasets.

Inclusion criteria for the registry 2012 were all patients receiving cardiac surgical procedures performed between January 1, 2012, and December 31, 2012, unrelated to the dates of admission or discharge as compared with other registries. Alike to all previous years, the number of procedures was counted rather than individual patients. For example, if a patient required additional coronary artery bypass grafting (CABG) due to a complication after initial aortic valve replacement during one admission, one count in the category “aortic valve replacement” and another in the category “coronary surgery” are enumerated. Thus, the registry contains more procedures than the real number of patients operated on.

Death of patients was defined as in-hospital mortality. As per the definition, the observed mortality is always attributed to the first cardiac procedure, for example, the death of a patient requiring CABG due to a complication of an aortic valve procedure would only be attributed to the aortic valve procedure.

The main reason for this structural setup of the registry—established over several decades—is to keep the German data privacy act with its specific regulations for patients. Furthermore, it seemed to be relevant getting detailed information about all performed procedures and not only the number of treated patients. Last but not the least, the process of data acquisition had to be simplified for all cardiac surgery units in Germany thus enabling the submission of a complete dataset, regardless of the locally existing hard- and software used for data management.

In 2012, a total of 79 institutions performed heart surgery. Fortunately, all units answered the questionnaire and delivered a complete dataset for the year 2012 including hospital mortality rates.


#

Registry Data 2012

[Table 1] illustrates the development of procedures using extracorporeal circulation (ECC) over more than two decades in Germany. The number of heart operations using ECC remains on a stable level.

Table 1

Frequency of open heart procedures in Germany from 2003 to 2012

Year

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Total number of units

78

79

79

80

80

79

80

79

78

79

Total number of operations

94,712

96,340

91,967

91,057

91,618

89,773

86,916

84,686

84,402

84,388

Average per unit

1,214

1,219

1,164

1,138

1,145

1,136

1,086

1,072

1,082

1,068

Overall, 177,694 procedures were reported to the registry for the year 2012, an increase of 2.5% (2011: 173,347 procedures). A total of 101,887 cardiac surgical procedures (excluded: implantable cardioverter defibrillator (ICD), pacemakers, and miscellaneous procedures without ECC) display an increase of 1.57% (n = 1,596) compared with the year 2011 (100,291 procedures) ([Table 2]). [Tables 3] [4] [5] to [6], [Tables V1] [V2] [V3] [V4] [V5] [V6] to [V7], [Tables C1] [C2] to [C3], [Tables Con1] and [Con2], [Tables Mis1] [Mis2] [Mis3] [Mis4] to [Mis5], and [Figs. 1] [2] [3] [4] [5] [6] [7] [8] to [9] demonstrate the compiled registry data of 2012 for various categories.

Zoom Image
Fig. 1 (A) Cardiac surgery in Germany from 2003 to 2012. (1) CABG and combinations: all types of isolated coronary surgery with or without ECC and any combined procedure. (2) Valve procedures: all types of isolated heart valve surgery; heart valve procedures in combination with aortic surgery are summarized in the miscellaneous group. (3) Congenital heart surgery: all procedures with or without ECC; atrial septal defect repair in adults in combination with CABG or heart valve surgery are summarized in the CABG or heart valve surgery group. (4) Miscellaneous procedures: all other types of procedures with ECC. (B) Development of cardiac surgery in Germany during the past 10 years. CABG, coronary artery bypass grafting; ECC, extracorporeal circulation.
Zoom Image
Fig. 2 Development of mortality for selected procedures.
Zoom Image
Fig. 3 Isolated CABG: the number of CABG declined since the year 2003 while the percentage of off-pump procedures slightly increased. CABG, coronary artery bypass grafting.
Zoom Image
Fig. 4 Isolated aortic valve replacement from 2003 to 2012 in Germany. The use of xenografts continuously increased while the aortic valve replacement using mechanical prostheses decreased. The sustained difference in mortality seems to be related to the difference in age pattern. Ross, homograft procedures, and TAVI are excluded in this overview. TAVI, transcatheter aortic valve implantation.
Zoom Image
Fig. 5 Surgical aortic valve replacement or TAVI. The figure shows an obvious increase of TAVI. In 2012, 35.5% of isolated aortic valve procedures were performed by endovascular or transapical implantation. TAVI, transcatheter aortic valve implantation.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (ICD and pacemaker procedures excluded) since 2003. Currently, 53.7% of the patients are at least 70 years. Patients younger than 20 years are excluded.
Zoom Image
Fig. 7 Distribution of urgency 2003 and 2012.
Zoom Image
Fig. 8 Isolated mitral valve surgery over the past 10 years. In 64.4% MV reconstructions and in 35.6% MV replacements were performed. In 1994, the rate of reconstruction just reached 21%.
Zoom Image
Fig. 9 Age distribution of patients undergoing congenital heart surgery in Germany over the past 10 years. No relevant changes can be observed. However, there may be a bias since not all relevant procedures can be allocated exactly to the congenital heart disease group in patients older than 18 years (e.g., aortic valve disease).
Table 2

