Thorac cardiovasc Surg 2017; 65(07): 505-518
DOI: 10.1055/s-0037-1606603
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

German Heart Surgery Report 2016: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery

Andreas Beckmann1, Anne-Katrin Funkat2, Jana Lewandowski1, Michael Frie3, Markus Ernst4, Khosro Hekmat5, Wolfgang Schiller6, Jan F. Gummert7, Wolfgang Harringer8
  • 1German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
  • 2Leipzig Heart Institute GmbH, Leipzig, Germany
  • 3FOM Hochschule für Oekonomie and Management, Essen, Germany
  • 4Clinic for Cardiac and Vascular Surgery, University of Kiel, Kiel, Germany
  • 5Department of Cardiac and Thoracic Surgery, University of Cologne, Cologne, Germany
  • 6Clinic for Cardiac Surgery, University of Bonn, Bonn, Germany
  • 7Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
  • 8Clinic for Cardiac, Thoracic and Vascular Surgery, Klinikum Braunschweig gGmbH, Braunschweig, Germany
Further Information

Address for correspondence

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

Publication History

14 August 2017

29 August 2017

Publication Date:
13 September 2017 (eFirst)

 

Abstract

Based on a long-standing voluntary registry founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2016 are analyzed. In 2016, a total of 103,128 heart surgery procedures (implantable defibrillator, pacemaker, and extracardiac procedures excluded) were submitted to the registry. Approximately 15.7% of the patients were at least 80 years of age, resulting in an increase of 0.9% compared with the data of 2015. For 37,614 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 4.4:1), an unadjusted in-hospital mortality of 2.9% was observed. Concerning the 33,451 isolated heart valve procedures (including 11,701 catheter-based procedures), the unadjusted in-hospital mortality was 4.3%.

This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, describes advancements in heart medicine, and is a basis for internal and external quality assurances for all participants. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate and patients are treated nationwide at all times.


#

Introduction

Legitimate demands for a sophisticated quality management in medicine—by authorities, scientific organizations, health care companies, and patients all over the world—have stimulated a quality awareness resulting in the development of versatile quality assurance activities such as benchmark projects, registries, and others to answer those needs. As early as 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 data collection of all cardiac surgical procedures in terms of a voluntary registry. Since 1989, the data are annually updated, summarized in registry format, and published in the scientific journal of the GSTCVS.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] The aims of this registry are to gather developments and upcoming trends in cardiac surgery in Germany; to compile various results for nearly all cardiac surgical procedures; to enable each participant a comparison of the reached individual institutional results to the nationwide achievements; and to facilitate an evaluation on an international level for the German society.

For monitoring actual conditions as well as developments in cardiac medicine, the registry covers all relevant techniques and also innovative technologies including minimally invasive cardiac surgery and all kinds of heart valve operations including transcatheter heart valve interventions (e.g. TAVI). Thereby, important findings for current patient safety and the future of patient care are collected and can be evaluated under different aspects.

Data and results presented in this report comprehend assorted data of the year 2016.


#

Materials and Methods

Since 2004, a standardized questionnaire gathers specific information for well-defined procedures exactly described by an annually updated German adaption of the International Classification of Procedures in Medicine called operation code (Operationen- und Prozedurenschlüssel).

All participating institutions were requested to complete the structured questionnaire by January 22, 2017, entering all performed procedures and associated in-hospital mortality. The recommended path for data export is an electronic transmission of an encrypted file to the office of the GSTCVS in Berlin. After transaction, the data are decrypted, evaluated for completeness, and compiled for further analysis, thus ensuring anonymity for each participating institution. This compilation algorithm guarantees a high compliance for submission of complete datasets.

