Thorac cardiovasc Surg 2015; 63(04): 258-269
DOI: 10.1055/s-0035-1551676
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Cardiac Surgery in Germany during 2014: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

Andreas Beckmann1, Anne-Kathrin Funkat2, Jana Lewandowski1, Michael Frie3, Markus Ernst4, Khosro Hekmat5, Wolfgang Schiller6, Jan F. Gummert7, Joachim Thomas Cremer4
  • 1German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
  • 2Clinic for Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Germany
  • 3FOM Hochschule fuer Oekonomie & Management, Essen, Germany
  • 4Clinic for Cardiac and Vascular Surgery, University Kiel, Kiel, Germany
  • 5Department of Cardiothoracic Surgery, University of Cologne, Köln, Germany
  • 6Clinic for Cardiac Surgery, University of Bonn, Bonn, Germany
  • 7Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
Further Information

Address for correspondence

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

Publication History

24 March 2015

27 March 2015

Publication Date:
26 May 2015 (eFirst)

 

Abstract

Based on a voluntary registry of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), data of all heart surgery procedures performed in 78 German cardiac surgical units during the year 2014 are presented. In 2014, a total of 100,398 cardiac surgical procedures (implantable cardioverter-defibrillator and pacemaker procedures excluded) were submitted to the registry. More than 14.2% of the patients were older than 80 years, describing an increase of 0.4% compared with the previous year. The unadjusted in-hospital mortality for 40,006 isolated coronary artery bypass grafting procedures (84.7% on-pump, 15.3% off-pump) was 2.6%. In 31,359 isolated valve procedures (including 9,194 catheter-based procedures), an in-hospital mortality of 4.4% was observed. This annual updated registry of the GSTCVS is published since 1989. It is an important tool for quality assurance and voluntary public reporting by illustrating current standards and actual developments for nearly all cardiac surgical procedures in Germany.


#

Introduction

Legitimate demands for a sophisticated 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 activities 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) (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 annually updated data of the registry are 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] The aims of this registry are to gather developments and current trends in cardiac surgery in Germany, compiling various results for nearly all cardiac surgical procedures, enabling each participating cardiac surgical unit a comparison of its own results to the nationwide achievements, and enabling an evaluation on an international level for the society.

For monitoring actual conditions as well as the development in cardiac medicine, the registry covers all relevant techniques and also innovative technologies including off-pump cardiac surgery, minimally invasive heart valve operations, and transcatheter aortic valve implantations [TAVI]. Thereby important findings for current patient safety and the future of patient care may be collected and evaluated.

Data and results presented in this report comprehend assorted data of the year 2014.


#

Materials and Methods

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

All participants were requested to complete the structured questionnaire until January 16, 2015, 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 has to be addressed 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 2014 were all patients receiving cardiac surgical procedures performed between January 1, 2014, and December 31, 2014, 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 bypass grafting 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 operated patients.

Death of patients was defined as in-hospital mortality. Per definition, the observed mortality is always attributed to the first cardiac procedure; for example, the death of a patient requiring coronary bypass grafting 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 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 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 2014, a total of 78 institutions performed heart surgery. Fortunately all units answered the questionnaire and delivered a complete dataset for the year 2014 including hospital mortality rates.


#

Registry Data 2014

[Table 1] illustrates the development of procedures using extracorporeal circulation (ECC) in Germany over one decade. Since 2010, the number of heart operations using ECC shows only a slight decline.

Overall 187,392 procedures were reported to the registry for the year 2014, an increase of 3.9% (2013: 180,367 procedures). A total of 104,484 cardiac surgical procedures (excluded: ICD, pacemakers and miscellaneous procedures without ECC) reveal an increase of 1.6% (n = 1,639) compared with the year 2013 (102,845 procedures) ([Table 2]). [Tables 3] to [4] [5], [V1] to [V2] [V3] [V4] [V5] [V6] [V7], [C1] to [C2], [C3], [Table Con1] and [Con2], and [Table Mis 1] to [Mis 2] [Mis 3] [Mis 4] [Mis 5] and [Figs. 1] [2] [3] [4] [5] [6] [7] [8] [9] demonstrate the compiled registry data of 2014 for various categories.

