Thorac cardiovasc Surg 2018; 66(08): 608-621
DOI: 10.1055/s-0038-1676131
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

German Heart Surgery Report 2017: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery

Andreas Beckmann
1  Deutsche Gesellschaft für, Thorax-, Herz- und Gefäßchirurgie [DGTHG], Langenbeck-Virchow-Haus, Luisenstr. 58-59, 10117 Berlin, Germany
,
Renate Meyer
2  BQS Institute for Quality and Patient Safety, Düsseldorf, Germany
,
Jana Lewandowski
1  Deutsche Gesellschaft für, Thorax-, Herz- und Gefäßchirurgie [DGTHG], Langenbeck-Virchow-Haus, Luisenstr. 58-59, 10117 Berlin, Germany
,
Michael Frie
3  FOM Hochschule fuer Oekonomie & Management, Essen, Germany
,
Andreas Markewitz
1  Deutsche Gesellschaft für, Thorax-, Herz- und Gefäßchirurgie [DGTHG], Langenbeck-Virchow-Haus, Luisenstr. 58-59, 10117 Berlin, Germany
,
Wolfgang Harringer
4  Clinic for Cardiac, Thoracic and Vascular Surgery, Klinikum Braunschweig gGmbH, Braunschweig, Germany
› Author Affiliations
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

03 November 2018

03 November 2018

Publication Date:
03 December 2018 (eFirst)

 

Abstract

Based on a longtime 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 2017 are analyzed. In 2017, a total of 179,337 procedures were submitted to the registry, and 101,728 were summarized as heart surgery procedures in the narrower sense. About 16.8% of these patients were at least 80 years old, resulting in an increase of 1.1% compared with the data of 2016. The 36,273 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 4.2:1) were associated with an unadjusted in-hospital survival rate of 97.3%. Concerning the 34,394 isolated heart valve procedures (including 12,965 transcatheter interventions), the unadjusted in-hospital survival rate was 96.0%.

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 in- and external quality assurance for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate, and nationwide patient treatment is guaranteed at any time.


#

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, public reporting, registries, and others to answer those needs. In 1978, the board of directors of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS, www.dgthg.de) decided to set up a data collection of all cardiac surgical procedures in terms of a voluntary unaudited registry.[1] [2] Since 1989, the data are updated annually, summarized in the sense of a registry and published in the scientific journal of the GSTCVS each year.[3] [4] [5] [6] [7] The prevalent 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 provide each participating institution with a benchmark of the reached 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 procedures 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 findings of the year 2017.


#

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 (OPS—Operationen- und Prozedurenschlüssel).

All participating institutions were requested to complete the structured questionnaire by January 26, 2018, 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 were decrypted, evaluated for completeness and compiled for further analysis, thus ensuring anonymity for each participating institution. This compilation algorithm enables a high compliance for submission of complete datasets.

Inclusion criteria for the registry data 2017 were all cardiac surgical procedures performed on patients between January 1, 2017 and December 31, 2017, 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 a patient initially required isolated coronary artery bypass grafting (CABG) later followed by a mitral valve reconstruction due to an undesirable event, one count in the category “coronary surgery” and a second one in the category “mitral valve reconstruction” 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, for example, the death of a patient requiring a replacement of the ascending aorta due to a complication after CABG would only be attributed to the coronary 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 count of treated patients. Last but not least the process of data acquisition had to be standardized and feasible for all participating departments in Germany, thus enabling the submission of a complete dataset, regardless of the locally existing hard- and software used for data acquisition.

In 2017, a total of 78 institutions performed heart surgery. As always, all departments answered the questionnaire and delivered a complete dataset for the year 2017 including in-hospital mortality rates. In addition, comparisons between the registry data and the external quality assurance in accordance with §§ 136/137 SGB V, obligatory for licensed German hospitals (§ 108 SGB V), are feasible.

For statistical analyses, categorized tables and a summarizing registry data file amalgamate all transmitted information of the 78 departments, providing the basis for this and further publications. Longitudinal data from earlier registry specifications are also included in the presentation. The period considered is restricted to the past 10 years.