Inclusion criteria for the registry 2016 were all cardiac surgical procedures performed on patients between January 1, 2016, and December 31, 2016, unrelated to the date of admission or discharge of the patients as compared with other registries. Like in the earlier years, the number of procedures was counted rather than individual patients. For example, if during one admission a patient initially required isolated mitral valve reconstruction later followed by a coronary artery bypass grafting (CABG) due to an undesirable event, one count in the category “mitral valve reconstruction” and a second one 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. Per definition, the observed mortality is always attributed to the first cardiac procedure, e.g. patient mortality will be attributed to an initial CABG procedure even if in a second procedure a replacement of the ascending aorta is performed due to a complication of the first operation. In case of fixing an undesirable event during the initial procedure, mortality will be counted under the more complex part of the operation.

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

In 2016, a total of 78 institutions performed heart surgery. Fortunately, all departments answered the questionnaire and delivered a complete dataset for the year 2016 including hospital mortality rates.


#

Registry Data 2016

[Table 1] gives an overview of cardiac surgical procedures by distribution between the 16 German states, based on the population count of the Federal Office for Statistics as of December 31, 2014. In this table, the range of heart operations per 100,000 inhabitants shows a minimum of 105.9 (Baden Württemberg) and a maximum of 168.8 (Sachsen-Anhalt), resulting in a nationwide mean value of 125.7 (2015: 126.6). Analyzing the heart operations by department dimension, 56% performed between 519 and 1,363 procedures ([Table 2]). Summarizing the departments by various heart surgical procedures, it can be determined that heart operations in patients for congenital heart disease (< 1 year, with extracorporeal circulation [ECC]) are conducted in 21 institutions and heart transplantations in 22 institutions ([Table 3]), in near accordance to the previous year. [Table 4] illustrates the number of procedures using ECC from 2007 to 2016 in Germany. Over the past decade, the number of heart operations using ECC shows a diminution by 12,536 procedures, certainly an achievement of established innovations and minimally invasive therapies in heart surgery.

Table 1

Heart operations/German states

German states

Quantity[a]

Population[b]

Heart procedures/100,000 inhabitants

Baden Württemberg

11,348

10,716,644

105.9

Bayern

14,159

12,691,568

111.6

Berlin

3,897

3,469,849

112.3

Brandenburg

3,332

2,457,872

135.6

Bremen

875

661,888

132.2

Hamburg

2,387

1,762,791

135.4

Hessen

7,599

6,093,888

124.7

Mecklenburg-Vorpommern

1,926

1,599,138

120.4

Niedersachsen

10,734

7,826,739

137.1

Nordrhein-Westfalen

23,134

17,638,098

131.2

Rheinland-Pfalz

5,360

4,011,582

133.6

Saarland

1,471

989,035

148.7

Sachsen

5,070

4,055,274

125.0

Sachsen-Anhalt

3,773

2,235,548

168.8

Schleswig-Holstein

4,078

2,830,864

144.1

Thüringen

2,945

2,156,759

136.5

Deutschland

102,088

81,197,537

125.7

a 1,018 foreign residents excluded.


b Federal Office for Statistics of Germany: Population; due date December 31, 2014.


Table 2

Units assorted by quantified categories (∑[a] [n = 103,128])

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Departments (number)

8

21

23

13

13

Average

387

817

1,156

1,698

2,632

Range

216–490

519–996

1,019–1,363

1,517–1,926

2,008–3,939

a Pacemaker/implantable cardioverter defibrillator and extracardiac surgery without ECC excluded.


Table 3

Departments summarized by heart surgery procedures 2016

Type of surgery performed

N

Coronary artery bypass grafting

77

Heart valve surgery

77

Surgery for CHD in pts <1 y with ECC

21[a]

HTx

22[b]

HLTx

4

Abbreviations: CHD, congenital heart disease; ECC, extracorporeal circulation; HTx, heart transplantation; HLTx, heart–lung transplantation; pts, patients; Tx, transplantation.


a N = 2,130: thereof: 15 to 19 procedures in 3 units, 30 to 49 procedures in 4 units, 57 to 94 procedures in 4 units, and 100 to 274 procedures in 10 units.


b N = 291: thereof: 1 to 3 Tx in four units, 5 to 9 Tx in eight units, 10 to 19 Tx in eight units, and 23 to 82 Tx in two units.


