Thorac cardiovasc Surg 2019; 67(05): 331-344
DOI: 10.1055/s-0039-1693022
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

German Heart Surgery Report 2018: 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
,
Renate Meyer
2  BQS Institute for Quality and Patient Safety, Düsseldorf, Germany
,
Jana Lewandowski
1  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Andreas Markewitz
1  German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Wolfgang Harringer
3  Clinic for Cardiac, Thoracic and Vascular Surgery, Klinikum Braunschweig GmbH, 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

20 May 2019

20 May 2019

Publication Date:
16 July 2019 (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 2018 are analyzed. For this period, a total of 174,902 procedures were submitted to the registry, 98,707 summarized as heart surgery procedures in the classical meaning. The unadjusted in-hospital survival rate for 33,999 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.8:1) was 97.1% and for 34,915 isolated heart valve procedures, 14,396 transcatheter interventions included, it was 96.0%. Concerning short- and long-term circulatory supports, a total of 2,871 extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) implants, respectively, 942 assist device implantations (L-/R-/BVAD, TAH) were registered. In 2018, the number of isolated heart transplantations increased to 312, a growth of 23% compared with the previous year. The isolated lung transplantations reached 340, a rise of nearly 19%. This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine, and is a basis for quality management 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 all the 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. Thirty years ago, the board of directors of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS, www.dgthg.de) decided to set up a periodic 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 sense of a registry, and published in the scientific society journal each year.[3] [4] [5] [6] [7] The prevalent aims are: to detect developments and upcoming trends in cardiac surgery in Germany; to compile various results for nearly all cardiac surgical procedures; to provide each participant with a benchmark of the 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 aortic valve implantation (TAVI). Thereby, important findings for current patient safety and the future of patient care are collected for evaluation under different aspects.

Data and results presented in this report comprehend assorted findings of the year 2018.


#

Materials and Methods

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

All participating institutions were requested to complete the structured questionnaire by January 21, 2019, 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 society office 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 2018 were all cardiac surgical procedures performed on patients between January 1, 2018, and December 31, 2018, unrelated to the date of patients' admission or discharge 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 three 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.

In 2018, a total of 78 institutions performed heart surgery. As always, all departments answered the questionnaire and delivered a complete dataset for the year 2018 including in-hospital mortality rates. In addition, comparisons between the registry data and the external quality assurance in accordance with §§ 135a/136/137 SGB V, obligatory for licensed German hospitals (§ 108 SGB V), are feasible.

For statistical analyses, categorized tables and a summary registry data file consolidate 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. Due to the lack of complete data for patients' risk adjustment, all mortality rates are unadjusted. Quantitative data are presented as absolute frequencies and arithmetic mean values. Where appropriate, the value range is presented additionally. Patient age, though originally a quantitative variable, is only available in age groups and therefore treated as a categorical variable. German population-based measures are calculated as frequencies per 100,000 inhabitants and are based on the latest published data of the Federal Office for Statistics (Destatis) from November 30, 2018.

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 2018

[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 November 30, 2018. The range of heart operations per 100,000 inhabitants again shows a minimum of 102.1 (Baden Württemberg, population: 11,076,352) and a maximum of 165.3 (Sachsen-Anhalt, population: 2,209,938), while the nationwide mean value was 117.9 (2017: 122.0). Analyzing quantified categories of heart operations by department dimension, nearly 67% of institutions are in two clusters with at least 518 up to 1,480 procedures, and 26% in those with a minimum of 1,569 up to a maximum of 3,872 performed procedures ([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]) are conducted in 22, isolated heart transplantations in 20, and combined heart–lung transplantations in 2 institutions ([Table 3]). The number of procedures using ECC in Germany from 2009 to 2018 is illustrated in [Table 4]. Over the past decade, the number of heart operations using ECC shows a decline by 14,585 procedures, presumably reflecting an achievement of established innovations such as catheter-based procedures in cardiac medicine 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