Categorical data are displayed as absolute and/or relative frequencies. All described mortality rates are unadjusted. Quantitative data are presented as absolute frequencies and arithmetic mean values. Where appropriate, the value range is presented additionally. Patients age, though originally a quantitative variable, is only available in age groups and therefore treated as a categorical variable. Population-based measures are calculated as frequencies per 100,000 inhabitants and are based on the German population by December 31st of the previous year.

The questionnaires were compiled using Microsoft Visual Basic for Applications. Analyses were performed with IBM SPSS Statistics v22 and Microsoft Excel 2010, and charts and tables were created with Microsoft Excel 2010.

Registry Data 2017

[Table 1] shows the distribution of cardiac surgical procedures between the 16 German states, based on the population count of the Federal Office for Statistics as of December 31st, 2016. The range of heart operations per 100,000 inhabitants again shows a minimum of 100.8 (Baden Württemberg, population: 10,951,893) and a maximum of 172.8 (Sachsen-Anhalt, population: 2,236,252), resulting in a nationwide mean-value of 122.0 (2016:125.7). Analyzing quantified categories of heart operations by department dimension, nearly 62% of institutions are in two clusters in which at least 529 and at most 1,462 procedures were performed ([Table 2]). Summarizing the departments by various heart surgical procedures, it can be asserted that heart operations in patients for congenital heart disease (< 1 year, with extracorporeal circulation [ECC]) were conducted in 22 and heart transplantations in just 20 institutions ([Table 3]), a slight shift compared with the previous year. [Table 4] illustrates the count of procedures using ECC in Germany from 2008 to 2017. Over the past decade, the count of heart operations using ECC shows a decline by 13,077 procedures, certainly an achievement of established innovations and minimally invasive therapeutic options in heart surgery.

Table 1

Heart operations/German states

Federal state

Quantity[a]

Population[b]

Heart procedures/100,000 inhabitants

Baden Württemberg

11,039

10,951,893

100.8

Bayern

14,128

12,930,751

109.3

Berlin

3,754

3,574,830

105.0

Brandenburg

3,413

2,494,648

136.8

Bremen

895

6,78,753

131.9

Hamburg

2,374

1,810,438

131.1

Hessen

7,506

6,213,088

120.8

Mecklenburg-Vorpommern

1,962

1,610,674

121.8

Niedersachsen

10,738

7,945,685

135.1

Nordrhein-Westfalen

22,339

17,890,100

124.9

Rheinland-Pfalz

5,257

4,066,053

129.3

Saarland

1,351

9,96,651

135.6

Sachsen

5,138

4,081,783

125.9

Sachsen-Anhalt

3,865

2,236,252

172.8

Schleswig-Holstein

4,002

2,881,926

138.9

Thüringen

2,930

2,158,128

135.8

Germany

100,691

82,521,653

122.0

a n = 1013, foreign residences excluded.


b Federal Office for Statistics of German: Population; due date December 31, 2016.


Table 2

Departments assorted by quantified categories (∑[a] [n = 101,728])

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Departments

6

26

22

13

11

Average

382

795

1,200

1,742

2,704

Range

258–476

529–983

1,001–1,462

1,510–1,974

2,039–3,958

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


a Pacemaker/ICD and extracardiac surgery without ECC excluded.


Table 3

Departments summarized by heart surgery procedures 2017

Category

n

Coronary artery bypass grafting

77

Heart valve surgery

77

CHD-procedures with ECC in patients < year

22[a]

HTx

20[b]

HLTx

5

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


a n = 2168: thereof: 1 operation in 1 unit, 26 to 41 operations in 5 units, 50 to 98 operations in 7 units, 128 to 241 operations in 9 units.


b n = 253: thereof: 1 to 3 transplants in 4 units, 5 to 9 transplants in 7 units, 11 to 20 transplants in 7 units, 21 to 71 transplants in 2 units.


