Thorac Cardiovasc Surg 2021; 69(04): 294-307
DOI: 10.1055/s-0041-1730374
Original Cardiovascular

German Heart Surgery Report 2020: 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
› Author Affiliations
 

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 2020 are analyzed. Under the more than extraordinary conditions of the ongoing worldwide coronavirus disease 2019 pandemic, a total of 161,817 procedures were submitted to the registry. A total of 92,809 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 29,444 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.6:1) was 97.2%. For the 35,469 isolated heart valve procedures, (17,471 transcatheter interventions included), the survival rate was 96.7%. Concerning short- and long-term circulatory support, a total of 2,852 extracorporeal life support/extracorporeal membrane oxygenation implantations, respectively, 843 assist device implantations (left/right/biventricular assist device, total artificial device), were registered. In 2020, the number of isolated heart transplantations increased to 340, a rise of 2.1% compared with the previous year. The isolated lung transplantations amounted to 291, a decrease of 6.4%.

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.


#

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. More than 30 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 scientific 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 GSTCVS.

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 presented in this report comprehend the survey of the year 2020 whereby the more than special circumstances, caused by the coronavirus disease 2019 (COVID-19) pandemic, must necessarily be taken into account when interpreting the results.


#

Materials and Methods

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

All participating institutions were requested to complete the structured questionnaire by January 25, 2021, 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 2020 were all cardiac surgical procedures performed on patients between January 1, 2020 and December 31, 2020, 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 number 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 hard- and software used locally.

In 2020, a total of 78 institutions performed heart surgery. As in the years before, all departments answered the questionnaire and delivered a complete dataset for the year 2020, 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 the transmitted information of all 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, 2019.

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 2020

[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, 2019. The range of heart operations per 100,000 inhabitants again shows a minimum of 94.4 (Bavaria, population: 13,124,737) and a maximum of 167.0 (Sachsen-Anhalt, population: 2,194,782), while the nationwide mean-value by the end of 2020 was 110.9 ([Table 1]). In addition, [Table 1] shows a state-by-state representation of confirmed COVID-19 cases/100,000 population with a median of 1,981 (range: 2,504), a minimum of 746 in Mecklenburg-Vorpommern and maximum of 3,250 in Sachsen. Analyzing quantified categories of heart operations by department dimension, categorizes more than 69% of institutions into two clusters with at least 541 up to 1,497 procedures, 22% into those with a minimum of 1,502 up to a maximum of 3,981 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 (CHD) (<1 year, with extracorporeal circulation [ECC]) are conducted in 21, isolated heart transplantations in 19, and combined heart-lung transplantations in 1 institution ([Table 3]).

Table 1

German states/Heart operations/confirmed COVID-19 cases

Federal state

Population[a]

Quantity[b]

Heart procedures/100,000 inhabitants

Total number of COVID-19 cases[c]

COVID-19 cases/100,000 population[c]

Baden Württemberg

11,100,394

10,842

97.7

237,993

2,144

Bayern

13,124,737

12,384

94.4

324,937

2,476

Berlin

3,669,491

3,738

101.9

96,788

2,638

Brandenburg

2,521,893

3,291

130.5

41,241

1,635

Bremen

681,202

736

108.0

13,559

1,990

Hamburg

1,847,253

2,231

120.8

36,417

1,971

Hessen

6,288,080

6,554

104.2

136,577

2,172

Mecklenburg-Vorpommern

1,608,138

2,060

128.1

11,997

746

Niedersachsen

7,993,608

9,223

115.4

106,789

1,336

Nordrhein-Westfalen

17,947,221

20,363

113.5

393,185

2,191

Rheinland-Pfalz

4,093,903

4,656

113.7

71,993

1,759

Saarland

986,887

1,119

113.4

19,879

2,014

Sachsen

4,071,971

4,864

119.5

132,356

3,250

Sachsen-Anhalt

2,194,782

3,665

167.0

29,200

1,330

Schleswig-Holstein

2,903,773

3,730

128.5

24,792

854

Thüringen

2,133,378

2,814

131.9

42,034

1,970

Germany

83,166,711

92,270

110.9

1,719,737

2,068

a Federal Office for Statistics of German Population; due date Dec 31, 2019.


b n = 539, foreign residences excluded.


c Robert Koch Institute: laboratory confirmed COVID-19 cases; due date Dec 31, 2020 12:00 am.