Table 4

Cardiac procedures using extracorporeal circulation (2007–2016)

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Units

80

79

80

79

78

79

79

78

78

78

Operations

91,618

89,773

86,916

84,686

84,402

84,388

84,040

83,787

81,527

79,082

Average

1,145

1,136

1,086

1,072

1,082

1,068

1,064

1,074

1,045

1,014

Overall, 184,789 procedures were reported to the registry for the year 2016 ([Table 5]), a decrease of 0.3% (2015: 185,270 procedures). A total of 103,128 heart surgical procedures (excluded: implantable cardioverter defibrillator, pacemakers, and miscellaneous procedures without ECC) in 2016 display a comparable quantity with a difference of 0.8% (n = 839) compared with 2015 (103,967 procedures) [Tables 6], [7], [V1] [V2] [V3] [V4] [V5] [V6] [V7], [C1], [C2], [Con1], [Con2], and [Mis1] [Mis2] [Mis3] [Mis4] [Mis5] and [Figs. 1] [2] [3] [4] [5] [6] [7] [8] [9] demonstrate various compiled registry data concerning 2016 under different aspects and for various categories.

Table 5

Frequency of cardiac procedures 2016

Category

With ECC

Without ECC

Total

Difference 2015 (%)

Coronary artery bypass grafting

42,813*

7,301*

50,114

−3.5

Heart valve procedures

21,877*

11,574*

33,451

+3.4

Surgery of thoracic aorta

7,369*

750*

8,119

+2.5

Surgery for CHD

4,762*

1,093*

5,855

−0.6

Cardiac surgery, other

1,072*

1,183*

2,255

−5.2

Assist device procedures**

789*

2,145*

2,934

−4.6

Extracardiac surgery

358*

57,023

57,381

+4.1

Pacemaker and ICD procedures

42*

24,638

24,680

−7.1

Total

79,082

105,707

184,789

−0.3

*Sum: n = 103,128 (heart surgery procedures).


**Sum: VADs/TAH/others devises (e.g. ECLS/ECMO).


Abbreviations: CHD, congenital heart disease; ECC, extracorporeal circulation; ICD, implantable cardioverter defibrillator; VADs; Ventricular assist devices; TAH, total artificial heart; ECLS, Extracoporeal life support; ECMO, Extracorporeal membrane oxygenation.


Table 6

Additional data for heart procedures with ECC in 2016 versus 2015

Procedures

2016

2015

Emergency

12,745

12.4%

12,843

12.4%

Redo

9,186

8.9%

8,994

8.7%

Abbreviation: ECC, extracorporeal circulation.


Table 7

Gender distribution

Female (%)

Male (%)

Heart valve procedures

43

57

Coronary procedures

23

77

Surgery for CHD

45

55

Surgery of thoracic aorta

34

66

Cardiac surgery, other

57

43

Assist devices

26

74

Pacemaker and ICD

36

64

Extracardiac surgery

35

65

Total

34

66

Abbreviations: CHD, congenital heart disease; ICD, implantable cardioverter defibrillator.


Table V1

Isolated valve procedures

Procedures

N

%

Single

17,855

680

3.8

Double

3,298

323

9.8

Triple

409

59

14.4

Transcatheter access (single valve)

11,701

363

3.1

Transcatheter access (double valve)

15

2

13.3

Not specified

173

9

5.2

Total

33,451

1,436

4.3

Note: Transcatheter valve procedures: 10,879 aortic valve implantations; 147 mitral valve implantations; 650 mitral valve repairs; 2 tricuspid valve implantations; 23 tricuspid valve repairs; 15 double aortic and mitral valve procedures; no pulmonary valve implantation.