Table 4

Cardiac procedures using extracorporeal circulation (2008–2017)

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Departments

79

80

79

78

79

79

78

78

78

78

Procedures

89,773

86,916

84,686

84,402

84,388

84,040

83,787

81,527

79,082

76,696

Average

1,136

1,086

1,072

1,082

1,068

1,064

1,074

1,045

1,014

983

Overall, 179,337 procedures were reported to the registry for the year 2017, a decrease of 3.0% (2016: 184,789 procedures). A total of 101,728 heart surgical procedures (excluded: implantable cardioverter defibrillator, pacemakers and miscellaneous procedures without ECC) in 2017 display a decline with a difference of 1.4% (n = 1,400) compared with 2016 (103,128 procedures) ([Table 5]). About 11.8% of the operations were conducted as emergency procedures, and 8.9% as a reoperation ([Table 6]). Concerning gender distribution, the registry shows an overall male/female ratio of 2:1 with major distinctions in specified categories ([Table 7]). 17,582 (51.1%) heart valve operations were performed as a single-valve procedure, and 6,763 (38.5%) of these through a minimal invasive access ([Tables V1], [V2]). In 9,484 (88.6%) isolated aortic valve operations under ECC conditions, xenograft prostheses were implanted ([Table V3], [Fig. 4]). In 4,023 (63.7%) isolated mitral valve procedures, a reconstruction under preservation of the native heart valve was performed ([Table V4], [V5]). The subdivision of 3,731 multiple heart valve procedures leads to 3,039 (81.5%) operations: a combination of mitral + tricuspid (n = 1656) or mitral + aortic (n = 1,383) valve procedures ([Table V6]). [Tables V7], [C1], [C2], [Con1], [Con2], [Mis1], [Mis2], [Mis3], [Mis4], [Mis5] and [Figs. 1] [2] [3] [4] [5] [6] [7] [8] [9] demonstrate further compiled registry data under different aspects and for various categories.

Zoom Image
Fig. 1 Selected heart surgical categories (2008–2017). 1. Isolated and combined CABG: all types 2. Isolated heart valve procedures: combination with aortic surgery summarized in 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.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2008–2017).
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (2008–2017).
Zoom Image
Fig. 4 Isolated aortic valve replacement (2008–2017). 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 2017. +Additional TAVI procedures calculated from the German legal quality assurance program, § 136ff, § 137a SGB V.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2008–2017). Notes: Patients < 20 years and pacemaker/implantable cardioverter defibrillator procedures were excluded.
Zoom Image
Fig. 7 Heart transplantation (2008–2017).
Zoom Image
Fig. 8 Isolated mitral valve surgery (2008–2017).
Zoom Image
Fig. 9 Age distribution for CHD (2008–2017). Notes: Bias possible due to the fact that not all relevant procedures can be allocated exactly to CHD-category in patients > 18 years (e.g., aortic valve disease).
Table 5

Frequency of cardiac procedures 2017

Category

With ECC

Without ECC

Total

Difference 2016 (%)

Coronary artery bypass grafting

40,418[a]

7,255[a]

47,673

−4.9

Heart valve procedures

21,535[a]

12,859[a]

34,394

+2.8

Surgery of thoracic aorta

7,580[a]

636[a]

8,216

+1.2

Surgery for CHD

4,852[a]

1,061[a]

5,913

+1.0

Cardiac surgery, other

1,124[a]

1,076[a]

2,200

−2.4

Assist device procedures

764[a]

2,145[a]

2,909

−0.9

Extracardiac surgery

388[a]

54,440

54,828

−4.4

Pacemaker-/ICD-procedures

35[a]

23,169

23,204

−6.0

Total

76,696

102,641

179,337

−3.0

Abbreviations: CHD, congenital heart disease; ECC, extracorporeal circulation; ECLS, extracorporeal life support; ECMO, extracorporeal membrane oxygenation; ICD, implantable cardioverter defibrillator; TAH, total artificial heart; VAD, ventricular assist device.


a Sum: n = 101,728 (heart surgery procedures).