Table 2

Departments assorted by quantified categories (∑[a] [n = 92,809])

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Departments

7

32

22

7

10

Average

343

784

1,215

1,700

2,671

Range

186–451

541–988

1,009–1,497

1,502–1,867

2,038–3,981

a CIED and extracardiac surgery without ECC are excluded.


Table 3

Departments summarized by heart surgery procedures 2020

Category

n

Coronary artery bypass grafting

77

Heart valve surgery

77

Pacemaker/ICD procedures

75/72

Surgery for CHD (pat. <1 year with ECC)

21[a]

Heart transplantation

19[b]

Heart-lung transplantation

1

a n = 2,061: thereof: 24–43 op. in 6, 59–89 op. in 5, 108–211 op. in 10 units.


b n = 340: thereof: 2–4 transpl. in 5, 7–9 transpl. in 4, 11–20 transpl. in 4, 28–73 transpl. in 6 units.


The number of procedures using ECC in Germany from 2011 to 2020 is illustrated in [Table 4]. The comparison from 2019 to 2020 shows a decline by 8,039 procedures, presumably reflecting an enormous effect of the COVID-19 pandemic and only to a small extent the achievement of established innovations, especially minimally invasive heart surgical options.

Table 4

Cardiac procedures using extracorporeal circulation (2011–2020)

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

Departments

78

79

79

78

78

78

78

78

78

78

Operations

84,402

84,388

84,040

83,787

81,527

79,082

76,696

72,331

71,759

63,720

Average

1,082

1,068

1,064

1,074

1,045

1,014

983

927

920

817

Overall, 161,817 procedures were reported to the registry for the year 2020, a difference of 7.9% compared with 2019 (175,705 procedures). In 2020, a total of 92,809 heart surgical procedures in the narrower sense displays a COVID-19-related decrease of 7.6% (n = 7,637) compared with 2019 (100,446 procedures) ([Table 5]). Concerning gender distribution, the registry shows an overall male/female ratio of almost 2:1 with the greatest difference (4:1) in the patient group with coronary procedures ([Table 6]). About 11.3% (n = 10,445) of the operations were conducted as emergency procedures, and 7.9% (n = 7,330) were reoperations ([Table 7]). A total of 14,773 (41.7%) isolated heart valve procedures were performed as single, 2,836 as double (8.0%), and 289 (0.8%) as triple valve procedures ([Table V1]). A total of 3,006 (36.7%) aortic valve and 3,342 (55.2%) mitral valve operations were performed via a minimally invasive access ([Table V2]). In 7,194 (87.9%) isolated aortic valve operations using ECC, xenograft prostheses were implanted, while in 3,878 (64.1%) isolated mitral valve operations, a reconstruction with preservation of the native mitral valve could be achieved ([Table V3], [Figs. 5] and [7]). In a total of 2,594 combined mitral valve repair procedures, 1,115 (43.0%) simultaneous CABG procedures, 825 tricuspid valve repairs (31.8%), 447 (17.2%) aortic valve procedures, and 207 (8.0%) concomitant CABG and aortic valve replacement (AVR) were performed ([Table V4]). The subgroup of 3,125 multiple heart valve procedures amounted to 2,613 (83.6%) operations, as a combination of mitral + tricuspid (n = 1,406) or mitral + aortic (n = 1,207) valve procedures ([Table V5]). Regarding 15,621 transcatheter aortic valve implantations (TAVI), 14,275 (91.4%) procedures were performed by transvascular and 1,346 (8.6%) by transapical access. In TAVI procedures without ECC, the unadjusted mortality for those by transvascular access was 1.9% (n = 277) resp. 5.2% (n = 70), for the transapical approach. On the other hand, TAVI under use of ECC shows a remarkably high unadjusted mortality rate of 27.1 (n = 70) and. 30.0% (n = 10) ([Table V6]), respectively, probably related to complications during the initial procedure.

Table 5

Frequency of cardiac procedures 2020

Category

With ECC

Without ECC

Total

Diff. 2019 (%)

CABG isolated

23,004[a]

6,440[a]

29,444

−14.0%

CABG combined

8,359

181

8,540

−13.5%

Heart valve procedures

18,137[a]

17,332[a]

35,469

−3.2%

Surgery of thoracic aorta

7,177[a]

655[a]

7,832

−5.0%

Surgery for CHD

4,714[a]

855[a]

5,569

−3.3%

Cardiac surgery, other

1,278[a]

1,251[a]

2,529

−5.9%

Assist device procedures

656[a]

2,375[a]

3,031

+ 15.2%

Extracardiac surgery

363[a]

48,796

49,159

−9.5%

Pacemaker and ICD procedures

32[a]

20,212

20,244

−5.0%

Total

63,720

98,097

161,817

7.9%

a Sum: n = 92,809 (heart surgery procedures).