Results of all 79 units performing cardiac surgery in 2012

Category

With ECC

Without ECC

Total

% change

Valve procedures

21,918

6,603

28,521

+ 5.7%

Coronary surgery

48,443

6,859

55,302

+ 0.0%

Congenital heart surgery

4,651

942

5,593

− 0.1%

Surgery of thoracic aorta

6,805

575

7,380

+ 2.5%

Other cardiac surgery

1,276

1,197

2,473

− 6.0%

Assist devices

812

1,806

2,618

+ 24.1%

Pacemaker and ICD

93

25,139

25,232

− 3.0%

Extracardiac surgery

390

50,185

50,575

+ 6.4%

Total

84,388

93,306

177,694

+ 2.5%

Abbreviation: ECC, extracorporeal circulation.


Note: The percentage indicates changes compared with 2011.


Table 3

Distribution of individual units according to the number of cardiac surgery procedures with or without ECC

Number of operations

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Number of units

6

24

26

13

10

Average per unit

378

803

1,186

1,706

2,781

Min–max

271–474

538–990

1,019–1,468

1,517–1,959

2,169–3,814

Abbreviation: ECC, extracorporeal circulation.


Note: One unit only performs operations in patients with congenital heart disease.


Table 4

Distribution of units according to surgical profiles in 2012

Procedures

Number of units

Coronary surgery

78

Valve surgery

78

Congenital heart surgery under use of ECC in children < 1 y

24[a]

Heart transplantation

22[b]

Heart–lung transplantation

4

Abbreviation: ECC, extracorporeal circulation.


a Surgery for congenital heart disease with ECC in children < 1 year (n = 2,024); thereof: 1–19 operations in 3 units, 21–45 operations in 7 units, 50–90 operations in 6 units, and 109–269 operations in 8 units.


b Heart transplantations (HTx) (n = 327): 64% of the HTx in 2012 were performed by 6 units with ≥15 HTx per year; thereof: 1–4 transplantations in 4 units, 5–7 transplantations in 6 units, 10–14 transplantations in 6 units, and 21–73 transplantations in 6 units.


Table 5

Additional demographic data for procedures with ECC in 2012 and 2011

2012

2011

Emergency operations

11,878

11.6%

11,911

11.9%

Redo procedures

8,424

8.2%

8,511

8.5%

Age > 69 y

97,572

53.7%

95,456

53.6%

Abbreviation: ECC, extracorporeal circulation.


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


Table 6

Gender distribution

Male/female ratio among cardiac procedures

Valve procedures

56%

44%

Coronary surgery

76%

24%

Congenital heart surgery

53%

47%

Surgery of thoracic aorta

69%

31%

Other cardiac surgery

52%

48%

Assist devices

77%

23%

Pacemaker and ICD

65%

35%

Extracardiac surgery

63%

37%

Total

66%

34%

Note: Coronary surgery (48,443 on-pump and 6,859 off-pump procedures) and all congenital heart surgery procedures are included in this table.