Table 6

Additional data 2017 versus 2016

Procedures with ECC

2017

2016

Emergency

12,032

11.8%

12,745

12.4%

Redo

9,049

8.9%

9,186

8.9%

Table 7

Gender distribution

Distribution

Female (%)

Male (%)

Heart valve procedures

44

56

Coronary artery procedures

22

78

CHD procedures

45

55

Surgery of thoracic aorta

34

66

Cardiac surgery, other

57

43

Assist device

28

72

Pacemaker and ICD

35

65

Extracardiac surgery

35

65

Total

34

66

Table V1

Isolated heart valve procedures

Procedure

n

%

Single valve

17,582

607

3.5

Double valve

3,321

312

9.4

Triple valve

410

51

12.4

Transcatheter access (single valve)

12,934

395

3.1

Transcatheter access (double valve)

31

7

22.6

Unspecified

116

9

7.8

Total

34,394

1,381

4.0

Transcatheter heart valve procedures: 12,063 aortic valve implantation; 130 mitral valve implantation; 696 mitral valve repair.


Three tricuspid valve implantation; 42 tricuspidal valve repair; 31 double aortic and mitral valve procedure; 0 pulmonary valve implantation.


Table V2

Single heart valve procedures

Access path

n

%

Aortic valve

 Sternotomy

7,243

258

3.6

 Partial sternotomy

3,467

44

1.3

 Transvascular

10,233

257

2.5

 Transapical

1,830

108

5.9

Mitral valve

 Sternotomy

3,131

213

6.8

 Minimal invasive

3,180

35

1.1

 Transcatheter

826

28

3.4

Tricuspidal valve

 Sternotomy

390

44

11.3

 Minimal invasive

115

12

10.4

 Transcatheter

45

2

4.4

Pulmonary valve

 Sternotomy

55

1

1.8

 Minimal invasive

1

0

0.0

 Transcatheter

0

0

Total

30,516

1,002

3.3

Table V3

Isolated aortic valve procedures

Prosthesis/native aortic valve

n

%

Xenograft

9,484

271

2.9

Mechanical prosthesis

1,050

22

2.1

Repair

154

3

1.9

Homograft

22

6

27.3

Total

10,710

302

2.8

Notes: A total of 3,467 (32%) were performed by partial sternotomy.


Transcatheter procedures and apical aortic conduits procedures (n = 0) excluded.


Table V4

Isolated mitral valve procedures

Prosthesis/native mitral valve

n

%

Repair

4,023

44

1.1

Xenograft

1,885

182

9.7

Mechanical prosthesis

394

22

5.6

Homograft

9

0

0.0

Total

6,311

248

3.9

Notes: 3,180 (50%) procedures performed via minimally invasive access.


Transcatheter procedures excluded.


Table V5

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

Mitral valve procedures

Repair

Implantation/replacement

Total

n

%

n

%

n

% repair

%

Isolated

4,023

44

1.1

2,288

204

8.9

6,311

63.7

248

3.9

 + Aortic valve

516

30

5.8

867

141

16.3

1,383

37.3

171

12.4

 + Tricuspid valve repair[a]

972

43

4.4

621

56

9.0

1,593

61.0

99

6.2

 + CABG

1,522

96

6.3

919

143

15.6

2,441

62.4

239

9.8

 + CABG + Aortic valve replacement

291

41

14.1

288

63

21.9

579

50.3

104

18.0

Total

7,324

254

3.5

4,983

607

12.2

12,307

59.5

861

7.0

a Sixty-three procedures (unspecified mitral + tricuspid valve surgery) excluded. Unadjusted mortality: 22% (14/63).


Table V6

Multiple heart valve procedures

Combination

n

%

Mitral + tricuspid

1,656

113

6.8

Aortic + mitral

1,383

171

12.4

Aortic + mitral + tricuspid

409

51

12.5

Aortic + tricuspid

232

27

11.6

Aortic + pulmonary[a]

35

0

0.0

Tricuspid + pulmonary

15

1

6.7

Aortic + mitral + pulmonary

1

0

0.0

Total

3,731

363

9.7

Notes: Transcatheter procedures excluded.


a Including Ross procedures


Table V7

Transcatheter heart valve procedures

Without ECC

With ECC

Total

n

n

n

%

Aortic valve implantation

11,971

336

92

29

12,063

365

3

 Transvascular

10,155

233

78

24

10,233

257

3

 Transapical

1,816

103

14

5

1,830

108

6

Mitral valve

814

26

12

2

826

28

3

 Repair

688

18

8

1

696

19

3

 Implantation

126

8

4

1

130

9

7

Tricuspid valve repair

44

2

1

0

45

2

4

 Repair

41

2

1

0

42

2

5

 Implantation

3

0

0

0

3

0

0

Aortic + mitral valve implantation

30

7

1

0

31

7

23

Aortic valve implantation[a] + CABG

25

3

5

3

30

6

20

Mitral valve implantation[b] + CABG

1

0

0

0

1

0

0

Aortic + mitral valve + CABG

0

0

0

0

0

0

Total

12,885

374

111

34

12,996

408

3

Notes: Pulmonary valve implantation for CHD excluded.