Table 6

Gender distribution

Distribution

Female

Male

n

%

n

%

Heart valve procedures

15,302

43

20,167

57

Coronary procedures

7,786

20

30,198

80

CHD procedures

2,481

45

3,088

55

Surgery of thoracic aorta

2,642

34

5,190

66

Cardiac surgery, other

1,457

58

1,072

42

Assist device

773

26

2,258

74

Pacemaker and ICD

7,672

38

12,572

62

Extracardiac surgery

16,274

33

32,885

67

Total

54,387

34

107,430

66

Table 7

Additional data 2020 versus 2019

Procedures with ECC

2020

2019

Emergency

10,445

11.3%

10,861

10.8%

Redo

7,330

7.9%

8,481

8.4%

Table V1

Isolated heart valve procedures

Procedure

n

%

Single valve

14,773

479

3.2

Double valve

2,836

237

8.4

Triple valve

289

34

11.8

Transcatheter access (single valve)

17,443

400

2.3

Transcatheter access (double valve)

28

3

10.7

Unspecified

100

12

12.0

Total

35,469

1,165

3.3

Notes: Transcatheter heart valve procedures: 15,701 aortic valve implantation; 161 mitral valve implantation; 1,325 mitral valve repair; 6 tricuspid valve implantation; 250 tricuspidal valve repair; 28 double aortic and mitral valve procedure; no pulmonary valve implantation.


Table V2

Single heart valve procedures

Access path

n

%

Aortic valve

Sternotomy

5,180

189

3.6

Partial sternotomy

3,006

31

1.0

Transvascular

14,345

296

2.1

Transapical

1,356

73

5.4

Mitral valve

Sternotomy

2,708

174

6.4

Minimal invasive

3,342

45

1.3

Transcatheter

1,486

26

1.7

Tricuspidal valve

Sternotomy

340

35

10.3

Minimal invasive

138

5

3.6

Transcatheter

256

5

2.0

Pulmonary valve

Sternotomy

57

0

0.0

Minimal invasive

0

0

Transcatheter

0

0

Total

32,214

879

2.7

Apical aortic conduits procedures (n = 2) are not included.


Table V3

Isolated aortic/mitral valve operations

Prosthesis/native heart valve

Aortic

Mitral

n

%

n

%

Xenograft

7.194

205

2.8

1.769

156

8.8

Mechanical prosthesis

830

10

1.2

398

17

4.3

Repair

137

2

1.5

3,878

45

1.2

Homograft

25

3

12.0

5

1

20.0

Total

8,186

220

2.7

6,050

219

3.6

Note: Transcatheter procedures and apical aortic conduits procedures (n = 2) excluded.


Table V4

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

Mitral valve procedures

Repair

Implantation/replacement

Total

n

%

n

%

n

%

Isolated

3,878

45

1.2

2,172

174

8.0

6,050

219

3.6

+ CABG

1,115

71

6.4

815

131

16.1

1,930

202

10.5

+ Tricuspid valve repair[a]

825

25

3.0

534

57

10.7

1,359

82

6.0

+ Aortic valve

447

23

5.1

760

104

13.7

1,207

127

10.5

+ CABG + aortic valve replacement

207

20

9.7

274

53

19.3

481

73

15.2

Total

6,472

184

2.8

4,555

519

11.4

11,027

703

6.4

a Forty-seven procedures (not specified mitral valve + tricuspid valve surgery) excluded, Mortality: 15% (7/47).