Compared to the data of previous years, several important developments continued in 2014 almost unchanged. Over the past 10 years, the age distribution of patients ([Fig. 6]) showed a shift to elderly patients with presently 54.3% of the cardiac procedures performed in patients of at least 70 years of age and 14.2% in patients of 80 years or older. However, mortality remained on the same low level or even decreased slightly over the last decade ([Fig. 2]). The rate of coronary artery bypass grafting (CABG) procedures decreased over the past years while the relative number of off-pump CABG showed no relevant variation (2014: 15.3%, 2013: 15.5%) ([Fig. 3]).

Since 2004, more than 50% of isolated mitral valve procedures were reconstructions. In 2014, the mitral valve reconstruction rate was 65.7% ([Fig. 8]). Based on the fact that all isolated mitral valve procedures are included in this registry, these data have to be interpreted with caution. Regardless of the underlying valve disease/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, [26] patients with mitral valve stenosis, endocarditis, and emergency procedures were excluded.

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

Again a remarkable trend is the still ongoing increase of TAVI procedures in Germany ([Fig. 5]), while the number of isolated aortic valve replacement procedures remained on a nearly unchanged level. Starting in 2006 with just 78 implantations (0.67% of isolated aortic valve procedures), in 2014 a total of 8,631 (42.3%) TAVIs were 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. It is well known that some additional institutions in Germany perform TAVI procedures under different infrastructure conditions and various external cooperations. This practice does not correlate to the recommendations of the European guideline[27] on the management of valvular heart disease. Considering this background, on January 22, 2015, the Federal Joint Committee (G-BA)—as the highest decision-making body of the joint self-government in Germany—issued the first version of the quality assurance directive for “minimal invasive heart valve interventions (TAVI, Mitral Clip reconstruction)” in which obligatory structures, defined processes, and qualified personnel are exactly specified.[28]

In addition, the short-, mid-, and long-term results of the German Aortic Valve Registry (GARY)[29] [30] [31] [32] [33] and the annual analyses of the legal quality assurance (§137 SGB V) are of outstanding patient benefit.


#

Discussion

The registry of the GSTCVS enables a comprehensive overview of all cardiac surgical procedures performed in Germany during 2014. The accuracy of this registry is considered to be high due to the implemented compilation algorithm using standardized 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.[30] In continuation with previous years, it can be concluded that cardiac surgery in Germany is performed on a constantly high level with high in-hospital survival rates 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 2013, the count of cardiac surgery procedures remains almost on the same level, which is partly due to the still increasing number of catheter-based heart valve procedures.

Further improvements in the basic configuration of the registry are recommended to enable a more detailed and particularly a risk-adjusted data analyses.[34] 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 the sense of a contribution for patient safety and to adduce evidence for the quality of cardiac surgery in Germany.


#
Appendix: Tables and Figures
Table 1

Open heart procedures using extracorporeal circulation (2005–2014)

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

Units

79

80

80

79

80

79

78

79

79

78

Operations

91,967

91,057

91,618

89,773

86,916

84,686

84,402

84,388

84,040

83,787

Average per unit

1,164

1,138

1,145

1,136

1,086

1,072

1,082

1,068

1,064

1,074

Table 2

Cardiac surgery categories (comparison: 2014 vs. 2013)

Category

With ECC

Without ECC

Total

% change

Heart valve procedures

22,335

9,024

31,359

+ 5.7

Coronary artery bypass grafting

47,246

6,559

53,805

− 0.8

Surgery for congenital heart disease

4,755

1,024

5,779

+ 3.6

Surgery of thoracic aorta

7,117

638

7,755

+ 1.1

Cardiac surgery, other

1,172

1,302

2,474

− 5.5

Assist device procedures

760

2,150

2,910

+ 9.5

Pacemaker and ICD procedures

40

26,212

26,252

+ 2.0

Extracardiac surgery

362

56,696

57,058

+ 9.4

Total

83,787

103,605

187,392

+ 3.9

Abbreviation: ECC, extracorporeal circulation.

Table 3

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

Quantity of operations

< 500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Number of units

7

20

26

12

13

Average per unit

342

928

1,152

1,864

2,087

Min–Max

238–427

546–988

1,027–1,495

1,513–1,992

2,045–3,972

Abbreviation: ECC, extracorporeal circulation.

Table 4

Total number of units according to surgical procedures in 2014

Type of surgery performed

Number of units

Coronary artery bypass grafting

77

Heart valve surgery

77

Surgery for CHD in children <1 y with ECC

23a

Heart transplantation

21b

Heart–lung transplantation

5

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

a n = 2,090 thereof: 7–19 procedures in 4 units, 23–47 procedures in 4 units, 59–90 procedures in 7 units, 104–296 procedures in 8 units.

b n = 294: 58% of heart transplantations (HTx) in 2014 were performed by 6 of 21 units with ≥ 15 HTx per year; thereof: 1–3 HTx in 4 units, 5–9 HTx in 5 units, 12–18 HTx in 10 units, 21–85 HTx in 2 units.