Table V2

Single heart valve procedures: access type

Heart valve/access

N

%

Aortic valve

21,963

680

3.1

 Sternotomy

7,879

310

3.9

 Partial sternotomy

3,205

45

1.4

 Transvascular

8,792

231

2.6

 Transapical

2,087

94

4.5

Mitral valve

7,014

303

4.3

 Sternotomy

3,115

214

6.9

 Minimal invasive

3,102

52

1.7

 Transcatheter

797

37

4.6

Tricuspid valve

531

58

10.9

 Sternotomy

381

47

12.3

 Minimal invasive

125

10

8.0

 Transcatheter

25

1

4.0

Pulmonary valve

48

2

4.2

 Sternotomy

48

2

4.2

 Minimal invasive

0

0

 Transcatheter

0

0

Total

29,556

1,043

3.5

Table V3

Isolated aortic valve procedures

Prosthesis/native valve

N

%

Xenograft

9,722

322

3.3

Mechanical prosthesis

1,201

28

2.3

Repair

123

2

1.6

Homograft

38

3

7.9

Total

11,084

355

3.2

Table V4

Isolated mitral valve procedures

Prosthesis/native valve

N

%

Repair

3,908

49

1.3

Xenograft

1,821

190

10.4

Mechanical prosthesis

473

26

5.5

Homograft

15

1

6.7

Total

6,217

266

4.3

Note: Transcatheter procedures are excluded.


Table V5

Multiple heart valve procedures

Combination

N

%

Mitral + tricuspid

1,665

142

8.5

Aortic + mitral

1,401

157

11.2

Aortic + mitral + tricuspid

407

58

14.3

Aortic + tricuspid

160

24

15.0

Aortic + pulmonary[a]

54

0

0.0

Tricuspid + pulmonary

18

0

0.0

Aortic + mitral + pulmonary

2

1

50.0

Total

3,707

382

10.3

Note: Transcatheter procedures excluded.


a Including Ross procedures.


Table V6

Isolated/combined mitral valve surgery—implantation/replacement versus repair

Mitral valve surgery

Repair

Implantation/replacement

All procedures

N

%

N

%

N

% repair

%

Isolated

3,908

49

1.3

2,309

217

9.4

6,217

62,9

266

4.3

 + Aortic valve

563

42

7.5

838

115

13.7

1,401

40,2

157

11.2

 + Tricuspid valve repair[a]

977

44

4.5

631

86

13.6

1,608

60,8

130

8.1

 + CABG

1,585

107

6.8

976

157

16.1

2,561

61,9

264

10.3

 + CABG + aortic valve replacement

310

30

9.7

309

64

20.7

619

50,1

94

15.2

Total

7,343

272

3.7

5,063

639

12.6

12,406

59,2

911

7.3

a 57 procedures (not specified mitral valve + tricuspid valve surgery) were excluded; †: 21% (12/57).


Table V7

Transcatheter heart valve procedures

Without ECC

With ECC

All procedures

N

N

N

%

Aortic valve implantation

10,765

290

114

35

10,879

325

3

 Transvascular

8,731

206

61

25

8,792

231

3

 Transapical

2,034

84

53

10

2,087

94

5

Mitral valve

770

31

27

6

797

37

5

 Repair

628

20

22

1

650

21

3

 Implantation

142

11

5

5

147

16

11

Tricuspid valve repair

24

1

1

0

25

1

4

 Repair

22

1

1

0

23

1

4

 Implantation

2

0

0

0

2

0

0

Aortic + mitral valve implantation

15

2

0

0

15

2

13

Aortic valve implantation[a] + CABG

33

4

16

6

49

10

20

Mitral valve implantation[b] + CABG

0

0

3

1

3

1

33

Aortic + mitral valve + CABG

0

0

0

0

0

0

Total

11,607

328

161

48

11,768

376

3

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


Notes: Pulmonary valve implantation for the correction of congenital lesions is not included, No procedure was reported for adults without congenital lesion, 19% of transcatheter aortic valve implantation (TAVI) by transapical access; and 1% of TAVI under use of ECC.


a Femoral, subclavian, or transaortic access.


b Transvascular and transapical access.


