Thorac cardiovasc Surg 2014; 62(05): 380-392
DOI: 10.1055/s-0034-1383430
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Cardiac Surgery in Germany during 2013: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

A. Funkat
1  Department of Cardiac Surgery, University of Leipzig, Leipzig, Germany
,
A. Beckmann
2  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
J. Lewandowski
2  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
M. Frie
3  FOM Hochschule fuer Oekonomie and Management, Essen, Germany
,
M. Ernst
4  Department of Thoracic and Cardiovascular Surgery, University Kiel, Kiel, Germany
,
W. Schiller
5  Department of Cardiac Surgery, University Bonn, Bonn, Germany
,
J. F. Gummert
6  Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
,
J. Cremer
4  Department of Thoracic and Cardiovascular Surgery, University Kiel, Kiel, Germany
› Author Affiliations
Further Information

Address for correspondence

Anne-K. Funkat, Dr.-Ing
Klinik für Herzchirurgie, Herzzentrum Leipzig GmbH – Universitätsklinik
Strümpellstr. 39, 04289 Leipzig
Germany   

Publication History

07 April 2014

15 April 2014

Publication Date:
04 July 2014 (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 2013 are presented. In 2013, a total of 99,128 cardiac surgical procedures (implantable cardioverter defibrillator [ICD] and pacemaker procedures excluded) were submitted to the registry. More than 13.8% of the patients were older than 80 years, which remains equal in comparison to the previous year. In-hospital mortality in 40,410 isolated coronary artery bypass grafting procedures (84.5% on-pump and 15.5% off-pump) was 2.9%. In 29,672 isolated valve procedures (including 7,722 catheter-based procedures), an in-hospital mortality of 4.7% 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 (GSTCVS) (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] [23] [24] 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). 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 2013.


#

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 20, 2014, asking for all performed procedures and associated in-hospital mortality. The recommended path for data export is an electronic transmission of an encrypted file which had to be addressed to the office of the GSTCVS. After transaction, the data were decrypted, 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 the complete dataset.

Inclusion criteria for the registry 2013 were all patients receiving cardiac surgical procedures performed between January 1, 2013, and December 31, 2013, unrelated to the date 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 2013, a total of 79 institutions performed heart surgery. Fortunately, all units answered the questionnaire and delivered a complete dataset for the year 2013 including hospital mortality rates.


#

Registry Data 2013

[Table 1] illustrates the development of procedures using extracorporeal circulation (ECC) over one decade in Germany. Since 2010, the count of heart operations using ECC remains on a stable level.

Table 1

Open heart procedures under use of ECC in Germany from 2004 to 2013

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Units

79

79

80

80

79

80

79

78

79

79

Operations

96,340

91,967

91,057

91,618

89,773

86,916

84,686

84,402

84,388

84,040

Average per unit

1,219

1,164

1,138

1,145

1,136

1,086

1,072

1,082

1,068

1,064

Abbreviation: ECC, extracorporeal circulation; TMLR, transmyocardial laser revascularization.


Overall, 180,367 procedures were reported to the registry for the year 2013, an increase of 1.5% (2012: 177,694 procedures). A total of 102,845 cardiac surgical procedures (excluded: implantable cardioverter defibrillator (ICD), pacemakers, and miscellaneous procedures without ECC) display an increase of 0.94% (n = 958) compared with the year 2012 (101,887 procedures) ([Table 2]). [Tables 3] [4] [5] to [6], [V1] [V2] [V3] [V4] [V5] [V6] to [V7], [C1] [C2] to [C3], [Con1] and [Con2], [Mis1] [Mis2] [Mis3] [Mis4] to [Mis5], and [Figs. 1 ] [2] [3] [4] [5] [6] [7] [8] to [9] demonstrate the compiled registry data of 2013 for various categories.