Table 5

Additional data for cardiac procedures with ECC in 2014 and 2013

2014

2013

Emergency operations

12,583

12.0%

11,944

11.6%

Redo procedures

8,809

8.4%

8,284

8.1%

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

Table V1

Isolated valve procedures (categories)

Procedures

N

Deaths

%

Single

18,408

625

3.4

Double

3,288

314

9.5

Triple

372

50

13.4

Transcatheter access (single value)

9,184

386

4.2

Transcatheter access (double value)

10

1

10.0

Not specified

97

8

8.2

Total

31,359

998

3.2

Notes: Combined procedures (with coronary artery bypass grafting, aortic surgery) are excluded.

Transcatheter valve procedures: 8,631 aortic valve implantations; 91 mitral valve implantations; 457 mitral valve repairs; 3 tricuspid valve implantations; 2 tricuspidal valve repairs; 10 combined procedures, aortic and mitral valve procedure; no pulmonary valve implantation.

Table V2

Single valve procedures (access type)

Heart valve/access

N

Deaths

%

Aortic valve

 Sternotomy

9,100

282

3.1

 Partial sternotomy

2,781

43

1.5

 Transvascular

5,570

184

3.3

 Transapical

3,061

167

5.5

Mitral valve

 Sternotomy

3,121

200

6.4

 Minimal invasive

2,792

43

1.5

 Transcatheter

548

33

6.0

Tricuspid valve

 Sternotomy

428

50

11.7

 Minimal invasive

133

6

4.5

 Transcatheter

5

2

40.0

Pulmonary valve

 Sternotomy

50

1

2.0

 Minimal invasive

2

0

0.0

 Transcatheter

0

0

Total

27,591

1,011

3.7

Notes: The absolute quantity of isolated aortic valve procedures via sternotomy remained on a constant level counting 11,881 in 2014 compared with 11,891 procedures in 2013.

A total of 2,792 (47.2%) mitral valve procedures were performed by a minimally invasive access.

Transcatheter procedures and apical aortic conduits procedures (n = 1) are not included.

Table V3

Isolated aortic valve procedures (prosthesis)

Prosthesis/native valve

N

Deaths

%

Mechanical prosthesis

1,360

29

2.1

Xenograft

10,375

292

2.8

Homograft

29

2

6.9

Reconstruction

117

2

1.7

Total

11,881

325

2.7

Notes: A total of 2,781 (23.4%) procedures were performed by a partial sternotomy. Transcatheter procedures and apical aortic conduits procedures (n = 1) are not included.

Table V4

Isolated mitral valve procedures (prosthesis)

Prosthesis/native valve

N

Deaths

%

Mechanical prosthesis

488

34

7.0

Xenograft

1,530

145

9.5

Homograft

8

1

12.5

Reconstruction

3,887

63

1.6

Total

5,913

243

4.1

Notes: A total of 2,792 (47.2%) were performed via minimally invasive access. Transcatheter procedures are excluded.

Table V5

Multiple valve procedures (categories)

Combination

N

Deaths

%

Aortic + mitral

1,335

144

10.8

Mitral + tricuspid

1,640

145

8.8

Aortic + tricuspid

220

22

10.0

Tricuspid + pulmonary

11

2

18.2

Aortic + pulmonarya

82

1

1.2

Aortic + mitral + tricuspid

369

49

13.3

Aortic + mitral + pulmonary

3

1

33.3

Total

3,660

364

9.9

Note: Transcatheter procedures are excluded.

aIncluding Ross procedures.

Table V6

Mitral valve surgery—implantation/replacement versus repair

Mitral valve surgery

N

Total deaths

% death

% repair

Implantation/replacement

Repair

N

Deaths

% death

N

Deaths

% death

Isolated

5,913

243

4.1

65.7

2,026

180

8.9

3,887

63

1.6

Mitral valve + aortic valve

1,335

144

10.8

47.0

707

104

14.7

628

0

0.0

Tricuspid valve repaira

1,602

137

8.6

65.5

552

1

0.2

1,050

81

7.7

CABG

2,630

256

9.7

70.1

787

124

15.8

1,843

132

7.2

CABG + aortic valve replacement

658

113

17.2

55.9

290

58

20.0

368

55

14.9

Total

12,138

893

7.4

64.1

4,362

467

10.7

7,776

331

4.3

aThirty-eight procedures (not specified mitral valve + tricuspid valve surgery) are excluded. Deaths: 21.1 (8/38).

