Thorac cardiovasc Surg 2016; 64(06): 462-474
DOI: 10.1055/s-0036-1592124
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

German Heart Surgery Report 2015: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery

Andreas Beckmann
1  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Anne-Katrin Funkat
2  Leipzig Heart Institute, Leipzig, Germany
,
Jana Lewandowski
1  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Michael Frie
3  FOM Hochschule für Oekonomie & Management, Essen, Germany
,
Markus Ernst
4  Department of Cardiac and Vascular Surgery, University Kiel, Kiel, Germany
,
Khosro Hekmat
5  Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
,
Wolfgang Schiller
6  Department of Cardiac Surgery, University Bonn, Bonn, Germany
,
Jan F. Gummert
7  Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
,
Armin Welz
6  Department of Cardiac Surgery, University Bonn, Bonn, Germany
› Author Affiliations
Further Information

Address for correspondence

Andreas Beckmann, MD
German Society for Thoracic and Cardiovascular Surgery
Langenbeck-Virchow-Haus, Luisenstr 58/59, 10117 Berlin
Germany   

Publication History

09 August 2016

22 August 2016

Publication Date:
01 September 2016 (eFirst)

 

Abstract

On the basis of a long-standing voluntary registry, which was founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all heart, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during 2015 are analyzed. In 2015, a total of 103,967 heart surgery procedures (implantable cardioverter defibrillator, pacemaker, and extracardiac procedures without ECC excluded) were submitted to the database. Approximately 14.8% of the patients were at least 80 years old, resulting in an increase of 0.6% compared with the data of 2014. For 38,601 isolated coronary artery bypass grafting procedures (relationship on-/off-pump: 5:1), the unadjusted inhospital mortality was 2.7%. Concerning the 32,346 isolated heart valve procedures (including 10,606 catheter-based implantations) an unadjusted inhospital mortality of 4.4% was observed.

This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, demonstrates advancements in heart medicine, and enables internal/external quality assurance for all participants. In addition, the registry demonstrates that the provision of heart surgery in Germany is appropriate and patients are treated nationwide in a round-the-clock service.


#

Introduction

Legitimate demands for a sophisticated quality management in medicine—by authorities, scientific organizations, health insurance companies, and patients all over the world—have stimulated 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 annual database of all cardiac surgical procedures in terms of a voluntary registry. Since 1989, the data are annually updated, summarized in a 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] The aims of this registry are to gather developments and current trends in cardiac surgery in Germany, to compile various results for nearly all cardiac surgical procedures, to enable each participating department for cardiac surgery comparing its own results to the nationwide achievements, and to facilitate an evaluation on an international level for the society.

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

Data and results presented in this report comprehend assorted data of 2015.


#

Material and Methods

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

All participating institutions were requested to complete the structured questionnaire, asking for all performed procedures and associated inhospital mortality, by January 24, 2016. The recommended path for data export is 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 2015 registry were all cardiac surgical procedures performed on patients between January 1, 2015, and December 31, 2015, unrelated to the date of admission or discharge as compared with other registries. Like in all previous years, the number of procedures was counted rather than individual patients. For example, if during one admission a patient required coronary bypass grafting due to a complication following initial mitral valve reconstruction, one count in the “mitral valve reconstruction” category and another in the “coronary surgery” category are enumerated. Thus, the registry contains a higher number of procedures than the real number of patients operated on.

Death of patients was defined as inhospital mortality. Per definition, the observed mortality is always attributed to the first cardiac procedure, for example, the death of a patient requiring a replacement of the ascending aorta due to a complication of coronary artery bypass grafting (CABG) would only be attributed to the coronary procedure. The denominator in the calculation of mortality rates is getting falsly higher with the assignment of complication procedures resulting in a marginal underestimation of mortality rates (calculus estimate: <0.1%).

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 getting not only the count of treated patients but also detailed information about all performed procedures. Last but not least, the process of data acquisition had to be standardized and feasible for all participating cardiac surgery departments in Germany, thus enabling the submission of a complete dataset, regardless of the locally existing hard- and software used for data management.

In 2015, a total of 78 institutions performed heart surgery in Germany. Fortunately, all units answered the questionnaire and delivered a complete dataset for 2015 including hospital mortality rates.