11,306

11,076,352

102.1

Bayern

13,690

13,082,541

104.6

Berlin

3,923

3,644,998

107.6

Brandenburg

3,414

2,511,943

135.9

Bremen

799

682,947

117.0

Hamburg

2,232

1,841,484

121.2

Hessen

7,395

6,268,099

118.0

Mecklenburg-Vorpommern

2,266

1,610,280

140.7

Niedersachsen

10,235

7,984,849

128.2

Nordrhein-Westfalen

20,610

17,932,567

114.9

Rheinland-Pfalz

5,119

4,085,831

125.3

Saarland

1,313

991,116

132.5

Sachsen

5,107

4,079,703

125.2

Sachsen-Anhalt

3,653

2,209,938

165.3

Schleswig-Holstein

4,005

2,897,035

138.2

Thüringen

2,876

2,144,446

134.1

Germany

97,943

83,044,129

117.9

a n = 764 foreign residents excluded.


b Federal Office for Statistics of German: Population; due date November 30, 2018.


Table 2

Departments assorted by quantified categories (∑[a] [n = 98,707])

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Departments

6

25

27

10

10

Average

367

789

1,190

1,750

2,716

Range

225–475

518–991

1,004–1,480

1,569–1,941

2,023–3,872

a Pacemaker/implantable cardioverter–defibrillator and extracardiac surgery without extracorporeal circulation are excluded.


Table 3

Departments summarized by heart surgery procedures 2018

Category

N

Coronary artery bypass grafting

77

Heart valve surgery

77

Surgery for CHD in pat. <1 y with ECC

22[a]

Heart transplantation

20[b]

Heart–lung transplantation

2

a N = 2,086: thereof: 6 to 16 operations in 2 units, 25 to 49 operations in 6 units, 58 to 97 operations in 4 units, and 109 to 234 operations in 10 units.


b N = 312: thereof: 1 to 4 transplants in six units, 6 to 9 transplants in three units, 10 to 19 transplants in six units, and 21 to 81 transplants in five units.


Table 4

Cardiac procedures using extracorporeal circulation (2009–2018)

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Departments

80

79

78

79

79

78

78

78

78

78

Operations

86,916

84,686

84,402

84,388

84,040

83,787

81,527

79,082

76,696

72,331

Average

1,086

1,072

1,082

1,068

1,064

1,074

1,045

1,014

983

927

Overall, 174,902 procedures were reported to the registry for the year 2018, a decrease of 2.5% (2017: 179,337 procedures). In 2018, a total of 98,707 heart surgical procedures in the narrower sense display a decline of 3.0% (n = 3,021) compared with 2017 (101,728 procedures) ([Table 5]). Concerning gender distribution, the registry shows an overall male:female ratio of 1.9:1 with the greatest distinction (3.3:1) in the patient group of coronary procedures ([Table 6]); 11.3% (n = 11,147) of the operations were conducted as emergency procedures, and 8.8% (n = 8,642) were reoperations ([Table 7]). A total of 16,840 (48.2%) isolated heart valve procedures were performed as single, 3,233 as double (9.3%), and 353 (1.0%) as triple valve procedures ([Table V1]); 7,021 (41.7%) single heart valve operations were performed via a minimally invasive access ([Table V2]). In 8,800 (87.8%) isolated aortic valve operations under ECC conditions, xenograft prostheses were implanted, while in 3,999 (64.3%) isolated mitral valve operations, a reconstruction with preservation of the native valve could be achieved ([Table V3], [Figs. 5] and [7]). The subdivision of 3,586 multiple heart valve procedures led to 3,014 (84.0) operations, as a combination of mitral + tricuspid (n = 1,607) or mitral + aortic (n = 1,407) valve procedures ([Tables V4] and [V5]).

Table 5

Frequency of cardiac procedures 2018

Category

With ECC

Without ECC

Total

Difference 2017 (%)

Coronary artery bypass grafting

37,051[a]

7,219[a]

44,270

−7.1

Heart valve procedures

20,671[a]

14,244[a]

34,915

+1.5

Surgery of thoracic aorta

7,562[a]

607[a]

8,169

−0.6

Surgery for CHD

4,882[a]

971[a]

5,853

−1.0

Cardiac surgery, other

1,119[a]

1,229[a]

2,348

+6.7

Assist device procedures

656[a]

2,106[a]

2,762

−5.1

Extracardiac surgery

355[a]

53,788

54,143

−1.2

Pacemaker and ICD procedures

35[a]

22,407

22,442

−3.3

Total

72,331

102,571

174,902

−2.5

a Sum: n = 98,707 (heart surgery procedures).


