Thorac Cardiovasc Surg 2020; 68(04): 263-276
DOI: 10.1055/s-0040-1710569
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

German Heart Surgery Report 2019: 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, Hamburg, 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
,
Jan Gummert
3  Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
› Institutsangaben
Weitere Informationen

Address for correspondence

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

Publikationsverlauf

15. April 2020

15. April 2020

Publikationsdatum:
14. Mai 2020 (online)

 

Abstract

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2019 are analyzed. For this period, a total of 175,705 procedures were submitted to the registry, 100,446 summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 34,224 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.8:1) was 97.3%. For the 36,650 isolated heart valve procedures (16,625 transcatheter interventions included), it was 96.4%. Concerning short- and long-term circulatory support, a total of 2,716 extracorporeal life support/extracorporeal membrane oxygenation implantations, resp. 953 assist device implantations (L-/ R-/ BVAD, TAH) were registered. In 2019, the number of isolated heart transplantations increased to 333, a rise of 6.7% compared to the previous year. The isolated lung transplantations amounted to 311, a decrease of 8.5%. This annually 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 represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.


#

Abbreviations

ASD: atrial septal defect
AVC: Atrioventricular canal
CABG: coronary artery bypass grafting
CHD: congenital heart disease
CIED: Cardiac Implantable Electronic Devices
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

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. This resulted 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 the 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 as well as 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 for evaluation under different aspects.

Data and results presented in this report comprehend the survey of the year 2019.


#

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 (ICPM) called “operation code” (OPS - Operationen- und Prozedurenschlüssel).

All participating institutions were requested to complete the structured questionnaire by January 20, 2020, 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 2019 were all cardiac surgical procedures performed on patients between January 1, 2019 and December 31, 2019, unrelated to the date of patients' admission or discharge as compared to 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 number of treated patients. Last but not the 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 data set, regardless of the hard- and software used locally.

In 2019, a total of 78 institutions performed heart surgery. As in the years before, all departments answered the questionnaire and delivered a complete data set for the year 2019, 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 descriptive 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 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) dated December 31, 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 2019

[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 31, 2018. The range of heart operations per 100,000 inhabitants again shows a minimum of 104.2 (Bavaria, population: 13,076,721) and a maximum of 168.7 (Sachsen-Anhalt, population: 2,208,321), while the nationwide mean-value by the end of 2018 was 120.0. Analyzing quantified categories of heart operations by department dimension categorizes nearly 62% of institutions into two clusters with at least 577 up to 1,483 procedures, 29% into those with a minimum of 1,517 up to a maximum of 4,099 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 21, and combined heart-lung transplantations in 4 institutions ([Table 3]).

Table 1

Heart operations/German states

Federal state

Quantity[a]

Population[b]

Heart procedures/100,000 inhabitants

Baden Württemberg

11,680

11,069,533

105.5

Bayern

13,626

13,076,721

104.2

Berlin

3,973

3,644,826

109.0

Brandenburg

3,576

2,511,917

142.4

Bremen

745

682,986

109.1

Hamburg

2,375

1,841,179

129.0

Hessen

6,899

6,265,809

110.1

Mecklenburg-Vorpommern

2,114

1,609,675

131.3

Niedersachsen

10,238

7,982,448

128.3

Nordrhein-Westfalen

21,820

17,932,651

121.7

Rheinland-Pfalz

5,181

4,084,844

126.8

Saarland

1,318

990,509

133.1

Sachsen

5,279

4,077,937

129.5

Sachsen-Anhalt

3,725

2,208,321

168.7

Schleswig-Holstein

4,088

2,896,712

141.1

Thüringen

2,975

2,143,145

138.8

Germany

99,612

83,019,213

120.0

a n = 834 foreign residents excluded.


b Federal Office for Statistics of German Population due date December 31, 2018.


Table 2

Departments assorted by quantified categories (∑[a] [n = 100,446])

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000-5,000

Departments

7

24

12

11

Average

372

797

1,186

1,685

2,728

Range

237–499

577–992

1,008–1,483

1,517–1,905

2,076–4,099

a CIED and extracardiac surgery without ECC are excluded.