Zoom Image
Fig. 1 Cardiac surgery in Germany from 2004 to 2013. (1) Coronary artery bypass grafting (CABG) and combinations: all types of isolated coronary surgery with or without extracorporeal circulation (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.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures 2004 to 2013.
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting. The number of coronary artery bypass procedures declined since the year 2004 while the percentage of off-pump procedures slightly increased.
Zoom Image
Fig. 4 Isolated aortic valve replacement from 2004 to 2013 in Germany. The use of xenografts continuously increased till 2008 and remained almost the same since then. Aortic valve replacement (AVR) using mechanical prosthesis decreased over the past 10 years. The sustained difference in mortality seems to be related to the difference in age pattern. (Ross, homograft implantations, and transapical or transvascular aortic valve implantation [TAVI] are excluded.)
Zoom Image
Fig. 5 Isolated AVR and transapical or transvascular aortic valve implantation (TAVI). The figure shows almost unvaried quantity of AVR and an obvious increase of TAVI. In 2013, 38.1% of reported isolated aortic valve procedures were performed by transvascular or transapical implantation.
Zoom Image
Fig. 6 Age distribution of cardiac procedures since 2004. Currently, 54.0% of the patients are at least 70 years (patients < 20 years and ICD/pacemaker procedures are excluded).
Zoom Image
Fig. 7 Urgency 2004 and 2013.
Zoom Image
Fig. 8 Isolated mitral valve surgery over the past 10 years. In 65.8% mitral valve (MV) repairs and in 34.2% MV replacements were performed. In 1994, the rate of reconstruction just reached 21%.
Zoom Image
Fig. 9 Age distribution for 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 clearly to the congenital heart disease group in patients older than 18 years (e.g., aortic valve disease).
Table 2

Cardiac surgery categories 2013 compared with 2012

With ECC

Without ECC

Total

% change

Heart valve procedures

22,119

7,553

29,672

+ 4.0

Coronary artery bypass grafting

47,582

6,680

54,262

− 1.9

Surgery for CHD

4,721

855

5,576

− 0.3

Surgery of thoracic aorta

7,045

626

7,671

+ 3.9

Cardiac surgery other

1,394

1,225

2,619

+ 5.9

Assist device procedures

791

1,866

2,657

+ 1.5

Pacemaker and ICD procedures

59

25,679

25,738

+ 2.0

Extracardiac surgery

329

51,843

52,172

+ 3.2

Total

84,040

96,327

180,367

+ 1.5

Abbreviations: CHD, congenital heart disease; ECC, extracorporeal circulation.


Table 3

Units assorted by volume categories (procedures with or without ECC)

Procedure volume

< 500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Units

7

25

26

12

9

Min–max

237–451

557–995

1,028–1,487

1,538–1,987

2,075–3,754

Average per unit

355

808

1,201

1,723

2,727

Abbreviation: ECC, extracorporeal circulation.


Table 4

Total number of units according to surgical procedures in 2013

Units

Coronary artery bypass grafting

78

Heart valve surgery

78

Surgery for CHD in children < 1 y with ECC[a]

24[a]

Heart transplantation[b]

22[b]

Heart–lung transplantation

4

Abbreviations: CHD, congenital heart disease; ECC, extracorporeal circulation.


a n = 2,047; thereof: 2–16 operations in three units, 26–41 operations in seven units, 58–98 operations in six units, and 114–318 operations in eight units.


b n = 301; 67% of the heart transplantations (HTx) in 2013 were performed by 7 of 24 units with ≥ 15 HTx per year; thereof: 1–4 transplantations in eight units, 5–9 transplantations in five units, 10–17 transplantations in six units, and 22–75 transplantations in five units.


Table 5

Additional data for procedures with ECC in 2013 compared with 2012

2013

2012

Emergency operations

11,944

11.6%

11,878

11.6%

Redo procedures

8,284

8.1%

8,424

8.2%

Age > 69 y[a]

98,042

54.0%

97,572

53.7%

Abbreviation: ECC, extracorporeal circulation.


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


a Patients < 20 years are excluded.


Table 6

Gender distribution

Male/female distribution

Male (%)

Female (%)

All procedures

66

34

Heart valve procedures

55

45

Coronary artery bypass grafting

76

24

Surgery for CHD

55

45

Surgery of thoracic aorta

68

32

Cardiac surgery other

48

52

Assist device procedures

73

27

Pacemaker and ICD procedures

64

36

Extracardiac surgery

65

35

Abbreviation: CHD, congenital heart disease.