Table 6

Gender distribution 2018

Distribution

Female

Male

N

%

N

%

Heart valve procedures

15,132

43

19,783

57

Coronary procedures

10,220

23

34,050

77

CHD procedures

2,624

45

3,229

55

Surgery of thoracic aorta

2,828

35

5,341

65

Cardiac surgery, other

1,323

56

1,025

44

Assist device

749

27

2,013

73

Pacemaker and ICD

8,451

38

13,991

62

Extracardiac surgery

18,949

35

35,194

65

Total

60,276

34

114,626

66

Table 7

Additional data 2018 versus 2017

Procedures with ECC

2018

2017

Emergency

11,147

11.3%

12,032

11.8%

Redo

8,642

8.8%

9,049

8.9%

Table V1

Isolated heart valve procedures

Procedure

N

%

Single valve

16,840

658

3.9

Double valve

3,233

285

8.8

Triple valve

353

48

13.6

Transcatheter access (single valve)

14,375

386

2.7

Transcatheter access (double valve)

21

2

9.5

Unspecified

93

10

10.8

Total

34,915

1,389

4.0

Notes: Transcatheter heart valve procedures: 13,279 aortic valve implantation; 156 mitral valve implantation; 831 mitral valve repair; 3 tricuspid valve implantation; 102 tricuspidal valve repair; 4 pulmonary valve implantation; and 21 combined aortic and mitral valves procedure.


Table V2

Single heart valve procedures

Access path

N

%

Aortic valve

 Sternotomy

6,534

270

4.1

 Partial sternotomy

3,488

64

1.8

 Transvascular

11,654

272

2.3

 Transapical

1,625

86

5.3

Mitral valve

 Sternotomy

2,819

208

7.4

 Minimal invasive

3,403

48

1.4

 Transcatheter

987

26

2.6

Tricuspidal valve

 Sternotomy

413

53

12.8

 Minimal invasive

129

11

8.5

 Transcatheter

105

2

1.9

Pulmonary valve

 Sternotomy

50

2

4.0

 Minimal invasive

1

0

0.0

 Transcatheter

4

0

0.0

Total

31,212

1,042

3.3

Notes: A total of 3,488 (35%) by partial sternotomy. A total of 3,403 (55%) mitral valve procedures by minimally invasive access. Apical aortic conduit procedures (n = 3) not included.


Table V3

Isolated aortic/mitral valve operations

Prosthesis/native heart valve

Aortic

Mitral

N

%

N

%

Xenograft

8,800

312

3.5

1,813

184

10.1

Mechanical prosthesis

992

21

2.1

400

22

5.5

Repair

193

0

0.0

3,999

49

1.2

Homograft

37

1

2.7

10

1

10.0

Total

10,022

334

3.3

6,222

256

4.1

Note: Transcatheter procedures and apical aortic conduit procedures (n = 3) not included.


Zoom Image
Fig. 1 Selected heart surgical categories (2009–2018). Notes: 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;miscellaneous procedures: all other types of procedures with ECC.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2009–2018).
Table V4

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

Mitral valve procedures

Repair

Implantation/replacement

 Total

N

%

N

%

N

%

%

Isolated

3,999

49

1.2

2,223

207

9.3

6,222

64.3

256

4.1

 CABG

1,302

86

6.6

903

139

15.4

2,205

59.0

225

10.2

 Tricuspid valve repair[a]

918

27

2.9

632

71

11.2

1,550

59.2

98

6.3

 Aortic valve

558

33

5.9

849

130

15.3

1,407

39.7

163

11.6

 CABG + aortic valve replacement

241

25

10.4

256

47

18.4

497

48.5

72

14.5

Total

7,018

220

3.1

4,863

594

12.2

11,881

59.1

814

6.9

a 57 procedures (not specified mitral valve + tricuspid valve surgery) excluded. Mortality: 9% (5/57).