Table V5

Multiple heart valve procedures

Combination

n

%

Mitral + tricuspid

1,406

89

6.3

Aortic + mitral

1,207

127

10.5

Aortic + mitral + tricuspid

287

34

11.8

Aortic + tricuspid

155

18

11.6

Aortic + pulmonary[a]

58

1

1.7

Tricuspid + pulmonary

10

2

20.0

Aortic + mitral + pulmonary

2

0

0.0

Total

3,125

271

8.7

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

15,621

347

80

22

15,701

369

2.4

Transvascular

14,275

277

70

19

14,345

296

2.1

Transapical

1,346

70

10

3

1,356

73

5.4

Mitral valve

1,428

24

58

2

1,486

26

1.7

Repair

1,279

14

46

0

1,325

14

1.1

Implantation

149

10

12

2

161

12

7.5

Tricuspid valve repair

256

5

0

0

256

5

2.0

Repair

250

4

0

0

250

4

1.6

Implantation

6

1

0

0

6

1

16.7

Aortic + mitral valve implantation

27

3

1

0

28

3

10.7

Aortic valve implantation[a] + CABG

21

1

16

8

37

9

24.3

Mitral valve implantation[b] + CABG

1

0

4

1

5

1

20.0

Aortic + mitral valve + CABG

0

0

0

0

0

0

Total

17,354

380

159

33

17,513

413

2.4

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.


Concerning 37,979 CABG procedures, 77.5% were performed as isolated operations (n = 29,444), 11.7% (n = 4,436) combined with AVR and 5.1% (n = 1,930) with simultaneous mitral valve procedures ([Table C1]). [Table C2] provides an overview of the isolated CABG operations focused on the number of bypass grafts and indicates the corresponding unadjusted mortality rates for on/off pump surgery.

Table C1

Isolated CABG and combined procedures with ECC

n

%

Isolated CABG

29,444

830

2.8

 + Aortic valve replacement

4,436

198

4.5

 + Other

1,582

96

6.1

 + Mitral valve repair

1,115

71

6.4

 + Mitral valve replacement

815

131

16.1

 + Aortic valve replacement + mitral valve repair

207

20

9.7

 + Aortic + mitral valve replacement

274

53

19.3

 + Aneurysm resection

69

3

4.3

 + Transcatheter aortic valve implantation

37

9

24.3

 + Transcatheter mitral valve procedure

5

1

20.0

Total

37,984

1,412

3.7

Table C2

Isolated CABG on-/off-pump surgery

Grafts

On-pump

Off-pump

Total

n

%

n

%

n

%

Single

748

42

5.6

1,225

24

2.0

1,973

66

3.3

Double

4,491

166

3.7

1,682

39

2.3

6,173

205

3.3

Triple

9,850

280

2.8

2,443

43

1.8

12,293

323

2.6

Quadruple

5,740

146

2.5

869

18

2.1

6,609

164

2.5

Quintuple + more

2,175

69

3.2

221

3

1.4

2,396

72

3.0

Total

23,004

703

3.1

6,440

127

2.0

29,444

830

2.8

[Tables Con1] and [Con2] and [Mis1] [Mis2] [Mis3] [Mis4] to [Mis5] demonstrate further compiled registry data under different aspects and for various categories.

Table Con1

Congenital heart surgery with/without ECC

Age (y)