#

Registry Data 2015

[Table 1] gives an overview of heart surgical procedures by distribution between the 16 German states. In the table, the range of heart operations per 100,000 inhabitants shows a minimum of 101.8 (Baden-Württemberg) and a maximum of 168.9 (Sachsen-Anhalt), resulting in a nationwide mean value of 126.6. Analyzing the heart operations for department dimension, 59% performed from 590 to 1,460 procedures ([Table 2]). Summarizing the departments by various heart surgical procedures, it can be ascertained that heart operations in patients for congenital heart disease (<1 year, with extracorporeal circulation [ECC]) are conducted in 23 and heart transplantations in 22 institutions ([Table 3]). [Table 4] illustrates the number of procedures using ECC from 2006 to 2015 in Germany. Over the past decade, the number of heart operations using ECC shows a diminution by 9,530 procedures, certainly an achievement of establishing innovations and minimally invasive therapies in heart surgery.

Table 1

Heart operations in German states

German states

Quantity[a]

Population[b]

Heart procedures/100,000 inhabitants

Baden-Württemberg

10,907

10,716,644

101.8

Bayern

14,542

12,691,568

114.6

Berlin

3,800

3,469,849

109.5

Brandenburg

3,194

2,457,872

129.9

Bremen

812

661,888

122.7

Hamburg

2,168

1,762,791

123.0

Hessen

7,875

6,093,888

129.2

Mecklenburg-Vorpommern

2,134

1,599,138

133.4

Niedersachsen

10,848

7,826,739

138.6

Nordrhein-Westfalen

23,164

17,638,098

131.3

Rheinland-Pfalz

5,637

4,011,582

140.5

Saarland

1,644

989,035

166.2

Sachsen

5,271

4,055,274

130.0

Sachsen-Anhalt

3,776

2,235,548

168.9

Schleswig-Holstein

4,180

2,830,864

147.7

Thüringen

2,843

2,156,759

131.8

Total

102,795

81,197,537

126.6

a 1,172 foreign residents excluded.


b Federal Offices for Statistics of German Population; due date December 31, 2014.


Table 2

Departments sorted by quantity (n = 103.967)

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Departments (no.)

7

21

25

12

13

Average

346

814

1,198

1,663

2,658

Range

233–445

590–992

1,032–1,460

1,508–1,966

2,021–4,102

Note: Pacemaker/ implantable cardioverter defibrillator and extracardiac surgery without extracorporeal circulation excluded.


Table 3

Departments summarized by heart surgery procedures in 2015

Procedures

N

Coronary artery bypass grafting

77

Heart valve surgery

77

Surgery for CHD patients < 1 yr with ECC

23[a]

HTx

22[b]

HLTx

2

a N = 2,041: 3–17 procedures in 4 units, 22–46 procedures in 5 units, 65–89 procedures in 5 units, and 110–265 procedures in 9 units.


b N = 283: 23–75 Tx in 4 units, 11–17 Tx in 5 units, 5–8 Tx in 8 units, and 2–4 Tx in 5 units.


Table 4

Open heart procedures using extracorporeal circulation (2006–2015)

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Departments

80

80

79

80

79

78

79

79

78

78

Procedures

91,057

91,618

89,773

86,916

84,686

84,402

84,388

84,040

83,787

81,527

Average

1,138

1,145

1,136

1,086

1,072

1,082

1,068

1,064

1,074

1,045

Overall, 185,270 procedures were reported to the registry in 2015, a decrease of 1.1% compared to 2014 (187,392 procedures). A total of 103,967 heart surgical procedures (excluding implantable cardioverter defibrillator, pacemakers, and miscellaneous procedures without ECC) in 2015 displays nearly the same quantity with a difference of just 0.5% (n = 517) compared to 2014 (104,484 procedures; [Table 5]). [Tables 6] and [7], [V1] [V2] [V3] [V4] [V5] [V6] to [V7], [C1] and [C2], [Con1] and [Con2], and [Mis1] [Mis2] [Mis3] [Mis4] to [Mis5] and [Figs. 1] [2] [3] [4] [5] [6] [7] [8] [9] demonstrate some compiled registry data of 2015 under different aspects and for various categories.