Note: Coronary artery bypass surgery (47,582 on-pump and 6,680 off-pump procedures) and all procedures for congenital heart surgery are included in this table.


Table V1

Isolated heart valve procedures

Procedures

N

Deaths

%

Single

18,108

622

3.4

Double

3,363

285

8.5

Triple

380

52

13.7

Single transcatheter access

7,712

434

5.6

Double transcatheter access

10

1

10.0

Unspecified

99

6

6.1

Total

29,672

1,400

4.7

Notes: Combined procedures (with CABG, aortic surgery) are excluded. Transcatheter valve procedures: 7,246 aortic valve implantations; 58 mitral valve implantations; 404 mitral valve repairs, 3 tricuspidal valve repairs, 10 combined aortic and mitral valve procedures, and 1 pulmonary valve implantation.


Table V2

Access type in single valve procedures

Position

N

Deaths

%

Aortic valve

 Sternotomy

9,541

294

3.1

 Partial sternotomy

2,350

46

2.0

 Transvascular

4,360

200

4.6

 Transapical

2,886

219

7.6

Mitral valve

 Sternotomy

3,083

199

6.5

 Minimal invasive

2,548

30

1.2

 Transcatheter

462

14

3.0

Tricuspidal valve

 Sternotomy

424

45

10.6

 Minimal invasive

131

8

6.1

 Transcatheter

3

1

33.3

Pulmonary valve

 Sternotomy

31

0

0.0

 Minimal invasive

0

 Transcatheter

1

0

0.0

Total

25,820

1,056

4.1

Notes: A total of 2,548 (45.2%) mitral valve procedures were performed by a minimally invasive access. The number of isolated aortic valve procedures by sternotomy remained on the same level counting 11,906 procedures in 2012 and 11,891 in 2013.


Table V3

Isolated aortic valve procedures

N

Deaths

%

Mechanical prosthesis

1,506

26

1.7

Xenograft

10,049

311

3.1

Homograft

210

2

1.0

Repair

122

1

0.8

Total

11,887

340

2.9

Notes: A total of 2,349 procedures (19.8%) were performed via partial sternotomy. Transcatheter procedures and apical aortic conduit procedures were not included.


Table V4

Isolated mitral valve procedures

N

Deaths

%

Mechanical prosthesis

486

36

7.4

Xenograft

1,432

133

9.3

Homograft

5

0

0.0

Repair

3,708

60

1.6

Total

5,631

229

4.1

Notes: A total of 2,548 procedures (45.2%) were performed via minimally invasive access. Transcatheter procedures were excluded.


Table V5

Multiple heart valve procedures

Combinations

N

Deaths

%

Aortic + mitral

1,420

129

9.1

Mitral + tricuspid

1,618

140

8.7

Aortic + tricuspid

219

13

5.9

Tricuspid + pulmonary

17

2

11.8

Aortic + pulmonary[a]

89

1

1.1

Aortic + mitral + tricuspid

380

51

13.4

Aortic + mitral + pulmonary

0

0

Total

3,743

336

9.0

Note: Transcatheter procedures were excluded.


a Including Ross procedures.


Table V6

Mitral valve surgery—implantation/replacement versus repair

Mitral valve surgery

N

Total deaths

% death

% repair

Replacement

Repair

N

Deaths

% death

N

Deaths

% death

Isolated

5,631

229

4.1

65.8

1,923

169

8.8

3,708

60

1.6

Mitral valve +

Aortic valve

1,420

129

9.1

46.8

756

99

13.1

664

0

0.0

Tricuspid valve repair[a]

1,559

127

8.1

63.4

571

1

0.2

988

87

8.8

CABG

2,647

239

9.0

71.4

756

100

13.2

1,891

139

7.4

CABG + aortic valve replacement

661

112

16.9

58.5

274

56

20.4

387

56

14.5

Total

11,918

836

7.0

64.1

4,280

425

9.9

7,638

342

4.5

Abbreviation: CABG, coronary artery bypass grafting.


a Fifty-nine procedures (not specified mitral valve + tricuspid valve surgery) were excluded. Deaths: 22.0 (13/59).