n

%

With ECC

Without ECC

With ECC

Without ECC

With ECC

Without ECC

< 1

2,084

660

78

17

3.7

2.6

1–17

1,832

167

21

1

1.1

0.6

≥ 18

866

28

28

0

3.2

0.0

Total

4,782

855

127

18

2.7

2.1

Table Con2

Procedures for congenital heart disease with and without ECC

Lesion/Procedure

Age < 1 year

Age 1 to 17 years

Age ≥ 18 years

n

%

n

%

n

%

ASD

34

0

0.0

245

0

0.0

208

7

3.4

Complete AV-canal

217

5

2.3

93

3

3.2

6

0

0.0

VSD

335

2

0.6

91

1

1.1

17

2

11.8

Fallot's tetralogy

182

1

0.5

41

0

0.0

1

0

0.0

DORV

55

2

3.6

21

1

4.8

1

0

0.0

TGA

144

3

2.1

9

0

0.0

0

TGA + VSD

61

2

3.3

5

0

0.0

0

Truncus arteriosus

31

2

6.5

6

0

0.0

0

Fontan circulation

0

250

0

0.0

4

0

0.0

Norwood

142

23

16.2

3

0

0.0

0

Pulmonary valve

60

1

1.7

217

3

1.4

57

1

1.8

Transcatheter pulmonary valve implantation

0

0

10

0

0.0

Aortic valve

59

1

1.7

214

3

1.4

333

7

2.1

Ross procedure

8

2

25.0

27

0

0.0

19

0

0.0

Mitral valve

44

1

2.3

123

0

0.0

84

4

4.8

Tricuspid valve

141

1

0.7

83

2

2.4

49

5

10.2

PDA

133

2

1.5

20

0

0.0

1

0

0.0

Coarctation

239

4

1.7

33

0

0.0

3

0

0.0

Others

857

43

5.0

483

7

1.4

101

2

2.0

HTx

1

0

0.0

24

2

8.3

0

HLTx

0

0

0

LTx

1

0

0.0

11

0

0.0

0

Total

2,744

95

3.5

1,999

22

1.1

894

28

3.1

Table Mis1

Ross procedures (autologous AV and PVR)

Age (y)

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

< 18

40

36

33

37

28

38

38

29

32

35

≥ 18

134

117

107

90

64

72

52

61

104

70

Total

174

153

140

127

92

110

90

90

136

105

Table Mis2

Heart and lung transplantation

Transplant

With ECC

Without ECC

n

%

n

%

HTx

340

30

8.8

HLTx

1

0

0.0

LTx

40

3

7.5

251

18

7.2

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


Eurotransplant (ET) report 2020: 327 HTx, 10 HTx + kidneyTx, 1 HTx + liverTx, 1 HLTx, 315 DLTx, 25 SLTx, 1 LTx + kidneyTx and 2 LTx + liverTx.


Table Mis3

Aortic surgery

Replacement[a]

With ECC

Without ECC

n

%

n

%

Supracoronary replacement of ascending aorta

1,166

106

9.1

Supracoronary ascending + aortic valve replacement

1,205

50

4.1

Infracoronary replacement of ascending aorta

Mechanical aortic valve conduits

327

20

6.1

Biological aortic conduits

1,046

102

9.8

David procedure

517

9

1.7

Yacoub procedure

101

3

3.0

Other

274

28

10.2

Aortic arch replacement[b]

2,396

345

14.4

Replacement of descending aorta

60

6

10.0

4

0

0.0

Thoraco-abdominal aortic replacement

82

15

18.3

18

1

5.6

Endostent descending aorta

3

1

33.3

633

27

4.3

Total

7,177

685

9.5

655

28

4.3

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: 463, abdominal procedures and 21 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

12,698

85

0.7

14

2

12,684

83

Implantation

8,510

58

0.7

2

0

8,508

58

Battery exchange

1,662

2

0.1

0

0

1,662

2

Revision procedures

2,526

25

1.0

12

2

2,514

23

ICD

6,489

58

0.9

16

4

6,473

54

Implantation

2,741

7

0.3

0

0

2,741

7

Battery exchange

1,427

1

0.1

0

0

1,427

1

Revision procedures

2,321

50

2.2

16

4

2,305

46

Miscellaneous

1,057

4

0.4

2

0

1,055

4

Total

20,244

147

0.7

32

6

20,212

141

Table Mis5

Surgical procedures for tachyarrhythmia

Energy source

Endocardiac

Epicardiac

n

n

n

Unipolar radio frequency

116

191

307

Unipolar cooled radio frequency

41

123

164

Bipolar radiofrequency

164

1,626

1,790

Cryothermy

1,424

351

1,775

Microwave

1

7

8

Focused ultrasound

1

93

94

Laser

1

0

1

Other

7

4

11

Total

1,755

2,395

4,150

Note: 202 procedures are unspecified with regard to endocardiac/epicardiac ablation.


Compared with the data of previous years some significant changes can be seen on one hand, while several developments remained almost unchanged in 2020 on the other hand. The number of CABG procedures, isolated or combined, shows a remarkable decrease of 13.9% in 2020, while for isolated heart valve procedures, the difference is just 3.2% ([Fig. 1]). However, unadjusted mortality rates for CABG, AVR, and mitral valve procedures vary just slight over the last decade ([Fig. 2]). The age distribution of patients continues to evolve toward an elderly patient population ([Fig. 3]). Presently, 32.2% of the cardiac procedures are performed in patients from 70 to 79 years of age, and 19.2% were in octo-/nonagenarians. The relative number of isolated off-pump CABG is steadily increasing, reaching 21.9% in 2020 (2019: 20.7%) ([Fig. 4]).