Table C1

Isolated CABG and combined procedures with ECC

Procedures

N

%

Isolated CABG

37,614

1,080

2.9

 + aortic valve replacement

6,742

321

4.8

 + other

2,401

154

6.4

 + mitral valve repair

1,585

107

6.8

 + mitral valve replacement

976

157

16.1

 + aortic valve replacement + mitral valve repair

310

30

9.7

 + aortic + mitral valve replacement

309

64

20.7

 + aneurysm resection

125

9

7.2

 + transcatheter aortic valve implantation

49

10

20.4

Total

50,111

1,932

3.9

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


Table C2

Isolated CABG with/without ECC

Grafts (n)

With ECC

Without ECC

All

N

%

N

%

N

%

Single

1,013

59

5.8

1,488

45

3.0

2,501

104

4.2

Double

6,604

247

3.7

1,941

36

1.9

8,545

283

3.3

Triple

13,524

405

3.0

2,361

35

1.5

15,885

440

2.8

Quadruple

7,261

178

2.5

961

15

1.6

8,222

193

2.3

Quintuple + more

2,254

59

2.6

207

1

0.5

2,461

60

2.4

Total

30,656

948

3.1

6,958

132

1.9

37,614

1,080

2.9

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


Table Con1

Congenital heart surgery with/without ECC

Age (y)

N

%

With ECC

Without ECC

With ECC

Without ECC

With ECC

Without ECC

< 1

2,154

835

80

25

3.7

3.0

1–17

1,672

238

18

3

1.1

1.3

≥ 18

1,001

20

33

1

3.3

5.0

Total

2,673

258

51

4

1.9

1.6

Abbreviation: ECC, extracorporeal circulation.


Table Con2

Procedures for congenital heart disease with and without ECC

Lesion/procedure

Age < 1 y

Age 1–17 y

Age  ≥ 18 y

N

%

N

%

N

%

ASD

35

0

0.0

245

0

0.0

272

4

1.5

Complete AV canal

213

5

2.3

75

1

1.3

13

0

0.0

VSD

295

0

0.0

110

0

0.0

20

0

0.0

Fallot's tetralogy

188

3

1.6

52

0

0.0

5

0

0.0

DORV

56

2

3.6

15

0

0.0

1

0

0.0

TGA

171

1

0.6

3

0

0.0

0

0

TGA + VSD

54

3

5.6

5

0

0.0

0

0

Truncus arteriosus

35

2

5.7

8

0

0.0

1

0

0.0

Fontan

2

0

0.0

214

1

0.5

8

1

12.5

Norwood

183

30

16.4

2

1

50.0

0

0

Pulmonary valve

64

1

1.6

199

2

1.0

71

4

5.6

Transcatheter pulmonary valve implantation

0

6

0

0.0

3

0

0.0

Aortic valve

50

1

2.0

188

5

2.7

347

8

2.3

Ross procedure

9

0

0.0

29

0

0.0

29

0

0.0

Mitral valve

35

1

2.9

100

0

0.0

86

9

10.5

Tricuspid valve

68

3

4.4

58

2

3.4

45

3

6.7

PDA

214

8

3.7

28

0

0.0

1

0

0.0

Coarctation

208

1

0.5

38

0

0.0

3

0

0.0

Others

1,105

44

4.0

481

7

1.5

116

5

4.3

HTx

4

0

0.0

38

1

2.6

0

0

HLTx

0

2

0

0.0

0

0

LTx

0

14

1

7.1

0

0

Total

2,989

105

3.5

1,910

21

1.1

1,021

34

3.3

Abbreviations: ASD, atrial septal defect; AV, atrioventricular; DORV, double outlet right ventricle; ECC, extracorporeal circulation; HLTx, heart–lung transplantation; HTx, heart transplantation; LTx, lung transplantation; PDA, patent ductus arteriosus; TGA, transposition of the great arteries; VSD, ventricular septal defect.