Table V7

Transcatheter heart valve procedures

Total

Deaths

% death

With ECC

Without ECC

N

Deaths

N

Deaths

Aortic valve implantation

7,246

419

5.8

161

66

7,085

353

 Transvascular[a]

4,360

200

4.6

69

31

4,291

169

 Transapical

2,886

219

7.6

92

35

2,794

184

Mitral valve

462

14

3.0

8

2

454

12

 Repair

404

13

3.2

4

1

400

12

 Implantation[b]

58

1

1.7

4

1

54

0

Tricuspidal valve repair

3

1

33.3

0

0

3

1

Aortic + mitral valve implantation

10

1

10.0

0

0

10

1

Aortic valve implantation[b] + CABG

62

18

29.0

24

12

38

6

Total

7,783

453

5.8

193

80

7,590

373

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


Notes: Pulmonary valve implantation for the correction of congenital lesions are excluded, one procedure was reported for adults without congenital lesion; 39.8% of TAVI procedures were performed by transapical access, 2.2% of TAVI procedures were performed under the use of ECC. It has to be assumed that ECC was mostly used in emergency situations, which explains the mortality of 41.0% 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

40,410

1,187

2.9

CABG +

 TMLR

3

1

33.3

 Aneurysm resection

187

9

4.8

 Aortic valve replacement

7,893

371

4.7

 Transcatheter aortic valve implantation

62

18

29.0

 Mitral valve replacement

756

100

13.2

 Mitral valve repair

1,891

139

7.4

 Aortic + mitral valve replacement

274

56

20.4

 Aortic valve replacement + mitral valve repair

387

56

14.5

Other

2,398

134

5.6

Total

54,261

2,071

3.8

Abbreviations: CABG, coronary artery bypass grafting; ECC, extracorporeal circulation; TMLR, transmyocardial laser revascularization.


Table C2

Isolated CABG with ECC

Distal anastomosis

N

Deaths

%

Single

1,078

64

5.9

Double

7,113

260

3.7

Triple

14,977

480

3.2

Quadruple

8,247

186

2.3

Quintuple + more

2,742

77

2.8

Total

34,157

1,067

3.1

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


Table C3

Isolated CABG off-pump

Distal anastomosis

N

Deaths

%

Single

1,400

37

2.6

Double

1,780

38

2.1

Triple

2,176

38

1.7

Quadruple

756

7

0.9

Quintuple + more

141

0

0.0

Total

6,253

120

1.9

Abbreviation: CABG, coronary artery bypass grafting.


Table Con1

Congenital heart surgery with/without ECC

Age

N

Deaths

%

(A) Without ECC

 Older than 18 y

26

0

0.0

 1–17 y

144

3

2.1

 Younger than 1 y

685

18

2.6

Total A

855

21

2.5

(B) With ECC

 Older than 18 y

962

27

2.8

 1–17 y

1,712

15

0.9

 Younger than 1 y

2,047

67

3.3

Total B

4,721

109

2.3

Abbreviation: ECC, extracorporeal circulation.