Zoom Image
Fig. 1 Selected heart surgical categories (2011–2020). Notes: Congenital heart surgery: Atrial septal defect repairs in adults or in combination with coronary artery bypass grafting (CABG) or heart valve procedures are summarized in the CABG or heart valve procedure groups; miscellaneous procedures: all other types of procedures with extracorporeal circulation.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2011–2020).
Zoom Image
Fig. 3 Age distribution of cardiac procedures (2011–2020). Notes: Patients < 20 years and CIED procedures excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2011–2020).

With regard to prosthetic valve distribution in 89.7% (n = 7,194) the sAVR was performed using a xenograft, while ([Fig. 5]) in 10.3% (n = 830) a mechanical prosthesis was implanted. The unchanged development of transcatheter heart valve procedures in Germany leads to a total of 17,354 procedures in 2020 ([Table V6]). For the last year, 15,701 (66.1%) TAVI and 8,049 (33.9%) surgical aortic valve replacement (sAVR) procedures were reported to the registry ([Fig. 6]). 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, 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[12] for “minimally invasive heart valve interventions (TAVI, transcatheter mitral clip reconstruction)”, currently under evaluation. 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] [21] [22] [23] provide various important findings and thus also contribute to an exceptional patient benefit.

Zoom Image
Fig. 5 Isolated aortic valve (AV) replacement (2011–2020). 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). +Additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V.

In 2020, the rate of isolated mitral valve reconstructions remains almost unchanged on a remarkable level of 64.1% (2019: 64.5%) ([Fig. 7]). 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,[24] 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 with this registry.

Zoom Image
Fig. 7 Isolated mitral valve surgery (2011–2020).

In 2020, almost half (48.9%; n = 2,721) of cardiac operations for CHD were performed in neonates/infants <1 year, 35.1% in children between 1 and 17 years, and 16.0% in patients at least 18 years of age ([Fig. 8]). Concerning ventricular assist device (left/right/biventricular assist device, total artificial heart) implantations (n = 843), a significant decrease of 11.5% compared with 2019 (n = 953) ([Fig. 9]) could be observed, while the heart transplantations increased to 340 (2019: n = 333) ([Fig. 10]). Nevertheless, the mechanical circulatory support therapy, in particular LVAD, is still of outstanding importance for patients with end-stage heart failure.

Zoom Image
Fig. 8 Age distribution for congenital heart disease (CHD) (2011–2020). 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 (2011–2020).
Zoom Image
Fig. 10 Heart transplantation (2011–2020).

#

Discussion

Even under the exceptional conditions of the CoVID-19 pandemic, the registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in Germany in 2020. The accuracy of this registry remains 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.[25] As observed in recent years, heart surgery in Germany is 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 could be guaranteed nationwide even under COVID-19 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 with 2019, the number of cardiac surgery procedures showed a relevant decrease for isolated/combined CABG and sAVR, an ongoing trend in view of the German population characteristics and in the context of application of the scientific guidelines.[26] [27] Despite this for the year 2020, it must be taken into account that the care of patients with heart disease was affected by the consequences of the severe acute respiratory syndrome coronavirus 2 pandemic with repeated shutdowns throughout Germany and various restrictions of elective/urgent heart surgical procedures due to limited intensive care resources in all German cardiac centers. Otherwise, the renewed 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 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 our country. 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
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
VAD: ventricular assist device
VSD: ventricular septal defect


#

Conflict of Interest

None declared.

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

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

Publication History

Received: 26 April 2021

Accepted: 26 April 2021

Publication Date:
27 June 2021 (online)

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Selected heart surgical categories (2011–2020). Notes: Congenital heart surgery: Atrial septal defect repairs in adults or in combination with coronary artery bypass grafting (CABG) or heart valve procedures are summarized in the CABG or heart valve procedure groups; miscellaneous procedures: all other types of procedures with extracorporeal circulation.
Zoom Image
Fig. 2 Unadjusted mortality for selected procedures (2011–2020).
Zoom Image
Fig. 3 Age distribution of cardiac procedures (2011–2020). Notes: Patients < 20 years and CIED procedures excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2011–2020).
Zoom Image
Fig. 5 Isolated aortic valve (AV) replacement (2011–2020). 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). +Additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V.
Zoom Image
Fig. 7 Isolated mitral valve surgery (2011–2020).
Zoom Image
Fig. 8 Age distribution for congenital heart disease (CHD) (2011–2020). 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 (2011–2020).
Zoom Image
Fig. 10 Heart transplantation (2011–2020).