Table Mis1

Ross procedures (autologous aortic and pulmonary valve replacement)

Age (y)

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

< 18

34

42

54

43

40

36

33

37

28

38

≥ 18

261

207

175

184

134

117

107

90

64

72

Total

295

249

229

227

174

153

140

127

92

110

Abbreviation: AV, aortic valve.


Table Mis2

Heart and lung transplantation

Organ

With ECC

Without ECC

N

%

N

%

HTx

291

38

13.1

HLTx

7

0

0.0

LTx

53

10

18.9

247

14

5.7

Abbreviations: HTx, heart transplantation; HLTx, heart–lung transplantation; LTx, lung transplantation; Tx, transplantation.


Notes: All pediatric transplantations (demonstrated in [Table Con2]) are included in this table, Eurotransplant report 2016: 287 HTx, 2 HTx + kidneyTx, 1 HTx + liverTx, 7 HLTx, 281 double lung transplantation, 38 single lung transplantation, 0 LTx + kidneyTx, and 2 LTx + liverTx.


Table Mis3

Aortic surgery

Replacement[a]

With ECC

Without ECC

N

%

N

%

Supracoronary replacement of ascending aorta

1,383

128

9.3

Supracoronary ascending + aortic valve replacement

1,325

69

5.2

Infracoronary ascending

 Mechanical valve conduits

441

33

7.5

 Biological valve conduits

999

110

11.0

 David procedure

537

15

2.8

 Yacoub procedure

120

5

4.2

 Other

286

21

7.3

Aortic arch replacement[b]

2,117

246

11.6

Replacement of descending aorta

43

20

46.5

7

1

14.3

Thoracoabdominal aortic replacement

101

16

15.8

24

5

20.8

Endostent descending aorta

17

0

0.0

719

46

6.4

Total

7,369

663

9.0

750

52

6.9

Abbreviation: 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 coronary artery bypass grafting) are summarized in this category.


a Procedures for abdominal aortic diseases excluded: 449 abdominal procedures and 734 endovascular abdominal stents.


b All possible combined procedures included, the only common denominator is aortic arch surgery.


Table Mis4

Pacemaker and ICD procedures

Device/category

With ECC

Without ECC

N

%

N

N

Pacemaker

13,882

118

0.9

25

4

13,857

114

 Implantation

8,968

71

0.8

8

1

8,960

70

 Battery exchange

1,907

2

0.1

2

0

1,905

2

 Revision procedures

3,007

45

1.5

15

3

2,992

42

ICD

9,368

85

0.9

17

2

9,351

83

 Implantation

4,140

21

0.5

2

1

4,138

20

 Battery exchange

2,019

3

0.1

0

0

2,019

3

 Revision procedures

3,209

61

1.9

15

1

3,194

60

Miscellaneous

1,430

11

0.8

0

0

1,430

11

Total

24,680

214

0.9

42

6

24,638

208

Abbreviations: ECC, extracorporeal circulation; ICD, implantable cardioverter defibrillator.


Table Mis5

Surgical ablation procedures for tachyarrhythmia

Energy source

Total

Endocardiac

Epicardiac

N

N

Unipolar radiofrequency

200

65

135

Unipolar cryo-radiofrequency

241

109

132

Bipolar radiofrequency

2,210

223

1,987

Cryothermy

1,523

1,307

216

Microwave

13

3

10

Focused ultrasound

89

22

67

Laser

0

0

0

Other

29

14

15

Total

4,305

1,743

2,562

Note: 419 procedures are not specified with regard to endocardiac/epicardiac ablation.