Table V1

Isolated heart valve procedures

Procedures

n

Deaths

%

Single

18,094

624

3.4

Double

3,133

289

9.2

Triple

400

52

13.0

Single, transcatheter access

6,795

382

5.6

Double, transcatheter access

9

2

22.2

Not specified

90

7

7.8

Total

28,521

1,356

4.8

Notes: Combined procedures (with CABG, aortic surgery) are excluded. Transcatheter procedures: 6,479 aortic valve implantations; 42 mitral valve implantations; 269 mitral valve repairs, 5 tricuspidal valve repairs, 9 double aortic and mitral valve procedures, and no pulmonary valve implantation.


Table V2

Access type in single valve procedures

Position

n

Deaths

%

Aortic sternotomy

9,738

314

3.2

Aortic partial sternotomy

2,168

36

1.7

Aortic transvascular

3,550

167

4.7

Aortic transapical

2,929

210

7.2

Mitral sternotomy

3,110

186

6.0

Mitral miscellaneous

2,512

42

1.7

Mitral transcatheter

311

4

1.3

Tricuspid sternotomy

407

36

8.8

Tricuspid miscellaneous

109

7

6.4

Tricuspid transcatheter

5

1

20.0

Pulmonary sternotomy

50

3

6.0

Pulmonary miscellaneous

0

Pulmonary transcatheter

0

0

Total

24,889

1,006

4.0

Notes: A total of 2,512 (45%) mitral valve procedures were performed by a minimally invasive access. The number of isolated aortic valve procedures by sternotomy increased from 11,668 procedures in 2011 to 11,906 in 2012.


Table V3

Isolated aortic valve procedures

Type

n

Deaths

%

Mechanical prosthesis

1652

37

2.2

Xenograft

10091

308

3.1

Homograft

36

4

11.1

Reconstruction

127

1

0.8

Total

11906

350

2.9

Notes: Of 11,906 procedures, 2168 (18%) were performed via partial sternotomy. Transcatheter procedures were not included.


Table V4

Isolated mitral valve procedures

Type

n

Deaths

%

Mechanical prosthesis

570

38

6.7

Xenograft

1,425

131

9.2

Homograft

6

0

0.0

Reconstruction

3,621

59

1.6

Total

5,622

228

4.1

Notes: Of 5,622 procedures, 2,512 (45%) were performed via minimally invasive access. Transcatheter procedures were excluded.


Table V5

Multiple heart valve procedures

Combination

n

Deaths

%

Aortic + mitral

1,345

165

12.3

Mitral + tricuspid

1,489

103

6.9

Aortic + tricuspid

185

18

9.7

Tricuspid + pulmonary

16

1

6.3

Aortic + pulmonary[a]

98

2

2.0

Aortic + mitral + tricuspid

399

52

13.0

Aortic + mitral + pulmonary

1

0

0.0

Total

3,533

341

9.7

Note: Transcatheter procedures were excluded.


a Including Ross procedures.


Table V6

Mitral valve surgery—implantation resp. replacement versus reconstruction

Mitral valve surgery

n

Total deaths

% death

% reconstruction

Replacement

% death

Reconstruction

% death

n

Deaths

n

Deaths

Isolated

5,622

228

4.1

64.4

2,001

169

8.4

3,621

59

1.6

Mitral valve +

Aortic valve

1,345

165

12.3

42.5

773

115

14.9

572

50

8.7

Tricuspid valve reconstruction[a]

1,445

99

6.9

65.3

501

54

10.8

944

45

4.8

CABG

2,640

252

9.5

70.2

786

129

16.4

1,854

123

6.6

CABG + aortic valve replacement

674

119

17.7

53.1

316

68

21.5

358

51

14.2

Total

11,726

863

7.4

62.7

4,377

535

12.2

7,349

328

4.5

Abbreviation: CABG, coronary artery bypass grafting.


a Forty-four procedures (not specified mitral valve + tricuspid valve surgery) were excluded. Deaths: 9.1% (4/44).