Table 3

Departments summarized by heart surgery procedures 2019

Category

n

Coronary artery bypass grafting

77

Heart valve surgery

77

Pacemaker/ICD procedures

76/73

Surgery for CHD in patient <1 year with ECC

22[a]

Heart transplantation

21[b]

Heart-lung transplantation

4

a n = 2099; thereof: 18 operations in 1 unit, 22 to 45 operations in 5 units, 57 to 95 operations in 7 units, 110 to 240 operations in 9 units.


b n = 333: thereof: 1 to 4 transplants in 8 units, 5 transplants in 3 units, 10 to 18 transplants in 3 units, 21 to 89 transplants in 7 units.


The number of procedures using ECC in Germany from 2010 to 2019 is illustrated in [Table 4]. Over the past decade, the number of heart operations using ECC shows a decline by 12,927 procedures, presumably reflecting an achievement of established innovations like catheter-based procedures in cardiac medicine and minimally invasive therapeutic options in heart surgery, such as off-pump CABG.

Table 4

Cardiac procedures using extracorporeal circulation (2010–2019)

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Departments

79

78

79

78

Procedures

84,686

84,402

84,388

84,040

83,787

81,527

79,082

76,696

72,331

71,759

Average

1,072

1,082

1,068

1,064

1,074

1,045

1,014

983

927

920

Overall, 175,705 procedures were reported to the registry for the year 2019, a difference of <0.5% compared to 2018 (174,902 procedures). In 2019, a total of 100,446 heart surgical procedures in the narrower sense displays an increase of 1.8% (n = 1,739) compared to 2018 (98,707 procedures) ([Table 5]). Concerning gender distribution, the registry shows an overall male/female ratio of 2.0:1 with the greatest difference (3.7:1) in the patient group with coronary procedures ([Table 6]). About 10.8% (n = 10,861) of the operations were conducted as emergency procedures, and 8.4% (n = 8,481) were reoperations ([Table 7]). Sixteen thousand three hundred sixty (44.6%) isolated heart valve procedures were performed as single, 3,206 as double (8.7%), and 355 (1.0%) as triple heart valve procedures ([Table V1]). Three thousand two hundred ninety-three (35.1%) aortic valve and 3,438 (53.6%) mitral valve operations were performed via a minimally invasive access ([Table V2]). In 8,305 (88.4%) isolated aortic valve operations using ECC, xenograft prostheses were implanted, while in 4,140 (64.5%) isolated mitral valve operations a reconstruction with preservation of the native mitral valve could be achieved ([Table V3], [Figs. 1] and [2]). In a total of 3,004 combined mitral valve repair procedures, 1,321 (44.0%) simultaneous CABG procedures, 927 tricuspid valve repairs (30.9%), and 505 (16.8%) aortic valve procedures were performed ([Table V4]). The subgroup of 3,561 multiple heart valve procedures amounted to 2,958 (83.1%) operations, as a combination of mitral + tricuspid (n = 1,600) or mitral + aortic (n = 1,358) valve procedures ([Table V5]). Regarding 15,304 transcatheter aortic valve implantations (TAVI), 13,886 (90.7%) procedures were performed by transvascular and 1,418 (9.3%) by transapical access. In TAVI procedures with the need of ECC, a remarkably high unadjusted mortality rate of 25.9% (n = 81) resp. 23.5% (n = 17) could be observed ([Table V6]), probably related to complications during the initial procedure.

Zoom Image
Fig. 1 Selected heart surgical categories (2010–2019). 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 (2010–2019).
Table 5

Frequency of cardiac procedures 2019

Category

With ECC

Without ECC

Total

Diff. 2018 (%)

CABG isolated

27,147[a]

7,077[a]

44,093

+ 0.6%

CABG combined

9,692[a]

177[a]

44,093

− 4.1%

Heart valve procedures

20,197[a]

16,453[a]

36,650

+ 5.0%

Surgery of thoracic aorta

7,591[a]

655[a]

8,246

+ 0.9%

Surgery for CHD

4,819[a]

938[a]

5,757

− 1.6%

Cardiac surgery, other

1,207[a]

1,480[a]

2,687

+ 14.4%

Assist device procedures

723[a]

1,907[a]

2,630

− 4.8%

Extracardiac surgery

352[a]

53,970

54,322

+ 0.3%

Pacemaker and ICD procedures

31[a]

21,289

21,320

− 5.0%

Total

71,759

103,946

175,705

+ 0.5%

a Sum: n = 100,446 (heart surgery procedures).