Fifteen percent of transcatheter aortic valve implantation (TAVI) by transapical access and less than 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

n

%

Isolated CABG

36,273

990

2.7

 + Aortic valve replacement

6,290

303

4.8

 + Other

1,950

113

5.8

 + Mitral valve repair

1,522

96

6.3

 + Mitral valve replacement

919

143

15.6

 + Aortic valve replacement + mitral valve repair

291

41

14.1

 + Aortic + mitral valve replacement

288

63

21.9

 + Aneurysm resection

109

8

7.3

 + Transcatheter aortic valve implantation

30

6

20.0

Total

47,672

1.763

3.7

Table C2

Isolated CABG with/without ECC

Grafts

With ECC

Without ECC

Total

n

%

n

%

n

%

Single

1,024

50

4.9

1,358

25

1.8

2,382

75

3.1

Double

6,030

197

3.3

1,922

30

1.6

7,952

227

2.9

Triple

12,676

392

3.1

2,570

35

1.4

15,246

427

28

Quadruple

7,032

175

2.5

975

16

1.6

8,007

191

2.4

Quintuple + more

2,477

70

2.8

209

0

0.0

2,686

70

2.6

Total

29,239

884

3.0

7,034

106

1.5

36,273

990

2.7

Table Con 1

Congenital heart surgery with/without ECC

Age (years)

n

%

With ECC

Without ECC

With ECC

Without ECC

With ECC

Without ECC

< 1

2,190

844

76

19

3.5

2.3

1–17

1,754

180

21

4

1.2

2.2

≥ 18

974

37

30

2

3.1

5.4

Total

2,728

217

51

6

1.9

2.8

Table Con2

Procedures for congenital heart disease with and without ECC

Lesion/Procedure

Age < 1 year

Age 1 to 17 years

Age ≥ 18 years

n

%

n

%

n

%

ASD

43

3

7.0

257

0

0.0

229

6

2.6

Complete AV canal

199

3

1.5

68

1

1.5

15

0

0.0

VSD

321

2

0.6

116

0

0.0

16

2

12.5

Fallot's tetralogy

205

1

0.5

54

0

0.0

2

0

0.0

DORV

47

2

4.3

27

0

0.0

2

0

0.0

TGA

171

5

2.9

6

1

16.7

0

0

TGA + VSD

69

5

7.2

7

2

28.6

0

0

Truncus arteriosus

30

2

6.7

6

0

0.0

0

0

Fontan circulation

3

0

0.0

260

4

1.5

7

0

0.0

Norwood

159

24

15.1

2

1

50.0

1

1

100.0

Pulmonary valve

64

1

1.6

211

1

0.5

78

3

3.8

Transcatheter pulmonary valve implantation

0

2

0

0.0

14

1

7.1

Aortic valve

45

1

2.2

196

1

0.5

379

9

2.4

Ross procedure

11

2

18.2

27

1

3.7

21

0

0.0

Mitral valve

51

1

2.0

111

4

3.6

91

4

4.4

Tricuspid valve

84

0

0.0

50

1

2.0

39

4

10.3

PDA

235

3

1.3

32

0

0.0

3

0

0.0

Coarctation

233

2

0.9

28

0

0.0

2

0

0.0

Others

1,063

38

3.6

432

4

0.9

112

2

1.8

HTx

1

0

0.0

32

2

6.3

0

0

HLTx

0

0

0

0

0

0

LTx

0

0

10

2

20.0

0

0

Total

3,034

95

3.1

1,934

25

1.3

1,011

32

3.2

Table Mis1

Ross procedures (autologous AV- and PVR)

Age (years)

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

< 18

42

54

43

40

36

33

37

28

38

38

≥ 18

207

175

184

134

117

107

90

64

72

52

Total

249

229

227

174

153

140

127

92

110

90

Table Mis2

Heart and lung transplantation

Transplant

With ECC

Without ECC

n

%

n

%

HTx

253

27

10.7

HLTx

5

1

20.0

LTx

36

9

25.0

250

12

4.8

Notes: All pediatric transplantations (demonstrated in Table Con2) are included in this table.