Table V7

Transcatheter valve procedures: 45.2% of TAVI were performed by transapical access

Total

Deaths

Death %

With ECC

Without ECC

n

Deaths

n

Deaths

Aortic valve implantation

6,479

377

5.8

182

62

6,297

315

 Transvascular access[a]

3,550

167

4.7

80

24

3,470

143

 Transapical access

2,929

210

7.2

102

38

2,827

172

Mitral valve

311

4

1.3

16

1

295

3

 Repair

269

4

1.5

11

1

258

3

 Implantation[b]

42

0

0.0

5

0

37

0

Tricuspid valve repair

5

1

20.0

2

0

3

1

Aortic + mitral valve implantation

9

2

22.2

1

0

8

2

Aortic valve implantation[b] + CABG

23

5

21.7

3

2

20

3

Total

6,827

389

5.7

204

65

6,623

324

Abbreviations: CABG, coronary artery bypass grafting; ECC, extracorporeal circulation; TAVI, transapical or transvascular aortic valve implantation.


Notes: Pulmonary valve implantation for congenital heart disease are excluded, no procedure was reported for adults without congenital lesion. 2.8% of TAVI procedures were performed under use of ECC. It has to be assumed that ECC was mostly used in emergency situations, which explains the mortality of 34.1% in this group. Nevertheless, this underlines the necessity of a cardiac surgery on-site for TAVI procedures.


a Femoral, subclavian, or transaortic access.


b Transvascular and transapical access.


Table C1

Isolated CABG with ECC and combined procedures with ECC

Procedures

n

Deaths

%

CABG

42,060

1,217

2.9

CABG +

 Transmyocardial laser revascularization

6

0

0.0

 Left ventricular-aneurysm resection

168

11

6.5

 Aortic valve replacement

8,216

432

5.3

 Transcatheter aortic valve implantation

23

5

21.7

 Mitral valve replacement

786

129

16.4

 Mitral valve repair

1,854

123

6.6

 Aortic + mitral valve replacement

316

68

21.5

 Aortic valve replacement + mitral valve repair

358

51

14.2

Other

1,515

95

6.3

Total

55,302

2,131

3.9

Abbreviations: CABG, coronary artery bypass grafting; ECC, extracorporeal circulation.


Table C2

Isolated CABG with ECC

Number of grafts

N

Deaths

%

Single

1,213

73

6.0

Double

7,399

250

3.4

Triple

15,667

466

3.0

Quadruple

8,734

242

2.8

Quintuple + more

2,560

57

2.2

Total

35,573

1,088

3.1

Abbreviations: CABG, coronary artery bypass grafting; ECC, extracorporeal circulation.


Table C3

Isolated CABG off-pump

Number of grafts

n

Deaths

%

Single

1,525

33

2.2

Double

1,938

45

2.3

Triple

2,132

40

1.9

Quadruple

750

10

1.3

Quintuple + more

142

1

0.7

Total

6,487

129

2.0

Abbreviation: CABG, coronary artery bypass grafting.


Table Con1

Patient's age distribution for congenital heart surgery

Age

n

Deaths

%

(A) Without ECC

 Older than 18 y

34

1

2.9

 1–17 y

142

0

0.0

 Younger than 1 y

766

20

2.6

 Total A

942

21

2.2

(B) With ECC

 Older than 18 y

989

23

2.3

 1–17 y

1,638

16

1.0

 Younger than 1 y

2,024

79

3.9

 Total B

4,651

118

2.5

Abbreviation: ECC, extracorporeal circulation.