Table V7

Transcatheter heart valve procedures

Total

Deaths

% death

With ECC

Without ECC

N

Deaths

N

Deaths

Aortic valve implantation

8,631

351

4.1

136

38

8,495

313

 Transvascular

5,570

184

3.3

58

18

5,512

166

 Transapical

3,061

167

5.5

78

20

2,983

147

Mitral valve

548

33

6.0

30

7

518

26

 Repair

457

19

4.2

21

1

436

18

 Implantation

91

14

15.4

9

6

82

8

Tricuspid valve repair

5

2

40.0

0

5

2

Repair

2

1

50.0

0

2

1

Implantation

3

1

33.3

0

3

1

Aortic + mitral valve implantation

10

1

10.0

4

0

6

1

Aortic valve implantationa + CABG

46

12

26.1

17

6

29

6

Mitral valve implantationb + CABG

2

1

50.0

1

1

1

0

Total

9,242

400

4.3

188

52

9,054

348

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

Notes: Pulmonary valve implantations for the correction of congenital heart defects are not included; no procedure for adults without congenital lesion was reported; 35.5% of transcatheter aortic valve implantations (TAVIs) were performed by transapical access; 1.6% of TAVI procedures were performed using ECC.

It has to be assumed that use of ECC is mostly an emergent procedure in a life-threatening situation for the patient resulting in an observed mortality of 27.9% in this group. Nevertheless, this underlines the necessity of well-defined directives including infrastructure, processes, and qualified employees for invasive heart valve procedures (e.g., TAVI).

aFemoral, subclavian, or transaortic access.

bTransvascular and transapical access.

Table C1

Isolated CABG and combined procedures with ECC

Procedures

N

Deaths

%

CABG

40,006

1,042

2.6

CABG +

 Aortic valve replacement

7,809

382

4.9

 Mitral valve repair

1,843

132

7.2

 Mitral valve replacement

787

124

15.8

 Aortic valve replacement + mitral valve repair

368

55

14.9

 Aortic + mitral valve replacement

290

58

20.0

 Aneurysmal resection

152

5

3.3

 Transcatheter aortic valve implantation

46

12

26.1

 TMLR

0

 Other

2,502

131

5.2

Total

53,803

1,941

3.6

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

Table C2

Isolated CABG with ECC

Number of grafts

N

Deaths

%

Single

1,193

63

5.3

Double

7,146

243

3.4

Triple

15,018

401

2.7

Quadruple

8,099

182

2.2

Quintuple + more

2,422

54

2.2

Total

33,878

943

2.8

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

Table C3

Isolated CABG off-pump

Number of grafts

N

Deaths

%

Single

1,361

17

1.2

Double

1,765

42

2.4

Triple

2,092

29

1.4

Quadruple

751

8

1.1

Quintuple + more

159

3

1.9

Total

6,128

99

1.6

Abbreviation: CABG, coronary artery bypass grafting.

Table Con1

Congenital heart surgery with/without ECC

Age (y)