Eurotransplant (ET) report 2017: 248 HTx, 2 HTx + kidneyTx, 2 HTx + liverTx, 5 HLTx, 272 DLTx, 31 SLTx, 0 LTx + kidneyTx and 1 LTx + liverTx.


Table Mis3

Aortic surgery

Replacement[a]

With ECC

Without ECC

n

%

n

%

Supracoronary replacement of ascending aorta

1,357

108

8.0

Supracoronary ascending + aortic valve replacement

1,348

73

5.4

Infracoronary ascending

 Mechanical aortic valve conduits

406

31

7.6

 Biological aortic valve conduits

984

113

11.5

 David procedure

487

11

2.3

 Yacoub procedure

122

4

3.3

 Other

284

23

8.1

Aortic arch replacement[b]

2,432

345

14.2

Replacement of descending aorta

58

4

6.9

6

1

16.7

Thoracoabdominal aortic replacement

99

23

23.2

19

1

5.3

Endostent descending aorta

3

0

0.0

611

37

6.1

Total

7,580

735

9.7

636

39

6.1

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 CABG) are summarized in this category.


a Procedures for abdominal aortic diseases excluded: 386 abdominal procedures and 19 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

13,560

120

0.9

14

2

13,546

118

 Implantation

8,963

79

0.9

3

2

8,960

77

 Battery exchange

1,814

3

0.2

1

0

1,813

3

 Revision

2,783

38

1.4

10

0

2,773

38

ICD

8,296

91

1.1

21

4

8,275

87

 Implantation

3,537

15

0.4

0

0

3,537

15

 Battery exchange

1,812

6

0.3

0

0

1,812

6

 Revision

2,947

70

2.4

21

4

2,926

66

Miscellaneous

1,348

6

0.4

0

0

1,348

6

Total

23,204

217

0.9

35

6

23,169

211

Table Mis5

Surgical procedures for tachyarrhythmia

Energy source

Endocardiac

Epicardiac

Total

n

n

Unipolar radiofrequency

100

165

265

Unipolar cryoradiofrequency

88

137

225

Bipolar radiofrequency

224

1,991

2,215

Cryothermy

1,306

253

1,559

Microwave

0

8

8

Focused ultrasound

29

108

137

Laser

0

0

0

Other

3

6

9

Total

1,750

2,668

4,418

Note: 391 procedures are not unspecified with regard to endocardiac/epicardiac ablation.


Compared with the data of previous years, several important developments continued almost unchanged in 2017. The age distribution of patients ([Fig. 6]) shows a continuous shift to an elderly patient population with presently 35.9% of the cardiac procedures performed in patients from 70 to 79 years of age and 16.8% in octo-/nonagenarians. However, unadjusted mortality rates remain on the same low level over the last decade ([Fig. 2]). The rate of CABG procedures decreased over the past decade, while the relative count for off-pump CABG has now reached a level of 19.4% (2016: 18.5%) ([Figs. 1], [3]).

There is still a continuous increase of TAVI in Germany ([Fig. 5], [Table V7]), while the count of isolated aortic valve procedures shows a slight decrease of 3.7%. In 2017, a total of 12,063 (53.3%) TAVI procedures were reported to the registry. It must be emphasized that the 78 participating departments which contribute their data to the registry do not represent all departments performing TAVI in Germany. In context to the recommendations of international guidelines[8] [9] [10] on the management of valvular heart disease, the German Federal Joint Committee implemented a quality assurance directive for “minimally invasive heart valve interventions (TAVI, transcatheter mitral clip reconstruction)” in July 2015, in which obligatory structures, defined processes, and qualified personnel are precisely specified. In addition, the annual analyses for selected procedures of the legally compulsory quality assurance (§136, 137 SGB V) as well as the results of the voluntary German Aortic Valve Registry[11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] contribute to public and scientific reporting.