Table Con2

Congenital heart surgery with and without ECC

Lesion/procedure

Age < 1 y

Age 1–17 y

Age ≥ 18 y

n

Deaths

%

n

Deaths

%

n

Deaths

%

ASD

51

0

0.0

254

0

0.0

287

6

2.1

Complete AV canal

174

5

2.9

62

0

0.0

11

0

0.0

VSD

326

3

0.9

112

1

0.9

21

0

0.0

Fallot tetralogy

177

5

2.8

45

0

0.0

9

0

0.0

DORV

44

2

4.5

12

0

0.0

2

0

0.0

TGA

159

4

2.5

3

0

0.0

1

0

0.0

TGA + VSD

65

0

0.0

8

1

12.5

0

0

Truncus arteriosus

31

2

6.5

5

0

0.0

1

0

0.0

Fontan

5

0

0.0

231

5

2.2

10

2

20.0

Norwood

187

26

13.9

2

0

0.0

0

0

Pulmonary valve

48

0

0.0

225

4

1.8

82

0

0.0

Transcatheter pulmonary valve implantation

1

0

0.0

6

0

0.0

9

1

11.1

Aortic valve

61

0

0.0

209

1

0.5

319

7

2.2

Ross procedure

10

1

10.0

26

0

0.0

29

0

0.0

Mitral valve

43

1

2.3

93

1

1.1

69

5

7.2

Tricuspid valve

44

2

4.5

51

0

0.0

44

1

2.3

PDA

286

9

3.1

14

0

0.0

3

0

0.0

Coarctation

195

1

0.5

44

0

0.0

6

0

0.0

Transplantation heart

6

0

0.0

17

1

5.9

0

0

Transplantation heart + lung

0

0

1

0

0.0

0

0

Transplantation lung

0

0

9

1

11.1

0

0

Others

877

53

6.0

351

24

6.8

120

3

2.5

Total

2,790

114

4.1

1,780

39

2.2

1,023

25

2.4

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


Table Mis1

Development of Ross procedures in various age groups

Autologous aortic valve replacement (Ross procedure)

2002

2005

2008

2009

2010

2011

2012

n

n

n

n

n

n

n

Patients ≥ 18 y

163

235

207

175

184

134

117

Patients < 18 y

61

46

42

54

43

40

36

Total

224

281

249

229

227

174

153

Table Mis2

Transplantation all pediatric transplantations (demonstrated in Table Con3) are included in this table

Transplantation

With ECC

Without ECC

n

Deaths

%

n

Deaths

%

Heart

327

38

11.6

Heart + lung

14

1

7.1

Lung

71

4

5.6

244

11

4.5

Notes: Eurotransplant (ET) 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, 1 lung + kidney transplantations, and 1 lung + liver transplantations. The differences (ET: − 28 LTx, − 5 HTx) may be explained by different inclusion criteria (time of transplantation) for the registry and the ET database.


Table Mis3

Aortic surgery

Aortic surgery[a]

With ECC

Without ECC

n

Deaths

%

n

Deaths

%

Supracoronary ascending

1,623

110

6.8

Infracoronary ascending

 Mechanical valve conduits

510

36

7.1

 Biological valve conduits

806

79

9.8

 David technique

463

10

2.2

 Yacoub technique

119

4

3.4

 Other

263

27

10.3

Supracoronary ascending + aortic valve replacement

1,363

66

4.8

Aortic arch replacement[b]

1,472

194

13.2

Descending

90

6

6.7

14

3

21.4

Thoracoabdominal

89

7

7.9

59

7

11.9

Endovascular stent, descending

7

0

0.0

502

24

4.8

Total

6,805

539

7.9

575

34

5.9

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


a Procedures for abdominal aortic diseases are not included: 486 abdominal and 488 endovascular stents, abdominal.