Table 5

Heart surgery categories 2015

Category

with ECC

without ECC

Total

Diff. 2014 (%)

Coronary artery bypass grafting

45,107

6,834

51,941

–3.5

Heart valve procedures

21,892

10,454

32,346

+3.1

Surgery of thoracic aorta

7,265

657

7,922

+2.2

Surgery for CHD

4,913

979

5,892

+2.0

Cardiac surgery and others

1,173

1,206

2,379

–3.8

Assist device procedures

765

2,310

3,075

+5.7

Extracardiac surgery

358

54,785

55,143

–3.4

Pacemaker and ICD procedures

54

26,518

26,572

+1.2

Total

81,527

103,743

185,270

–1.1

Table 6

Additional data for heart surgery procedures with ECC in 2015 versus 2014

Procedures

2015

2014

N

%

N

%

Emergency

12,843

12.4%

12,583

12.0%

Redo

8,994

8.7%

8,809

8.4%

Table 7

Gender distribution

Female (%)

Male (%)

Heart valve procedures

44

56

Coronary procedures

22

78

Surgery for CHD

44

56

Surgery of thoracic aorta

33

67

Cardiac surgery, other

52

48

Assist Devices

29

71

Pacemaker and ICD

35

65

Extracardiac surgery

34

66

Total

33

67

Table V1

Isolated heart valve procedures

Procedures

N

%

Single

17,986

649

3.6

Double

3,280

305

9.3

Triple

358

47

13.1

Transcatheter access(single valve)

10,581

405

3.8

Transcatheter access(double valve)

25

2

8.0

Not specified

116

6

5.2

Total

32,346

1,414

4.4

Transcatheter heart valve procedures: 9,813 aortic valve implantations; 111 mitral valve implantations; 632 mitral valve repairs; 1 tricuspid valve implantation; 24 tricuspidal valve repairs; 25 combined aortic and mitral valve procedures; no pulmonary valve implantation.


Table V2

Single heart valve procedures: access type

Heart valve/access

N

%

Aortic valve

21,120

715

3.4

 Sternotomy

8,291

292

3.5

 Part. sternotomy

3,016

49

1.6

 Transvascular

7,311

218

3.0

 Transapical

2,502

156

6.2

Mitral valve

6,770

283

4.2

 Sternotomy

3,099

205

6.6

 Minimally invasive

2,928

49

1.7

 Transcatheter

743

29

3.9

Tricuspidal valve

617

53

8.6

 Sternotomy

444

45

10.1

 Minimally invasive

148

6

4.1

 Transcatheter

25

2

8.0

Pulmonary valve

56

3

5.4

 Sternotomy

56

3

5.4

 Minimally invasive

0

0

 Transcatheter

0

0

Total

28,563

1,054

3.7

Note: Apical aortic conduits procedures (n = 4) excluded.


Table V3

Isolated aortic valve procedures

Prosthesis/repair

N

%

Xenograft

9,839

311

3.2

Mechanical prosthesis

1,311

23

1.8

Repair

124

5

4.0

Homograft

33

2

6.1

Total

11,307

341

3.0

Table V4

Isolated mitral valve procedures

Prosthesis/repair

N

%

Repair

3,833

52

1.4

Xenograft

1,680

165

9.8

Mechanical prosthesis

505

35

6.9

Homograft

9

2

22.2

Total

6,027

254

4.2

Table V5

Multiple heart valve procedures

N

%

Mitral + tricuspid

1,685

118

7.0

Aortic + mitral

1,372

170

12.4

Aortic + mitral + tricuspid

357

47

13.2

Aortic + tricuspid

174

15

8.6

Aortic + pulmonary[a]

39

1

2.6

Tricuspid + pulmonary

10

1

10.0

Aortic + mitral + pulmonary

1

0

0.0

Total

3,638

352

9.7

Note: Transcatheter procedures excluded.


a Ross procedures included.


Table V6

Isolated/combined mitral valve procedures: implantation/replacement vs. repair

Mitral valve surgery

Repair

Implantation/replacement

All procedures

N

%

N

%

N

% repair

%

Isolated

3,833

52

1.4

2,194

202

9.2

6,027

63.6

254

4.2

  + Aortic valve

603

38

6.3

769

132

17.2

1,372

44.0

170

12.4

  + Tricuspid valve repair[a]

1,025

44

4.3

611

66

10.8

1,636

62.7

110

6.7

  + CABG

1,711

132

7.7

918

134

14.6

2,629

65.1

266

10.1

  + CABG + aortic valve replacement

318

40

12.6

286

59

20.6

604

52.6

99

16.4

Total

7,490

306

4.1

4,778

593

12.4

12.268

61.1

899

7.3

a A total of 49 procedures (not specified mitral valve + tricuspid valve surgery) excluded; †: (8/49) 16%.