Table V5

Multiple heart valve procedures

Combinations

N

%

Mitral + tricuspid

1,607

103

6.4

Aortic + mitral

1,407

163

11.6

Aortic + mitral + tricuspid

352

47

13.4

Aortic + tricuspid

168

19

11.3

Aortic + pulmonary[a]

37

0

0.0

Tricuspid + pulmonary

14

0

0.0

Aortic + mitral + pulmonary

1

1

100.0

Total

3,586

333

9.3

Note: Transcatheter procedures are excluded.


a Including Ross procedures.


[Tables V6], [C1], [C2], [Con1], [Con2], and [Mis1] to [Mis5] as well as [Figs. 1] [2] [3] [4], [6], [8]–[10] demonstrate further compiled registry data under different aspects and for various categories.

Table V6

Transcatheter heart valve procedures

Without ECC

With ECC

Total

N

N

N

%

Aortic valve implantation

13,190

336

89

22

13,279

358

3

 Transvascular

11,582

254

72

18

11,654

272

2

 Transapical

1,608

82

17

4

1,625

86

5

Mitral valve

925

25

62

1

987

26

3

 Repair

777

13

54

0

831

13

2

 Implantation

148

12

8

1

156

13

8

Tricuspid valve repair

105

2

0

0

105

2

2

 Repair

102

2

0

0

102

2

2

 Implantation

3

0

0

0

3

0

0

Aortic + mitral valve implantation

20

2

1

0

21

2

10

Aortic valve implantation[a] + CABG

23

3

7

2

30

5

17

Mitral valve implantation[b] + CABG

0

0

7

2

7

2

29

Aortic + mitral valve + CABG

0

0

0

0

0

0

Total

14,263

368

166

27

14,429

395

3

Notes: Pulmonary valve implantation for congenital heart disease excluded; 12% of transcatheter aortic valve implantation (TAVI) by transapical access and less than 1% of TAVI under the 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

33,999

976

2.9

 Aortic valve replacement

5,668

273

4.8

 Other

1,749

106

6.1

 Mitral valve repair

1,302

86

6.6

 Mitral valve replacement

903

139

15.4

 Aortic valve replacement + mitral valve repair

241

25

10.4

 Aortic valve + mitral valve replacement

256

47

18.4

 Aneurysm resection

115

10

8.7

 Transcatheter aortic valve implantation

30

5

16.7

Total

44,263

1,667

3.8

Table C2

Isolated CABG with/without ECC

Grafts

With ECC

Without ECC

Total

N

%

N

%

N

%

Single

881

59

6.7

1,327

34

2.6

2,208

93

4.2

Double

5,576

213

3.8

1,973

37

1.9

7,549

250

3.3

Triple

11,672

328

2.8

2,627

41

1.6

14,299

369

2.6

Quadruple

6,405

166

2.6

886

13

1.5

7,291

179

2.5

Quintuple + more

2,446

81

3.3

206

4

1.9

2,652

85

3.2

Total

26,980

847

3.1

7,019

129

1.8

33,999

976

2.9

Table Con1

Congenital heart surgery with/without ECC

Age (y)