Table 6

Gender distribution 2019

Female

Male

Distribution

n

%

n

%

Heart valve procedures

15,656

43

20,994

57

Coronary procedures

9,292

21

34,801

79

CHD procedures

2570

45

3,187

55

Surgery of thoracic aorta

2,804

34

5,442

66

Cardiac surgery, other

1,633

61

1,054

39

Assist device

705

27

1,925

73

Pacemaker and ICD

8,135

38

13,185

62

Extracardiac surgery

18,764

35

35,558

65

Total

59,559

38

116,146

62

Table 7

Additional data 2019 versus 2018

Procedures with ECC

2019

2018

Emergency

10,861

10.8%

11,147

11.3 %

Redo

8,481

8.4%

8,642

8.8%

Table V1

Isolated heart valve procedures

Procedure

n

%

Single valve

16,360

534

3.3

Double valve

3,206

318

9.9

Triple valve

355

58

16.3

Transcatheter access (single valve)

16,595

400

2.4

Transcatheter access (double valve)

30

4

13.3

Unspecified

104

11

10.6

Total

36,650

1,325

3.6

Transcatheter heart valve procedures: 15,304 aortic valve implantations; 152 mitral valve implantations; 988 mitral valve repairs.


Seven tricuspid valve implantations; 142 tricuspidal valve repairs; 30 double aortic and mitral valve procedures; 2 pulmonary valve implantations.


Table V2

Single heart valve procedures

Access path

n

%

Aortic valve

Sternotomy

6,098

215

3.5

Partial sternotomy

3,293

55

1.7

Transvascular

13,886

289

2.1

Transapical

1,418

77

5.4

Mitral valve

Sternotomy

2,981

186

6.2

Minimal invasive

3,438

32

0.9

Transcatheter

1,140

33

2.9

Tricuspidal valve

Sternotomy

365

37

10.1

Minimal invasive

125

7

5.6

Transcatheter

149

1

0.7

Pulmonary valve

Sternotomy

55

2

3.6

Minimal invasive

0

Transcatheter

2

0

0.0

Total

32,950

934

2.8

Apical aortic conduits procedures (n = 5) are not included.


Table V3

Isolated aortic/mitral valve operations

Prosthesis/native heart valve

Aortic

Mitral

n

%

n

%

Xenograft

8,305

245

3.0

1,891

170

9.0

Mechanical prosthesis

908

22

2.4

385

16

4.2

Repair

158

2

1.3

4,140

32

0.8

Homograft

20

1

5.0

3

0

0.0

Total

9,391

270

2.9

6,419

218

3.4

Transcatheter procedures and apical aortic conduits procedures (n = 5) are not included.


Table V4

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

Mitral valve procedures

Repair

Implantation/replacement

Total

n

%

n

%

n

% repair

%

Isolated

4,140

32

0.8

2,279

186

8.2

6,419

64.5

218

3.4

+ CABG

1,321

82

6.2

840

133

15.8

2,161

61.1

215

9.9

+ Tricuspid valve repair[a]

927

33

3.6

603

74

12.3

1,530

60.6

107

7.0

+ Aortic valve

505

31

6.1

853

136

15.9

1,358

37.2

167

12.3

+ CABG + Aortic valve replacement

251

36

14.3

274

48

17.5

525

47.8

84

16.0

Total

7,144

214

3.0

4,849

577

11.9

11,993

59.6

791

6.6

a Seventy procedures (not specified mitral valve + tricuspid valve surgery) excluded. Mortality: 19% (13/70).


Table V5

Multiple heart valve procedures

Combination

n

%

Mitral + tricuspid

1,600

120

7.5

Aortic + mitral

1,358

167

12.3

Aortic + mitral + tricuspid

354

58

16.4

Aortic + tricuspid

175

27

15.4

Aortic + pulmonary[a]

56

1

1.8

Tricuspid + pulmonary

17

3

17.6

Aortic + mitral + pulmonary

1

0

0.0

Total

3,561

376

10.6

Notes: Transcatheter procedures are excluded.


a Including Ross procedures.