N

Deaths

%

Without ECC

 ≥ 18

37

0

0.0

 1–17

195

0

0.0

 < 1

792

24

3.0

Total

1024

24

2.3

With ECC

 ≥ 18

934

26

2.8

 1 to 17

1731

11

0.6

 < 1

2090

59

2.8

Total

4755

96

2.0

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

52

1

1.9

263

0

0.0

266

4

1.5

Complete AV-canal

193

6

3.1

77

2

2.6

24

1

4.2

VSD

318

3

0.9

89

0

0.0

18

0

0.0

Fallot tetralogy

202

2

1.0

30

1

3.3

1

0

0.0

DORV

49

0

0.0

23

1

4.3

0

TGA

142

2

1.4

6

0

0.0

0

TGA + VSD

62

2

3.2

17

0

0.0

1

0

0.0

Truncus arteriosus

42

2

4.8

5

0

0.0

0

Fontan

1

0

0.0

232

1

0.4

6

0

0.0

Norwood

160

19

11.9

0

0

Pulmonary valve

58

1

1.7

249

0

0.0

86

1

1.2

Transcatheter pulmonary valve implantation

0

7

0

0.0

14

0

0.0

Aortic valve

59

0

0.0

215

0

0.0

304

9

3.0

Ross procedure

10

3

30.0

27

0

0.0

13

1

7.7

Mitral valve

48

0

0.0

111

1

0.9

88

6

6.8

Tricuspid valve

88

1

1.1

70

0

0.0

42

4

9.5

PDA

251

5

2.0

13

0

0.0

2

0

0.0

Coarctation

202

1

0.5

35

0

0.0

9

0

0.0

Heart transplant

4

0

0.0

25

0

0.0

0

Heart + lung transplant

0

0

0

Lung transplant

0

10

0.0

0

Others

962

35

3.6

451

6

1.3

97

0

0.0

Total

2903

83

2.9

1955

12

0.6

971

26

2.7

Abbreviations: ASD, atrial septal defect; DORV, double outlet right ventricle; ECC, extracorporeal circulation; PDA, persistant ductus arteriosus; TGA, transposition of great arteries; VSD, ventricular septal defect.

Table Mis1

Ross procedures (age groups)

Autologous AVR and PVR

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

In patients ≥ 18 y

235

228

261

207

175

184

134

117

107

90

In patients < 18 y

46

50

34

42

54

43

40

36

33

37

Total

281

278

295

249

229

227

174

153

140

127

Table Mis2

Heart and lung transplantation

With ECC

Without ECC

N

Deaths

%

N

Deaths

%

HTx

294

33

11.2

HLTx

9

4

44.4

LTx

62

7

11.3

244

13

5.3

Abbreviation: ECC, extracorporeal circulation.

Notes: All pediatric transplantations (demonstrated in table Con3) are included in this table.

Eurotransplant (ET) has reported for the same period 292 heart transplantations (HTx), 3 heart + kidney transplantations, 0 heart + liver transplantations, 9 heart–lung transplantations (HLTx), 296 double lung (DLTx), 46 single lung transplantations (SLTx), 0 lung + kidney transplantations, and 1 lung + liver transplantations.

Table Mis3

Aortic surgery

Replacementa

With ECC

Without ECC

N

Deaths

%

N

Deaths

%

Supracoronary ascending aorta

1,560

118

7.6

Supracoronary ascending aorta+ AVR

1,218

47

3.9

Infracoronary ascending aorta

Mechanical heart valve conduits

456

22

4.8

Biological heart valve conduits

891

98

11.0

David procedure

493

7

1.4

Yacoub procedure

117

7

6.0

Other

267

15

5.6

Aortic archb

1,968

241

12.2

Descending aorta

68

14

20.6

6

1

16.7

Thoracoabdominal aorta

76

10

13.2

18

7

38.9

Endostent descending aorta

3

1

33.3

614

35

5.7

Total

7,117

580

8.1

638

43

6.7

Notes: All procedures involving aortic surgery are included in this table (Isolated and all possible combined procedures, e.g., additional coronary artery bypass grafting).

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

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

Table Mis4

Pacemaker and ICD procedures

Device/category

N

Deaths

% death

With ECC

Without ECC

N

Deaths

N

Deaths

Pacemaker

14,398

97

0.7

14

3

14,384

94

Implantation

9,299

67

0.7

0

0

9,299

67

Battery exchange

2,033

0

0.0

0

0

2,033

0

Revision

3,066

30

1.0

14

3

3,052

27

ICD

10,104

73

0.7

25

4

10,079

69

Implantation

4,660

17

0.4

0

0

4,660

17

Battery exchange

2,031

4

0.2

0

0

2,031

4

Revision

3,413

52

1.5

25

4

3,388

48

Miscellaneous

1,750

10

0.6

1

1

1,749

9

Total

26,252

180

0.7

40

8

26,212

172

Table Mis5

Surgical ablation procedures for arrhythmia

Total

Endocardiac (n)

Epicardiac (n)

Energy source

Unipolar radiofrequency

205

92

113

Unipolar cryo-radiofrequency

329

201

128

Bipolar radiofrequency

2,396

312

2,084

Cryothermy

1,760

1,464

296

Microwave

17

4

13

Focused ultrasound

224

28

196

Laser

0

0

0

Other

20

7

13

Total

4,951

2,108

2,843

Notes: All isolated ablation procedures and all possible combination of procedures (e.g., coronary artery bypass grafting + ablation) are included. A total of 484 procedures are not specified with regard to endocardiac/epicardiac ablation.