Zoom Image
Fig. 1 Selected heart surgical categories (2007–2016). (1) CABG and combined procedures: all types of coronary surgery. (2) Heart valve procedures: combination with aortic surgery summarized under miscellaneous procedures. (3) Congenital heart surgery: ASD repairs in adults or in combination with CABG or heart valve procedures are summarized in the CABG or heart valve procedure groups. (4) Miscellaneous procedures: all other types of procedures with ECC. ASD, atrial septal defect; CABG, coronary artery bypass grafting; ECC, extracorporeal circulation.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2007–2016). AV, aortic valve; CABG, coronary artery bypass grafting; MV, mitral valve; TAVI, transcatheter heart valve intervention.
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (2007–2016).
Zoom Image
Fig. 4 Isolated aortic valve replacement (2007–2016). Notes: Ross procedures, homograft implantations, and transcatheter heart valve intervention excluded.
Zoom Image
Fig. 5 Isolated aortic valve replacement and transcatheter aortic valve implantation (TAVI) The annual count of TAVI submitted to the voluntary registry of German Society for Thoracic and Cardiovascular Surgery does not represent all TAVI procedures performed in Germany in 2016. +Additional TAVI procedures calculated from the German legal quality assurance program, § 137 SGB V.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2007–2016). Notes: Patients < 20 years and pacemaker/implantable cardioverter defibrillator procedures were excluded.
Zoom Image
Fig. 7 Urgency categories (2007 vs. 2016) Emergency = acutely life-threatening cardiac/vascular disease.
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Fig. 8 Isolated mitral valve surgery (2007–2016).
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Fig. 9 Age distribution for CHD (2007–2016). Notes: Bias possible due to the fact that not all relevant procedures can be allocated exactly to CHD category in patients older than 18 years (e.g., aortic valve disease). CHD, congenital heart disease.

Compared with the data of previous years, several important developments continued in 2016 almost unchanged. The age distribution of patients ([Fig. 6]) shows a continuous shift to an elderly patient population with presently 52.8% of the cardiac procedures performed in patients of at least 70 years of age and 15.7% in octogenarians. However, mortality remained on the same low level over the represented decade ([Fig. 2]). In this context it has to be noted that all designated mortality rates of this registry are unadjusted values. This must be taken into account for any interpretation. The rate of CABG procedures decreased over the past decade, while the relative number for off-pump CABG now reached a level of 18.5% (2015: 16.5%) ([Fig. 3]).

A still ongoing trend is the increase of TAVI procedures in Germany ([Fig. 5], [Table V7]), while the count of isolated aortic valve replacement procedures remained on a comparable level with just a slight decrease of 2.0%. Starting in 2006 with just 78 implantations (0.67% of isolated aortic valve procedures), in 2016 a total of 10,879 (49.8%) TAVIs was reported to the registry. It must be emphasized that the 78 institutions which contribute their data to this registry do not represent all departments performing TAVI in Germany. In each case, the proceeding must correlate to the recommendations of international guidelines.[28] [29] [30] For the German health service, a quality assurance directive for “minimally invasive heart valve interventions (TAVI, mitral valve clip reconstruction)” came into effect by law in July 2015, in which obligatory structures, defined processes, and qualified personnel are precisely specified. In addition to this registry responding to the directive of the Federal Joint Committee (G-BA), the results of the voluntary German Aortic Valve Registry[31] [32] [33] [34] [35] [36] [37] [38] as well as the annual analyses for selected procedures in the context of the legally compulsory quality assurance (§137 SGB V) contribute to an exceptional patient benefit.

Since 2004, more than 50% of isolated mitral valve procedures have been reconstructions. In 2016, a mitral valve reconstruction could be achieved in 62.9% of the procedures ([Fig. 8]). Based on the fact that all isolated mitral valve procedures are included without exception, regardless of the underlying valve disease concerning 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,[39] patients with mitral valve stenosis, endocarditis, and emergency procedures are usually excluded. Therefore, the published rates of mitral valve repair have to be interpreted with caution if compared with this registry.