Table V7

Transcatheter heart valve procedures

without ECC

with ECC

All procedures

N

N

N

%

Aortic valve implantation

9,675

330

138

44

9,813

374

4

 Transvascular

7,236

192

75

26

7,311

218

3

 Transapical

2,439

138

63

18

2,502

156

6

Mitral valve procedure

731

26

12

3

743

29

4

 Repair

625

20

7

1

632

21

3

 Implantation

106

6

5

2

111

8

7

Tricuspidal valve procedure

23

1

2

1

25

2

8

 Repair

22

1

2

1

24

2

8

 Implantation

1

0

0

0

1

0

0

Aortic + mitral valve implantation

25

2

0

0

25

2

8

Aortic valve implantation[a] + CABG

37

2

13

8

50

10

20

Mitral valve implantation[b] + CABG

1

0

1

1

2

1

50

Aortic + mitral valve + CABG

2

0

0

0

2

0

0

Total

10,494

361

166

57

10,660

418

4

Note: Pulmonary valve implantations for the correction of congenital lesions are not included; No procedure was reported for adults without congenital lesion. 25% of TAVI by transapical access; 1.5% of TAVI under use of ECC.


a Femoral, subclavian, or transaortic access.


b Transvascular and transapical access.


Table C1

Isolated/combined CABG with ECC

N

%

Isolated CABG

38,601

1,057

2.7

 + Aortic valve replacement

7,214

396

5.5

 + Other

2,705

156

5.8

 + Mitral valve repair

1,711

132

7.7

 + Mitral valve replacement

918

134

14.6

 + Aortic valve replacement + mitral valve repair

318

40

12.6

 + Aortic + mitral valve replacement

286

59

20.6

 + Aneurysm resection

133

7

5.3

 + Transcatheter aortic valve implantation

50

10

20.0

 + TMLR

1

0

0.0

Total

51,937

1,991

3.8

Table C2

Isolated CABG with/without ECC

Grafts (N)

with ECC

without ECC

All

N

%

N

%

N

%

Single

1,009

56

5.6

1,359

32

2.4

2,368

88

3.7

Double

6,840

236

3.5

1,755

33

1.9

8,595

269

3.1

Triple

14,353

388

2.7

2,185

38

1.7

16,538

426

2.6

Quadruple

7,776

206

2.6

847

7

0.8

8,623

213

2.5

Quintuple + more

2,273

60

2.6

204

1

0.5

2,477

61

2.5

Total

32,251

946

2.9

6,350

111

1.7

38,601

1,057

2.7

Table Con1

Congenital heart surgery with/without ECC

Age (yrs)

N

%

with ECC

without ECC

with ECC

without ECC

with ECC

without ECC

<1

2,041

736

63

13

3.1

1.8

1–17

1,796

206

9

1

0.5

0.5

≥18

1,076

37

24

1

2.2

2.7

Total

4,913

979

96

15

2.0

1.5

Table Con2

Lesions/procedures for CHD with and without ECC

Lesion/procedures

Age < 1 yr

Age 1–17 yrs

Age ≥ 18 yrs

N

%

N

%

N

%

ASD

33

0

0.0

254

1

0.4

246

4

1.6

Complete AV canal

183

2

1.1

88

1

1.1

10

1

10.0

VSD

305

0

0.0

86

0

0.0

25

2

8.0

Fallot's tetralogy

205

3

1.5

49

0

0.0

2

0

0.0

DORV

48

0

0.0

21

1

4.8

1

0

0.0

TGA

160

2

1.3

10

0

0.0

2

0

0.0

TGA + VSD

63

2

3.2

10

0

0.0

0

0

Truncus arteriosus

38

3

7.9

7

0

0.0

0

0

Fontan

1

0

0.0

253

3

1.2

6

1

16.7

Norwood

146

20

13.7

1

0

0.0

0

0

Pulmonary valve

73

2

2.7

240

1

0.4

75

0

0.0

 Transcatheter pulmonary valve implantation

0

4

0

0.0

17

0

0.0

Aortic valve

61

2

3.3

246

0

0.0

394

5

1.3

Ross procedure

7

1

14.3

21

0

0.0

29

0

0.0

Mitral valve

46

4

8.7

88

0

0.0

108

8

7.4

Tricuspid valve

95

1

1.1

59

0

0.0

62

2

3.2

PDA

225

3

1.3

26

1

3.8

2

0

0.0

Coarctation

218

4

1.8

39

0

0.0

7

0

0.0

Others

890

28

3.1

479

3

0.6

119

2

1.7

HTx

7

0

0.0

42

0

0.0

0

0

HLTx

0

0

0

0

0

LTx

0

9

0

0.0

0

0

Total

2,804

77

2.7

2,032

11

0.5

1,105

25

2.3

Table Mis1

Ross procedures (autologous AV- and PVR)