N

%

With ECC

Without ECC

With ECC

Without ECC

With ECC

Without ECC

< 1

2,109

734

76

12

3.6

1.6

1–17

1,800

210

14

0

0.8

0.0

≥ 18

1,048

27

32

0

3.1

0.0

Total

4,957

971

122

12

2.5

1.2

Table Con2

Procedures for congenital heart disease with and without ECC

Lesion/procedure

Age < 1 y

Age 1–17 y

Age ≥ 18 y

N

%

N

%

N

%

ASD

36

0

0.0

288

0

0.0

254

4

1.6

Complete AV canal

206

4

1.9

91

0

0.0

10

0

0.0

VSD

358

1

0.3

122

0

0.0

9

1

11.1

Fallot's tetralogy

182

5

2.7

37

1

2.7

3

0

0.0

DORV

49

3

6.1

19

0

0.0

0

0

TGA

166

5

3.0

8

0

0.0

1

1

100.0

TGA + VSD

72

2

2.8

6

0

0.0

0

0

Truncus arteriosus

34

2

5.9

5

1

20.0

1

0

0.0

Fontan circulation

1

0

0.0

216

0

0.0

3

0

0.0

Norwood

164

23

14.0

1

0

0.0

0

0

Pulmonary valve

47

0

0.0

213

5

2.3

56

1

1.8

Transcatheter pulmonary valve implantation

0

5

0

0.0

11

0

0.0

AV

49

0

0.0

183

1

0.5

418

10

2.4

Ross procedure

6

0

0.0

23

0

0.0

30

2

6.7

Mitral valve

47

2

4.3

118

2

1.7

107

5

4.7

Tricuspid valve

93

5

5.4

63

1

1.6

52

5

9.6

PDA

188

3

1.6

15

0

0.0

0

0

Coarctation

200

0

0.0

20

0

0.0

4

0

0.0

Others

937

33

3.5

531

2

0.4

116

3

2.6

HTx

6

0

0.0

34

1

2.9

0

0

HLTx

0

0

0

0

0

LTx

2

0

0.0

12

0

0.0

0

0

Total

2,843

88

3.1

2,010

14

0.7

1,075

32

3.0

Table Mis1

Ross procedures (autologous AV and PVR)

Age (y)

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

< 18

54

43

40

36

33

37

28

38

38

29

≥ 18

175

184

134

117

107

90

64

72

52

61

Total

229

227

174

153

140

127

92

110

90

90

Table Mis2

Heart and lung transplantation

Transplant

With ECC

Without ECC

N

%

N

%

HTx

312

33

10.6

HLTx

2

0

0.0

LTx

45

4

8.9

295

10

3.4

Notes: All pediatric transplantations (demonstrated in [Table Con2]) are included in this table. Eurotransplant (ET) report 2018: 312 HTx, 4 HTx + kidney Tx, 0 HTx + liver Tx, 2 HLTx, 317 DLTx, 54 SLTx, 0 LTx + kidney Tx, and 2 LTx + liver Tx.


Table Mis3

Aortic surgery

Replacement[a]

With ECC

Without ECC

N

%

N

%

Supracoronary replacement of ascending aorta

1,308

111

8.5

Supracoronary ascending + aortic valve replacement

1,308

68

5.2

Infracoronary ascending

 Mechanical aortic valve conduits

400

22

5.5

 Biological aortic conduits

1,062

113

10.6

 David procedure

474

4

0.8

 Yacoub procedure

127

0

0.0

 Other

259

17

6.6

Aortic arch replacement[b]

2,497

319

12.8

Replacement of descending aorta

44

6

13.6

4

0

0.0

Thoracoabdominal aortic replacement

81

7

8.6

16

3

18.8

Endostent descending aorta

2

0

0.0

587

32

5.5

Total

7,562

667

8.8

607

35

5.8

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


a Procedures for abdominal aortic diseases excluded: 438, abdominal procedures and 18, 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

13,433

101

0.8

19

1

13,414

100

 Implantation

8,983

61

0.7

4

0

8,979

61

 Battery exchange

1,734

4

0.2

0

0

1,734

4

 Revision procedures

2,716

36

1.3

15

1

2,701

35

ICD

7,382

73

1.0

15

3

7,367

70

 Implantation

3,194

11

0.3

0

0

3,194

11

 Battery exchange

1,671

4

0.2

0

0

1,671

4

 Revision procedures

2,517

58

2.3

15

3

2,502

55

Miscellaneous

1,627

14

0.9

1

1

1,626

13

Total

22,442

188

0.8

35

5

22,407

183

Table Mis5

Surgical procedures for tachyarrhythmia

Energy source

Endocardiac

Epicardiac

Total

N

N

Unipolar radiofrequency

95

182

277

Unipolar cryoradiofrequency

84

118

202

Bipolar radiofrequency

231

2,035

2,266

Cryothermy

1,343

380

1,723

Microwave

4

17

21

Focused ultrasound

9

113

122

Laser

0

0

0

Other

13

11

24

Total

1,779

2,856

4,635

Note: A total of 279 procedures are unspecified with regard to endocardiac/epicardiac ablation.


Zoom Image
Fig. 3 Age distribution of cardiac procedures (2009–2018). Notes: patients <20 years and pacemaker/implantable cardioverter—defibrillator procedures were excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2009–2018).
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Fig. 5 Isolated aortic valve replacement (2009–2018). Notes: Ross procedures, homograft implantations, and transcatheter heart valve intervention excluded.
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Fig. 6 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 2018. +Additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V.
Zoom Image
Fig. 7 Isolated mitral valve surgery (2009–2018).
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Fig. 8 Age distribution for CHD (2009–2018). 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).
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Fig. 9 Development of mechanical circulatory support (2009–2018).
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Fig. 10 Heart transplantation (2009–2018).