The continued increase of left ventricular assist device implantations ([Fig. 10]) emphasizes the importance of mechanical circulatory support therapies, while biventricular assist device and total artificial heart implantations are of subordinate importance with only 3.6%.

Zoom Image
Fig. 10 Development of mechanical circulatory support (2007–2016). BVAD, biventricular assist device; LVAD, left ventricular assist device; TAH, total artificial heart.

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Discussion

The registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in Germany in 2016. The accuracy of this registry is considered to be high due to the implemented compilation algorithm using standardized operation coding which is 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.[40] In continuation with previous years, it can be concluded that heart surgery in Germany is performed on a constantly high level with superior in-hospital patient survival rates compared with international registries. In addition, the registry demonstrates that the German heart surgical provision is appropriate and the treatment of patients is guaranteed nationwide at any time (24/7/365). These aspects are especially important in the context of various activities in health care policy and the demographic change of the German population leading to an increase of patient age and related comorbidities and resulting in higher preoperative risk profile.

Compared with 2015, the number of cardiac surgery procedures remains on nearly the same level, due to the continuous increase of catheter-based heart valve procedures.

Further improvements in the basic configuration of the registry are recommended to enable more detailed and particularly risk-adjusted data analyses. 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 departments in Germany. This will be of outstanding importance in the sense of a contribution for patient safety and to obtain evidence for the high quality of heart surgery in Germany.


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No conflict of interest has been declared by the author(s).

Acknowledgments

On behalf of the German Society for Thoracic and Cardiovascular Surgery, the authors would like to thank the heads of the departments and their employees of all cardiac surgery units in Germany for their continued cooperation and support to realize this registry.


Address for correspondence

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


Zoom Image
Fig. 1 Selected heart surgical categories (2007–2016). (1) CABG and combined procedures: all types of coronary surgery. (2) Heart valve procedures: combination with aortic surgery summarized under miscellaneous procedures. (3) Congenital heart surgery: ASD repairs in adults or in combination with CABG or heart valve procedures are summarized in the CABG or heart valve procedure groups. (4) Miscellaneous procedures: all other types of procedures with ECC. ASD, atrial septal defect; CABG, coronary artery bypass grafting; ECC, extracorporeal circulation.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2007–2016). AV, aortic valve; CABG, coronary artery bypass grafting; MV, mitral valve; TAVI, transcatheter heart valve intervention.
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (2007–2016).
Zoom Image
Fig. 4 Isolated aortic valve replacement (2007–2016). Notes: Ross procedures, homograft implantations, and transcatheter heart valve intervention excluded.
Zoom Image
Fig. 5 Isolated aortic valve replacement and transcatheter aortic valve implantation (TAVI) The annual count of TAVI submitted to the voluntary registry of German Society for Thoracic and Cardiovascular Surgery does not represent all TAVI procedures performed in Germany in 2016. +Additional TAVI procedures calculated from the German legal quality assurance program, § 137 SGB V.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2007–2016). Notes: Patients < 20 years and pacemaker/implantable cardioverter defibrillator procedures were excluded.
Zoom Image
Fig. 7 Urgency categories (2007 vs. 2016) Emergency = acutely life-threatening cardiac/vascular disease.
Zoom Image
Fig. 8 Isolated mitral valve surgery (2007–2016).
Zoom Image
Fig. 9 Age distribution for CHD (2007–2016). Notes: Bias possible due to the fact that not all relevant procedures can be allocated exactly to CHD category in patients older than 18 years (e.g., aortic valve disease). CHD, congenital heart disease.
Zoom Image
Fig. 10 Development of mechanical circulatory support (2007–2016). BVAD, biventricular assist device; LVAD, left ventricular assist device; TAH, total artificial heart.