Zoom Image
Fig. 1 Cardiac surgery in Germany (2005–2014). (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) Heart 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 (2005–2014).
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (CABG) (2005–2014). The quantity of coronary artery bypass procedures declined since the year 2005 while the CABG off-pump procedures reached a nearly constant level of 15.3%.
Zoom Image
Fig. 4 Isolated aortic valve replacement (2005–2014). The use of xenografts continuously increased till 2008 and reached a stable count since then. AVR implanting mechanical prosthesis decreased over the past 10 years. The observed difference in patients' mortality was probably based on the difference in age pattern and related comorbidities (Ross procedure, homograft implantations, and transcatheter aortic valve implantation are excluded).
Zoom Image
Fig. 5 Isolated AVR and transcatheter aortic valve implantation (TAVI). The figure shows a stable quantity of AVR procedures and a continuous increase of TAVI. In 2014, 8,631 TAVI were reported to the voluntary registry of the GSTCVS; however, this number does not represent all TAVI procedures performed in Germany in 2014. +Additional patients with TAVI procedures calculated from the German legal quality assurance program, § 137 SGB V.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2005–2014). In 2014, 54.3% of the patients are at least 70 years (patients < 20 years and ICD/pacemaker procedures excluded).
Zoom Image
Fig. 7 Procedures timing (2005 vs. 2014).
Zoom Image
Fig. 8 Isolated mitral valve surgery (2005–2014). In 2014, 65.7% MV reconstructions and 34.3% MV replacements were performed. Two decades ago, the repair rate was only 21%.
Zoom Image
Fig. 9 Age distribution for congenital heart surgery (2005–2014). There are no relevant changes over the past 10 years. However, there may be a bias because not all relevant procedures can be allocated clearly to the congenital heart surgery category for patients older than 18 years (e.g., aortic valve disease).
Zoom Image
Fig. 10 Development of mechanical circulatory support (2005–-2014). Continuous increase of left ventricular assist device (LVAD) implantations. However, the number of implanted paracorporeal biventricular assist devices (BVAD) decreases furthermore and the count of total artificial heart implantations (TAH) dropped down to 15 in 2014.

Table V1 has been corrected in the above article as per erratum published online on June 10, 2015. DOI of erratum is: 10.1055/s-0035-1556566.


#

Acknowledgments

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


Address for correspondence

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


Zoom Image
Fig. 1 Cardiac surgery in Germany (2005–2014). (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) Heart 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 (2005–2014).
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (CABG) (2005–2014). The quantity of coronary artery bypass procedures declined since the year 2005 while the CABG off-pump procedures reached a nearly constant level of 15.3%.
Zoom Image
Fig. 4 Isolated aortic valve replacement (2005–2014). The use of xenografts continuously increased till 2008 and reached a stable count since then. AVR implanting mechanical prosthesis decreased over the past 10 years. The observed difference in patients' mortality was probably based on the difference in age pattern and related comorbidities (Ross procedure, homograft implantations, and transcatheter aortic valve implantation are excluded).
Zoom Image
Fig. 5 Isolated AVR and transcatheter aortic valve implantation (TAVI). The figure shows a stable quantity of AVR procedures and a continuous increase of TAVI. In 2014, 8,631 TAVI were reported to the voluntary registry of the GSTCVS; however, this number does not represent all TAVI procedures performed in Germany in 2014. +Additional patients with TAVI procedures calculated from the German legal quality assurance program, § 137 SGB V.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2005–2014). In 2014, 54.3% of the patients are at least 70 years (patients < 20 years and ICD/pacemaker procedures excluded).
Zoom Image
Fig. 7 Procedures timing (2005 vs. 2014).
Zoom Image
Fig. 8 Isolated mitral valve surgery (2005–2014). In 2014, 65.7% MV reconstructions and 34.3% MV replacements were performed. Two decades ago, the repair rate was only 21%.
Zoom Image
Fig. 9 Age distribution for congenital heart surgery (2005–2014). There are no relevant changes over the past 10 years. However, there may be a bias because not all relevant procedures can be allocated clearly to the congenital heart surgery category for patients older than 18 years (e.g., aortic valve disease).
Zoom Image
Fig. 10 Development of mechanical circulatory support (2005–-2014). Continuous increase of left ventricular assist device (LVAD) implantations. However, the number of implanted paracorporeal biventricular assist devices (BVAD) decreases furthermore and the count of total artificial heart implantations (TAH) dropped down to 15 in 2014.