Table V6

Transcatheter heart valve procedures

Without ECC

With ECC

Total

n

n

n

%

Aortic valve implantation

15,206

341

98

25

15,304

366

2.4

Transvascular

13,805

268

81

21

13,886

289

2.1

Transapical

1,401

73

17

4

1,418

77

5.4

Mitral valve

1,069

25

71

8

1,140

33

2.9

Repair

925

14

63

5

988

19

1.9

Implantation

144

11

8

3

152

14

9.2

Tricuspid valve repair

148

1

0

149

1

0.7

Repair

141

1

0

142

1

0,7

Implantation

7

0

7

0

Aortic + mitral valve implantation

28

3

2

1

30

4

13.3

Aortic valve implantation[a] + CABG

18

1

12

4

30

5

16.7

Mitral valve implantation[b] + CABG

0

2

0

2

0

Aortic + mitral valve + CABG

0

Total

16,469

371

186

38

16,655

409

2.5

Notes: Pulmonary valve implantation for CHD excluded.


9% of TAVI by transapical access and less than 1% of TAVI under ECC conditions.


a Femoral, subclavian, or transaortic access.


b Transvascular and transapical access.


[Tables C1]+[C2], [Con1]+[2], [Mis1] [2] [3] [4] [5] as well as [Figs. 1] [2] [3] [4] [5] [6] [7] [8] [9] to [10] demonstrate further compiled registry data under different aspects and for various categories.

Zoom Image
Fig. 3 Age distribution of cardiac procedures (2010–2019). Notes: Patients < 20 years and cardiac implantable electronic device procedures were excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (2010–2019). CABG, coronary artery bypass grafting.
Zoom Image
Fig. 5 Isolated aortic valve (AV) replacement (2010–2019). Notes: Ross procedures, homograft implantations, and transcatheter heart valve interventions excluded.
Zoom Image
Fig. 6 Isolated aortic valve replacement and transcatheter aortic valve implantation (TAVI). The annual number of TAVI submitted to this voluntary registry does not represent all TAVI procedures performed in Germany in 2019. +Additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V.
Zoom Image
Fig. 7 Isolated mitral valve surgery (2010–2019).
Zoom Image
Fig. 8 Age distribution for congenital heart disease (CHD) (2010–2019). 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 Mechanical circulatory support devices (2010–2019).
Zoom Image
Fig. 10 Heart transplantations (2010–2019).
Table C1

Isolated CABG and combined procedures with ECC

n

%

Isolated CABG

34,224

928

2.7

+ Aortic valve replacement

5,289

226

4.3

+ Other

1,752

124

7.1

+ Mitral valve repair

1,321

82

6.2

+ Mitral valve replacement

840

133

15.8

+ Aortic valve replacement + mitral valve repair

251

36

14.3

+ Aortic + mitral valve replacement

274

48

17.5

+ Aneurysm resection

110

4

3.6

+ Transcatheter aortic valve implantation

30

5

16.7

Total

44,091

1,586

3.6

Table C2

Isolated CABG with/without ECC

Grafts

With ECC

Without ECC

Total

n

%

n

%

n

%

Single

955

55

5.8

1,332

22

1.7

2,287

77

3.4

Double

5,609

185

3.3

1,879

32

1.7

7,488

217

2.9

Triple

11,740

338

2.9

2,677

39

1.5

14,417

377

2.6

Quadruple

6,370

161

2.5

968

15

1.5

7,338

176

2.4

Quintuple + more

2,473

81

3.3

221

0

0.0

2,694

81

3.0

Total

27,147

820

3.0

7,077

108

1.5

34,224

928

2.7

Table Con1

Congenital heart surgery with/without ECC

Age (years)

