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.
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.
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.
Fig. 3 Age distribution of cardiac procedures (2009–2018). Notes: patients <20 years and
pacemaker/implantable cardioverter—defibrillator procedures were excluded.
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2009–2018).
Fig. 5 Isolated aortic valve replacement (2009–2018). Notes: Ross procedures, homograft implantations, and transcatheter heart valve intervention
excluded.
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.
Fig. 7 Isolated mitral valve surgery (2009–2018).
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).
Fig. 9 Development of mechanical circulatory support (2009–2018).
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