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


Table Mis4

Pacemaker and ICD procedures

Pacemaker and ICD

Total

Deaths

Death %

With ECC

Without ECC

n

Deaths

n

Deaths

Pacemaker: implantation

9,276

54

0.6

17

2

9,259

52

Pacemaker: exchange

1,976

5

0.3

0

0

1,976

5

Pacemaker: revision

2,966

38

1.3

42

4

2,924

34

ICD: implantation

4,963

12

0.2

1

0

4,962

12

ICD: exchange

1,812

1

0.1

0

0

1,812

1

ICD: revision

3,228

44

1.4

29

0

3,199

44

Miscellaneous

1,011

6

0.6

4

0

1,007

6

Total

25,232

160

0.6

93

6

25,139

154

Table Mis5

Surgical ablation procedures

Energy

Total

Endocardiac ablation, n

Total, n

Unipolar radiofrequency

198

159

39

Unipolar cryoradiofrequency

469

272

197

Bipolar radiofrequency

1,967

263

1,704

Cryothermy

1,706

1,439

267

Microwave

38

22

16

Focused ultrasound

688

71

617

Laser

1

0

1

other

11

2

9

Total

5,078

2,228

2,850

Notes: All isolated ablation procedures and all possible combination of procedures (e.g., CABG + ablation) are included. Total of n = 319 procedures are not specified with regard to endocardiac/epicardiac ablation.


Compared with the data of previous years, several important developments continue unchanged in 2012. Over nearly two decades, the distribution of patient age ([Fig. 6]) showed a shift to older patients with presently 53.7% of the cardiac procedures performed in patients of at least 70 years of age and 13.8% in patients of 80 years or older. However, mortality remained on the same low level or even decreased slightly over the represented decades (see [Fig. 1B]). The rate of CABG procedures decreased over the past years while the relative number of off-pump CABG showed a slight increase to 15.4% (2011: 14.7%) ([Fig. 3]).

Since 2004 more than 50% of isolated mitral valve procedures are reconstructions, in 2012 mitral valve reconstruction could be achieved in 64.4% of the procedures ([Fig. 8]). On the basis of the fact that all isolated mitral valve procedures are included, regardless of the underlying disease, valve morphology, or urgency of operation, it has to be assumed that the relative rate of mitral valve reconstruction would certainly be even higher if patients without possibility or indication for reconstruction would have been excluded (e.g., mitral valve stenosis, calcifications, or endocarditis). In other publications, for example Gammie et al,[23] patients with mitral valve stenosis, endocarditis, and emergency procedures were excluded, so the reconstruction rate must be interpreted with caution compared to this registry.

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

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Fig. 10 Development of mechanical circulatory support in Germany over the past 9 years. There is a significant increase in implantations of left ventricular assist devices (LVAD). However, in 2012, the number of implanted paracorporeal biventricular support systems (BVAD) was only 66% compared with the previous years. The number of total artificial heart (TAH) implantations remained on a low level.

Again the most remarkable trend is the repeated extensive increase of TAVI procedures ([Fig. 5]), although the number of isolated aortic valve replacement procedures remained on a stable level. Starting in 2006 with just 78 implantations (0.67% of isolated aortic valve procedures), in 2012 a total of 6,479 (35.5%) TAVI were reported to the registry in 2012. It must be emphasized that the 79 institutions which contribute their data to this registry do not represent all departments performing TAVI in Germany. In addition, there are some institutions performing TAVI via transvascular access without a cardiac surgery on-site. This proceeding is not in accordance with the recommendations of the European guideline on the management of valvular heart disease version 2012.[24]

In this context, the short-, mid-, and long-term results of the German Aortic Valve Registry and the annual findings of the legal quality assurance (§137 SGB V), conducted by the AQUA Institute, are of outstanding patient benefit.