n

%

With ECC

Without ECC

With ECC

Without ECC

With ECC

Without ECC

< 1

2,121

744

81

25

3.8

3.4

1–17

1,806

179

15

1

0.8

0.6

≥ 18

969

15

34

1

3.5

6.7

Total

4,896

938

130

27

2.7

2.9

Table Con2

Procedures for congenital heart disease with and without ECC

Lesion/Procedure

Age < 1 year

Age 1–17 years

Age ≥ 18 year

n

%

n

%

n

%

ASD

47

0

0.0

291

0

0.0

244

6

2.5

Complete AV canal

200

4

2.0

89

4

4.5

10

0

0.0

VSD

331

2

0.6

133

0

0.0

15

0

0.0

Fallot's tetralogy

180

0

0.0

42

0

0.0

2

0

0.0

DORV

68

3

4.4

14

2

14.3

0

TGA

157

5

3.2

3

0

0.0

0

TGA + VSD

62

0

0.0

9

0

0.0

0

Truncus arteriosus

29

3

10.3

5

0

0.0

0

Fontan circulation

0

231

1

0.4

4

0

0.0

Norwood

153

26

17.0

1

0

0.0

0

Pulmonary valve

62

1

1.6

210

0

0.0

67

2

3.0

Transcatheter pulmonary valve implantation

0

0

2

0

0.0

Aortic valve

50

2

4.0

224

3

1.3

370

12

3.2

Ross procedure

8

4

50.0

24

0

0.0

52

0

0.0

Mitral valve

39

1

2.6

93

0

0.0

92

7

7.6

Tricuspid valve

81

6

7.4

56

2

3.6

40

4

10.0

PDA

191

6

3.1

26

0

0.0

1

0

0.0

Coarctation

199

2

1.0

30

0

0.0

0

Others

1,001

41

4.1

461

4

0.9

85

4

4.7

HTx

7

0

0.0

37

0

0.0

0

HLTx

0

0

0

LTx

0

6

0

0.0

0

Total

2,865

106

3.7

1,985

16

0.8

984

35

3.6

Table Mis1

Ross procedures (autologous AV- and PVR)

Age (years)

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

< 18

43

40

36

33

37

28

38

29

32

≥ 18

184

134

117

107

90

64

72

52

61

104

Total

227

174

153

140

127

92

110

90

136

Table Mis2

Heart and lung transplantation

Transplant

With ECC

Without ECC

n

%

n

%

HTx

333

33

9.9

HLTx

6

2

33.3

LTx

42

4

9.5

269

11

4.1

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


Eurotransplant (ET) report 2019: 333 HTx, 4 HTx + kidneyTx, 1 HTx + liverTx, 6 HLTx, 327 DLTx, 26 SLTx, 0 LTx + kidneyTx and 2 LTx + liverTx.


Table Mis3

Aortic surgery

Replacement [a]

With ECC

Without ECC

n

%

n

%

Supracoronary replacement of ascending aorta

1,377

116

8.4

Supracoronary ascending + aortic valve replacement

1,372

58

4.2

Infracoronary replacement of ascending aorta

 Mechanical aortic valve conduits

349

16

4.6

 Biological aortic conduits

1,034

120

11.6

 David procedure

479

9

1.9

 Yacoub procedure

111

5

4.5

 Other

345

31

9.0

Aortic arch replacement[b]

2,398

316

13.2

Replacement of descending aorta

51

6

11.8

3

1

33.3

Thoracoabdominal aortic replacement

75

14

18.7

11

1

9.1

Endostent descending aorta

0

0

641

32

5.0

Total

7,591

691

9.1

655

34

5.2

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: 424, abdominal procedures and 27 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

12,952

101

0.8

11

3

12,941

98

 Implantation

8,722

60

0.7

1

0

8,721

60

 Battery exchange

1,682

1

0.1

1

0

1,681

1

 Revision procedures

2,548

40

1.6

9

3

2,539

37

ICD

6,864

71

1.0

18

2

6,846

69

 Implantation

2,933

16

0.5

4

0

2,929

16

 Battery exchange

1,569

2

0.1

0

1,569

2

 Revision procedures

2,362

53

2.2

14

2

2,348

51

Miscellaneous

1,504

19

1.3

2

0

1,502

19

Total

21,320

191

0.9

31

5

21,289

186

Table Mis5

Surgical procedures for treatment of tachyarrhythmias

Energy source

Endocardiac

Epicardiac

Total

n

n

Unipolar radio frequency

97

181

278

Unipolar cooled radio frequency

73

141

214

Bipolar radio frequency

262

1,857

2,119

Cryothermy

1,388

401

1,789

Microwave

0

15

Focused ultrasound

6

118

124

Laser

0

Other

10

0

10

Total

1,836

2,713

4,549

Note: 361 procedures are unspecified with regard to endocardiac/epicardiac ablation.