Table Con2

Procedures for congenital heart disease with and without ECC

Lesion

Age < 1 y

Age 1–17 y

Age ≥ 18 y

N

Deaths

%

N

Deaths

%

N

Deaths

%

ASD

35

0

0.0

252

0

0.0

277

7

2.5

Complete AV canal

175

4

2.3

81

1

1.2

17

0

0.0

VSD

302

2

0.7

119

0

0.0

29

2

6.9

Fallot tetralogy

195

2

1.0

42

1

2.4

3

0

0.0

DORV

43

0

0.0

14

0

0.0

1

0

0.0

TGA

150

0

0.0

2

0

0.0

0

0

TGA + VSD

48

3

6.3

3

0

0.0

0

0

Truncus arteriosus

31

2

6.5

5

0

0.0

0

0

Fontan

4

0

0.0

246

3

1.2

6

1

16.7

Norwood

150

22

14.7

0

0

0

0

Pulmonary valve

66

1

1.5

226

0

0.0

71

2

2.8

Transcatheter pulmonary valve implantation

0

0

14

0

0.0

10

0

0.0

Aortic valve

48

3

6.3

195

0

0.0

276

3

1.1

Ross procedure

6

0

0.0

27

0

0.0

20

0

0.0

Mitral valve

41

1

2.4

109

3

2.8

94

5

5.3

Tricuspid valve

76

0

0.0

54

2

3.7

56

2

3.6

PDA

245

5

2.0

13

0

0.0

0

0

Coarctation

194

2

1.0

30

0

0.0

8

0

0.0

Transplantation heart

2

0

0.0

33

0

0.0

0

0

Transplantation heart + lung

0

0

0

0

0

0

Transplantation lung

0

0

12

1

8.3

0

0

Others

921

38

4.1

379

7

1.8

120

5

4.2

Total

2,732

85

3.1

1,856

18

1.0

988

27

2.7

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

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

replacement (Ross procedure)

In patients ≥ 18 y

250

235

228

261

207

175

184

134

117

107

In patients < 18 y

50

46

50

34

42

54

43

40

36

33

Total

300

281

278

295

249

229

227

174

153

140

Table Mis2

Organ transplantation

Transplantation

With ECC

Without ECC

N

Deaths

%

N

Deaths

%

Heart

301

41

13.6

Heart + lung

12

4

33.3

Lung

114

18

15.8

209

10

4.8

Abbreviation: ECC, extracorporeal circulation.


Notes: All pediatric transplantations (demonstrated in [Table Con2]) are included in this table. Eurotransplant (ET) has reported for the same period 297 heart transplantations (HTx), 2 heart + kidney transplantations, 1 heart + liver transplantations, 12 heart–lung transplantations (HLTx), 320 double lung (DLTx), 38 single lung transplantations (SLTx), 0 lung + kidney transplantations, and 0 lung + liver transplantations.


Table Mis3

Aortic surgery

Aortic surgery[a]

With ECC

Without ECC

N

Deaths

%

N

Deaths

%

Supracoronary ascending aorta replacement

1,634

115

7.0

Supracoronary ascending + aortic valve replacement

1,280

62

4.8

Infracoronary ascending aorta replacement

 Mechanical valve conduit

490

29

5.9

 Biological valve conduit

872

89

10.2

 David procedure

472

12

2.5

 Yacoub procedure

169

2

1.2

 Other

292

13

4.5

Aortic arch replacement[b]

1,680

212

12.6

Replacement of descending aorta

69

5

7.2

11

2

18.2

Thoraco-abdominal aortic replacement

81

13

16.0

26

4

15.4

Endostent descending aorta

6

0

0.0

589

37

6.3

Total

7,045

552

7.8

626

43

6.9

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


Notes: 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 Procedures for abdominal aortic diseases are not included: 549 abdominal procedures and 609 endovascular abdominal stents.


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


Table Mis4

Pacemaker and ICD procedures

Device/category

Total

Deaths

% death

With ECC

Without ECC

N

Deaths

N

Deaths

Pacemaker total

14,397

104

0.7

29

3

14,368

101

 Implantation

9,315

74

0.8

4

2

9,311

72

 Battery exchange

2,030

7

0.3

1

0

2,029

7

 Revision procedures

3,052

23

0.8

24

1

3,028

22

ICD total

9,942

82

0.8

29

7

9,913

75

 Implantation

4,613

24

0.5

0

0

4,613

24

 Battery exchange

2,022

2

0.1

0

0

2,022

2

 Revision procedures

3,307

56

1.7

29

7

3,278

49

Miscellaneous

1,399

7

0.5

1

0

1,398

7

Total

25,738

193

0.7

59

10

25,679

183

Table Mis5

Surgical ablation procedures

Energy source

Total

Endocardiac

Epicardiac

N

N

Unipolar radiofrequency

166

116

50

Unipolar cryoradiofrequency

421

246

175

Bipolar radiofrequency

2,348

296

2,052

Cryothermy

1,593

1,387

206

Microwave

13

2

11

Focused ultrasound

434

27

407

Laser

0

0

0

Other

4

0

4

Total

4,979

2,074

2,905

Notes: All isolated ablation procedures and all possible combination of procedures (e.g., CABG + ablation) are included. Total of n = 379 procedures are not specified with regard to endocardiac/epicardiac ablation.