In 2017, the rate of mitral valve reconstructions shows a slight increase up to 63.7% (2016: 62.9%) ([Fig. 8]). Based on the fact that each isolated mitral valve procedure is included regardless of the underlying valve disease concerning morphology or urgency of operation, it can be assumed that the relative rate of mitral valve reconstruction would certainly be even higher if patients without possibility or indication for reconstruction would have been excluded (e.g., mitral valve stenosis, calcifications, or endocarditis). In other publications, for example, Gammie et al,[23] patients with mitral valve stenosis, endocarditis, and emergency procedures 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 in left/right ventricular assist device implantations emphasizes the importance of mechanical circulatory support therapies (n = 1,027), while biventricular and total artificial heart implantations are of subordinate importance with only 2.3% in 2017 ([Fig. 10]).

Zoom Image
Fig. 10 Development of mechanical circulatory support (2008–2017).

#
#

Discussion

The registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in Germany in 2017. 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.[24] As observed in recent years, heart surgery in Germany is continuously performed on a high level with superior in-hospital patient survival rates compared with international surveys. In addition, the registry demonstrates that the provision of heart surgery in Germany is appropriate and patient care is guaranteed nationwide at any time (24/7/365). These aspects are especially important in the context of various activities in health care politics and the demographic trends of the German population leading to patients at increased age combined with related comorbidities and a complex preoperative risk profile, respectively.

Compared with 2016, the count of cardiac surgery procedures remains on a comparable level, predominantly induced by the continuous increase in catheter-based heart valve procedures.

Further developments and improvements in the registry are recommended to enable more specified assessments and particularly risk-adjusted data-analyses. However, if significant fundamental changes related to the modality of data collection are conducted, it has to be considered that data compatibility still allows further longitudinal data analysis.

Completeness, validity, and further progress depend on continued efforts and a close collaboration of the GSTCVS and 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.


#

Abbreviations

ASD: atrial septal defect
AVC: Atrioventricular canal
CABG: coronary artery bypass grafting
CHD: congenital heart disease
DLTx: double lung transplantation
DORV: double outlet right ventricle
ECC: extracorporeal circulation
ECLS: extracorporal life support
ECMO: extracorporal membrane oxygenation
HLTx: heart-lung transplantation
HTx: heart transplantation
ICD: implantable cardioverter defibrillator
LTx: lung transplantation
PDA: patent ductus arteriosus
PTS: patients
SLTx: single lung transplantation
TAH: total artificial heart
TAVI: transcatheter aortic valve implantation
TGA: transposition of great arteries
TMLR: transmyocardial laser revascularization
Tx: transplantation
VADs: ventricular assist devices
VSD: ventricular septal defect

#

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

Acknowledgments

The German Society for Thoracic and Cardiovascular Surgery would like to thank all heads of the departments for cardiac surgery in Germany and their employees for their continued cooperation and support for realization of the annual update of 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 Selected heart surgical categories (2008–2017). 1. Isolated and combined CABG: all types 2. Isolated heart valve procedures: combination with aortic surgery summarized in 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.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2008–2017).
Zoom Image
Fig. 3 Isolated coronary artery bypass grafting (2008–2017).
Zoom Image
Fig. 4 Isolated aortic valve replacement (2008–2017). 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 2017. +Additional TAVI procedures calculated from the German legal quality assurance program, § 136ff, § 137a SGB V.
Zoom Image
Fig. 6 Age distribution of cardiac procedures (2008–2017). Notes: Patients < 20 years and pacemaker/implantable cardioverter defibrillator procedures were excluded.
Zoom Image
Fig. 7 Heart transplantation (2008–2017).
Zoom Image
Fig. 8 Isolated mitral valve surgery (2008–2017).
Zoom Image
Fig. 9 Age distribution for CHD (2008–2017). Notes: Bias possible due to the fact that not all relevant procedures can be allocated exactly to CHD-category in patients > 18 years (e.g., aortic valve disease).
Zoom Image
Fig. 10 Development of mechanical circulatory support (2008–2017).