Compared to the data of previous years, several important developments remained almost unchanged in 2019. The age distribution of patients ([Fig. 5]) shows a continuous shift towards an elderly patient population. Presently, 33.5% of the cardiac procedures are performed in patients from 70 to 79 years of age, and 18.6% in octo-/nonagenarians. However, unadjusted mortality rates just show a discrete change over the last decade ([Fig. 4]). The number of CABG procedures, isolated or combined, decreased over the past decade, while the relative number of isolated off-pump CABG remains on a nearly unchanged level of 20.7% compared to the previous year (2018: 20.6%) ([Figs. 3], [6]).

There is still a continuous increase in transcatheter heart valve procedures in Germany with a total of 16,469 procedures in 2019 ([Table V6]). For the last year 15,304 (62.4%) TAVI and 9,233 (37.6%) surgical aortic valve replacement procedures were reported to the registry ([Fig. 7]). It must be emphasized that exclusively the German departments for cardiac surgery contribute these data. Therefore, the registry cannot reach completeness because procedures documented by cardiology departments are missed. 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] the German Federal Joint Committee (G-BA) implemented a quality assurance directive for “minimally invasive heart valve interventions (TAVI, transcatheter mitral clip reconstruction)” in July 2015. In this 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 (GARY),[13] [14] [15] [16] [17] [18] [19] [20] provide various important findings and thus also contribute to an exceptional patient benefit.

In 2019, the rate of isolated mitral valve reconstructions remains almost unchanged on a remarkable level of 64.5% (2018: 64.3%) ([Fig. 2]). Based on the fact that each isolated mitral valve procedure is included, regardless of the underlying mitral 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,[21] patients with mitral valve stenosis, endocarditis, and emergency procedures are usually excluded. Therefore, other published rates of mitral valve repair have to be interpreted with caution if compared to this registry.

In 2019, the ventricular assist device (L-/ R-/ BVAD, TAH) implantations (n = 953) showed a slight increase of 1.2% compared to 2018 (n = 942) ([Fig. 9]), while the heart transplantations (n = 333) reached a new height for the past 5 years ([Fig. 10]). Nevertheless, the mechanical circulatory support therapy, in particular left ventricular assist device, is still of outstanding importance for patients with end-stage heart failure.


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Discussion

The registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in Germany in 2019. 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.[22] As observed in recent years, heart surgery in Germany is continuously performed on a high level with superior in-hospital patient survival compared to 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 perioperative risk profile.

Compared to 2018, the number of cardiac surgery procedures showed a slight decrease for isolated + combined coronary artery bypass procedures, an ongoing trend in view of the German population characteristics and in the context of application of the scientific guidelines.[23] [24] Otherwise, the renewed increase in heart transplantations is a reason for hope that this positive development will continue.

Further 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 were to be implemented, a modified structure would have to ensure 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.


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Conflict of Interest

None declared.

Acknowledgements

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

Andreas Beckmann, MD
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 (2010–2019). 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.
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Fig. 2 Unadjusted mortality for selected procedures (2010–2019).
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Fig. 3 Age distribution of cardiac procedures (2010–2019). Notes: Patients < 20 years and cardiac implantable electronic device procedures were excluded.
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Fig. 4 Isolated coronary artery bypass grafting (2010–2019). CABG, coronary artery bypass grafting.
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Fig. 5 Isolated aortic valve (AV) replacement (2010–2019). Notes: Ross procedures, homograft implantations, and transcatheter heart valve interventions excluded.
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Fig. 6 Isolated aortic valve replacement and transcatheter aortic valve implantation (TAVI). The annual number of TAVI submitted to this voluntary registry does not represent all TAVI procedures performed in Germany in 2019. +Additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V.
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Fig. 7 Isolated mitral valve surgery (2010–2019).
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Fig. 8 Age distribution for congenital heart disease (CHD) (2010–2019). 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 Mechanical circulatory support devices (2010–2019).
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Fig. 10 Heart transplantations (2010–2019).