Compared with the data of previous years, several important developments continued in 2013 almost unchanged. Over the past 10 years, the distribution of patient age ([Fig. 6]) showed a shift to older patients with presently 54.0% 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 decade (see [Fig. 2]). The rate of CABG decreased over the past years, while the relative number of off-pump CABG showed a slight increase to 15.5% (2012: 15.4%) ([Fig. 3]).

Since 2004, more than 50% of isolated mitral valve procedures are reconstructions, in 2013 mitral valve reconstruction could be achieved in 65.8% 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[25] patients with mitral valve stenosis, endocarditis, and emergency procedures were excluded. Therefore, the published rate of mitral valve repair must be interpreted with caution compared with this registry.

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

Zoom Image
Fig. 10 Development of mechanical circulatory support in Germany over the past 10 years. Significant increase of left ventricular assist device (LVAD) implantations. However, the number of implanted paracorporeal biventricular assist devices (BVAD) dropped down by 68% during the past 4 years. The number of total artificial heart implantations (TAH) remained on the same 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 2013 a total of 7,246 (38.1%) TAVI were reported to the registry. 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 does not correlate to the recommendations of the European guideline on the management of valvular heart disease, version 2012.[26]

In this context, the short-, mid-, and long-term results of the German Aortic Valve Registry[27] [28] 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 2013. The accuracy of this registry is considered to be high due to the implemented compilation algorithm using operation coding as a relevant criterion for reimbursement purposes. This is supported by other authors who could demonstrate a high accuracy for major outcome parameters in unaudited registries.[29] 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 continuous increase of patient age and related comorbidities, both leading to a higher preoperative risk profile.

Compared with 2012, 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 in sense of a contribution for patient safety and to adduce evidence for quality of cardiac surgery in Germany.


#
#

Acknowledgments

On behalf of the German Society for Thoracic and Cardiovascular Surgery, the authors 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

Anne-K. Funkat, Dr.-Ing
Klinik für Herzchirurgie, Herzzentrum Leipzig GmbH – Universitätsklinik
Strümpellstr. 39, 04289 Leipzig
Germany   


Zoom Image
Fig. 1 Cardiac surgery in Germany from 2004 to 2013. (1) Coronary artery bypass grafting (CABG) and combinations: all types of isolated coronary surgery with or without extracorporeal circulation (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.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures 2004 to 2013.
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting. The number of coronary artery bypass procedures declined since the year 2004 while the percentage of off-pump procedures slightly increased.
Zoom Image
Fig. 4 Isolated aortic valve replacement from 2004 to 2013 in Germany. The use of xenografts continuously increased till 2008 and remained almost the same since then. Aortic valve replacement (AVR) using mechanical prosthesis decreased over the past 10 years. The sustained difference in mortality seems to be related to the difference in age pattern. (Ross, homograft implantations, and transapical or transvascular aortic valve implantation [TAVI] are excluded.)
Zoom Image
Fig. 5 Isolated AVR and transapical or transvascular aortic valve implantation (TAVI). The figure shows almost unvaried quantity of AVR and an obvious increase of TAVI. In 2013, 38.1% of reported isolated aortic valve procedures were performed by transvascular or transapical implantation.
Zoom Image
Fig. 6 Age distribution of cardiac procedures since 2004. Currently, 54.0% of the patients are at least 70 years (patients < 20 years and ICD/pacemaker procedures are excluded).
Zoom Image
Fig. 7 Urgency 2004 and 2013.
Zoom Image
Fig. 8 Isolated mitral valve surgery over the past 10 years. In 65.8% mitral valve (MV) repairs and in 34.2% MV replacements were performed. In 1994, the rate of reconstruction just reached 21%.
Zoom Image
Fig. 9 Age distribution for 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 clearly 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 10 years. Significant increase of left ventricular assist device (LVAD) implantations. However, the number of implanted paracorporeal biventricular assist devices (BVAD) dropped down by 68% during the past 4 years. The number of total artificial heart implantations (TAH) remained on the same low level.