#

Discussion

The registry of the GSTCVS enables a comprehensive overview of all cardiac surgical procedures performed in Germany in 2012. The accuracy of this registry is considered to be high due to the implemented compilation algorithm using operation codes. This is supported by other authors who could demonstrate a high accuracy for major outcome parameters in unaudited registries.[25] In continuation to previous years, it can be concluded that cardiac surgery in Germany is performed on a constantly high level with a low in-hospital mortality compared with other international registries. This conclusion is especially important in an era of demographic change of the German population resulting in a continuously increasing patient age and related comorbidities, both leading to a higher preoperative risk profile.

Compared with 2011, the number of cardiac surgery procedures nearly remains on the same level due to the still increasing number of catheter-based valve procedures.

Further improvements in the basic configuration of the registry are necessary to allow a more detailed and particularly a risk-adjusted analysis of the data. However, if significant structural changes of data collection for the registry are conducted, it must be ensured that data compatibility still allows further longitudinal data analysis.

Completeness, validity, and further developments will depend on continued efforts of the GSTCVS in close collaboration with all cardiac surgical units in Germany. This will be of outstanding importance for the contribution to patient safety as well as to facilitate a high quality of cardiac surgery in Germany.


#
#

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 cardiac surgery units in Germany for their continued cooperation and support to realize this registry.


Address for correspondence

Dr. Andreas Beckmann
Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie [DGTHG]
Langenbeck-Virchow-Haus, Luisenstr. 58-59, 10117 Berlin
Germany   


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Fig. 1 (A) Cardiac surgery in Germany from 2003 to 2012. (1) CABG and combinations: all types of isolated coronary surgery with or without ECC and any combined procedure. (2) Valve procedures: all types of isolated heart valve surgery; heart valve procedures in combination with aortic surgery are summarized in the miscellaneous group. (3) Congenital heart surgery: all procedures with or without ECC; atrial septal defect repair in adults in combination with CABG or heart valve surgery are summarized in the CABG or heart valve surgery group. (4) Miscellaneous procedures: all other types of procedures with ECC. (B) Development of cardiac surgery in Germany during the past 10 years. CABG, coronary artery bypass grafting; ECC, extracorporeal circulation.
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Fig. 2 Development of mortality for selected procedures.
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Fig. 3 Isolated CABG: the number of CABG declined since the year 2003 while the percentage of off-pump procedures slightly increased. CABG, coronary artery bypass grafting.
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Fig. 4 Isolated aortic valve replacement from 2003 to 2012 in Germany. The use of xenografts continuously increased while the aortic valve replacement using mechanical prostheses decreased. The sustained difference in mortality seems to be related to the difference in age pattern. Ross, homograft procedures, and TAVI are excluded in this overview. TAVI, transcatheter aortic valve implantation.
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Fig. 5 Surgical aortic valve replacement or TAVI. The figure shows an obvious increase of TAVI. In 2012, 35.5% of isolated aortic valve procedures were performed by endovascular or transapical implantation. TAVI, transcatheter aortic valve implantation.
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Fig. 6 Age distribution of cardiac procedures (ICD and pacemaker procedures excluded) since 2003. Currently, 53.7% of the patients are at least 70 years. Patients younger than 20 years are excluded.
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Fig. 7 Distribution of urgency 2003 and 2012.
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Fig. 8 Isolated mitral valve surgery over the past 10 years. In 64.4% MV reconstructions and in 35.6% MV replacements were performed. In 1994, the rate of reconstruction just reached 21%.
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Fig. 9 Age distribution of patients undergoing congenital heart surgery in Germany over the past 10 years. No relevant changes can be observed. However, there may be a bias since not all relevant procedures can be allocated exactly to the congenital heart disease group in patients older than 18 years (e.g., aortic valve disease).
Zoom Image
Fig. 10 Development of mechanical circulatory support in Germany over the past 9 years. There is a significant increase in implantations of left ventricular assist devices (LVAD). However, in 2012, the number of implanted paracorporeal biventricular support systems (BVAD) was only 66% compared with the previous years. The number of total artificial heart (TAH) implantations remained on a low level.