Age (y)

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

<18

50

34

42

54

43

40

36

33

37

28

≥18

228

261

207

175

184

134

117

107

90

64

Total

278

295

249

229

227

174

153

140

127

92

Table Mis2

Heart and lung transplantation

with ECC

without ECC

N

%

N

%

HTx

283

38

13,4

HLTx

2

0

0,0

LTx

57

13

22,8

206

13

6,3

Eurotransplant (ET) report for 2015: 283 HTx, 1 HTx + kidneyTx, 0 HTx + liverTx, 2 HLTx, 262 DLTx, 27 SLTx, 0 LTx + kidneyTx and 4 LTx + liverTx.


Table Mis3

Aortic surgery

Replacement[a]

with ECC

without ECC

N

%

N

%

Supracoronary replacement of ascending aorta

1,433

127

8.9

Supracoronary ascending + aortic valve replacement

1,329

63

4.7

Infracoronary ascending

 Mechanical valve conduits

508

36

7.1

 Biological valve conduits

989

109

11.0

 David procedure

514

8

1.6

 Yacoub procedure

89

3

3.4

 Other

279

23

8.2

Aortic arch replacement[b]

1,977

271

13.7

Replacement of descending aorta

56

4

7.1

8

0

0.0

Thoracoabdominal aortic replacement

86

10

11.6

24

4

16.7

Endostent descending aorta

5

0

0.0

625

53

8.5

Total

7,265

654

9.0

657

57

8.7

a Procedures for abdominal aortic diseases excluded: 549 abdominal procedures and 609 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

N

%

with ECC

without ECC

N

N

Pacemaker

14,295

98

0.7

27

1

14,268

97

 Implantation

9,337

68

0.7

8

1

9,329

67

 Battery exchange

1,935

0

0.0

0

0

1,935

0

 Revision

3,023

30

1.0

19

0

3,004

30

ICD

10,104

83

0.8

26

5

10,078

78

 Implantation

4,673

19

0.4

0

0

4,673

19

 Battery exchange

2,048

3

0.1

0

0

2,048

3

 Revision

3,383

61

1.8

26

5

3,357

56

Miscellaneous

2,173

13

0.6

1

0

2,172

13

Total

26,572

194

0.7

54

6

26,518

188

Table Mis5

Surgical ablation therapy

Energy source

Total

Endocardiac

Epicardiac

N

N

Unipolar radiofrequency

229

77

152

Unipolar cryoradiofrequency

254

122

132

Bipolar radiofrequency

2.306

309

1,997

Cryothermy

1.606

1,340

266

Microwave

13

3

10

Focused ultrasound

66

7

59

Laser

9

1

8

Other

23

4

19

Total

4,506

1,863

2,643

Note: 496 procedures unspecified with regard to endocardiac/epicardiac ablation.


Zoom Image
Fig. 1 Cardiac surgery in Germany (2006–2015). (1) Coronary artery bypass grafting (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: atrial septal defect repair 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 extracorporeal circulation.
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Fig. 2 Unadjusted mortality for selected procedures (2006–2015).
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Fig. 3 Isolated coronary artery bypass grafting (2006–2015).
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Fig. 4 Isolated aortic valve replacement (2006–2015). Ross procedures, homograft implantations, and transcatheter aortic valve implantation excluded.
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Fig. 5 Isolated aortic valve replacement and transcatheter aortic valve implantation (TAVI). + Additional TAVI procedures calculated from the German legal quality assurance program (§137 SGB V).
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Fig. 6 Age distribution of cardiac procedures (2006–2015). Patients < 20 years and pacemaker/implantable cardioverter defibrillator procedures excluded.
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Fig. 7 Urgency categories (2006 vs. 2015). Emergency = acutely life-threatening cardiac/vascular disease.
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Fig. 8 Isolated mitral valve surgery (2006–2015).
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Fig. 9 Age distribution for congenital heart surgery (2006–2015). Bias possible due to the fact that not all relevant procedures can be allocated exactly to the congenital heart disease category in patients older than 18 years (e.g., aortic valve disease).