Compared with the data of previous years, several important developments remained almost unchanged in 2018. The age distribution of patients ([Fig. 3]) shows a continuous shift toward an elderly patient population, with presently 34.8% of the cardiac procedures being performed in patients from 70 to 79 years of age, and 17.6% in octo-/nonagenarians. However, unadjusted mortality rates remain on the same low level over the past decade ([Fig. 2]). The number of CABG procedures, isolated or combined, decreased over the past decade, while the relative count for isolated off-pump CABG has now reached a level of 20.6% (2017: 19.4%) ([Figs. 1] and [4]).

There is still a continuous increase of transcatheter heart valve procedures in Germany ([Table V6]). In 2018, a total of 13,279 (57.5%) TAVI procedures and 9,829 (42.5%) surgical aortic valve replacements were reported to the registry ([Fig. 6]). It must be emphasized that exclusively the German departments for cardiac surgery contribute their data and therefore the registry cannot reach completeness by the way of exception. On the basis of and in addition to the recommendations of international scientific guidelines resp. expert consensus on the management of valvular heart disease,[8] [9] [10] [11] in July 2015, the German Federal Joint Committee (G-BA) implemented a quality assurance directive for “minimally invasive heart valve interventions (TAVI, transcatheter mitral clip reconstruction),” in which obligatory structures, defined processes, and qualified personnel are precisely specified.[12] Further surveys for selected procedures, such as the legally compulsory quality assurance (§135a SGB V) or the voluntary nationwide German Aortic Valve Registry,[13] [14] [15] [16] [17] [18] provide various important findings and thus contribute to an exceptional patient benefit.

In 2018, the rate of mitral valve reconstructions shows a slight increase to 64.3% (2017: 63.7%) ([Fig. 7]). 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 a 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,[19] 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.

In 2018, the ventricular assist device (L-/R-/BVAD, TAH) implantations (n = 942) showed a decrease of 8.2% compared with 2017 (n = 1,027) ([Fig. 9]), while the heart transplantations (n = 312) reached the highest level for the past 5 years ([Fig. 10]). Nevertheless, the mechanical circulatory support therapy, in particular LVAD, is still of outstanding importance for patients with end-stage heart failure.


#

Discussion

The registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in Germany in 2018. 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.[20] As observed in recent years, heart surgery in Germany is continuously performed on a high level with superior in-hospital patient survival compared with international surveys. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate, and that patient care is guaranteed nationwide at all times (24/7/365). These aspects are especially important in the context of various activities in health care policy and considering the background of demographic trends of the German population, leading to patients at increased age combined with related comorbidities and an accordingly complex preoperative risk profile.

Compared with 2017, the number of cardiac surgery procedures showed a disproportionate decrease for coronary artery bypass procedures, a curious trend in view of the German population characteristics and in the context of application of the scientific guidelines.[21] [22] Otherwise, the remarkable increase in heart transplantations is a reason for hope that this positive development will continue.

Further improvements of 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 will still allow 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 as 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
SAVR: surgical aortic valve replacement
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

#

Conflict of Interest

None.

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 to realize 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 (2009–2018). Notes: 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;miscellaneous procedures: all other types of procedures with ECC.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2009–2018).
Zoom Image
Fig. 3 Age distribution of cardiac procedures (2009–2018). Notes: patients <20 years and pacemaker/implantable cardioverter—defibrillator procedures were excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2009–2018).
Zoom Image
Fig. 5 Isolated aortic valve replacement (2009–2018). Notes: Ross procedures, homograft implantations, and transcatheter heart valve intervention excluded.
Zoom Image
Fig. 6 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 2018. +Additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V.
Zoom Image
Fig. 7 Isolated mitral valve surgery (2009–2018).
Zoom Image
Fig. 8 Age distribution for CHD (2009–2018). 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. 9 Development of mechanical circulatory support (2009–2018).
Zoom Image
Fig. 10 Heart transplantation (2009–2018).