Compared to previous years' data, several important developments continued to be almost unchanged in 2015. The age distribution of patients ([Fig. 6]) shows again the shift to an elderly patient population, with presently 53.1% of the cardiac procedures performed in patients aged at least 70 years and 14.8% in patients aged 80 years or older. However, mortality remained on the same low level over the represented decade ([Fig. 2]). The rate of CABG procedures decreased over the past years, whereas the relative number of off-pump CABG procedures reached a level of 16.5% in 2015 as compared to 15.3% in 2014 ([Fig. 3]).

Since 2004, more than 50% of isolated mitral valve procedures have been reconstructions. In 2015, mitral valve reconstruction could be achieved in 63.6% of the procedures ([Fig. 8]). Based on the fact that without exception all isolated mitral valve procedures are included, 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 by Gammie et al,[27] patients with mitral valve stenosis, endocarditis, and emergency procedures were 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 increasing relevance of mechanical circulatory support.

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Fig. 10 Development of mechanical circulatory support (2006–2015).

Again, a remarkable trend is the still ongoing increase of TAVI procedures in Germany ([Fig. 5]), whereas the count of isolated aortic valve replacement procedures showed a slight decrease of 4.9%. Starting in 2006 with just 78 implantations (0.67% of isolated aortic valve procedures), in 2015, 9,813 (46.7%) TAVI 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 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 on the management of valvular heart disease (version 2012).[28] In July 2015, the first version of the quality assurance directive for “minimally invasive heart valve interventions (TAVI, mitral clip reconstruction),” in which obligatory structures, defined processes, and qualified personnel are exactly specified, was released by the German Federal Joint Committee (G-BA).

In addition to the registry data, 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 importance concerning the judgement of developments and quality - and thus for patient benefit.


#

Discussion

The registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in Germany in 2015. 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.[34] In continuation with previous years, it can be concluded that heart surgery in Germany is performed on a constantly high level with very high inhospital survival rates of patients compared with international registries. In addition, the registry data demonstrate that the provision of heart surgery in Germany is appropriate and nationwide patient treatment is guaranteed in a round-the-clock service (24/7/365). These conclusions 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 resulting in higher preoperative risk profiles.

Compared to 2014, the number of cardiac surgery procedures remains on nearly the same level 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 more detailed and particularly risk-adjusted data analyses. However, if significant structural changes in 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 adduce evidence for high quality of heart surgery in Germany.


#

Abbreviations

ASD: atrial septal defect
CABG: coronary artery bypass grafting
CHD: congenital heart disease
DLTx: double lung transplantation
DORV: double outlet right ventricle
ECC: extracorporeal circulation
HLTx: heart-lung transplantation
HTx: heart transplantation
ICD: implantable cardioverter defibrillator
PDA: patent ductus arteriosus
SLTx: single lung transplantation
TAVI: transcatheter aortic valve implantation
TGA: transposition of the great arteries
TMLR: transmyocardial laser revascularisation
Tx: Organ transplantation
VSD: ventricular septal defect

#

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
German Society for Thoracic and Cardiovascular Surgery
Langenbeck-Virchow-Haus, Luisenstr 58/59, 10117 Berlin
Germany   


Zoom Image
Fig. 1 Cardiac surgery in Germany (2006–2015). (1) Coronary artery bypass grafting (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: atrial septal defect repair 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 extracorporeal circulation.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2006–2015).
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (2006–2015).
Zoom Image
Fig. 4 Isolated aortic valve replacement (2006–2015). Ross procedures, homograft implantations, and transcatheter aortic valve implantation excluded.
Zoom Image
Fig. 5 Isolated aortic valve replacement and transcatheter aortic valve implantation (TAVI). + Additional TAVI procedures calculated from the German legal quality assurance program (§137 SGB V).
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2006–2015). Patients < 20 years and pacemaker/implantable cardioverter defibrillator procedures excluded.
Zoom Image
Fig. 7 Urgency categories (2006 vs. 2015). Emergency = acutely life-threatening cardiac/vascular disease.
Zoom Image
Fig. 8 Isolated mitral valve surgery (2006–2015).
Zoom Image
Fig. 9 Age distribution for congenital heart surgery (2006–2015). Bias possible due to the fact that not all relevant procedures can be allocated exactly to the congenital heart disease category in patients older than 18 years (e.g., aortic valve disease).
Zoom Image
Fig. 10 Development of mechanical circulatory support (2006–2015).