Thorac Cardiovasc Surg 2022; 70(05): 362-376
DOI: 10.1055/s-0042-1754353
Original Cardiovascular

German Heart Surgery Report 2021: 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
,
Daniela Blaßfeld
1   German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
,
Andreas Böning
3   Department for Adult, Pediatric Cardiac and Vascular Surgery, University Clinic Gießen, Gießen, 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 2021 are analyzed. Under more than extraordinary conditions of the further ongoing worldwide coronavirus disease 2019 (COVID-19) pandemic, a total of 161,261 procedures were submitted to the registry. In total, 92,838 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 27,947 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.2:1) was 97.3%. For the 36,714 isolated heart valve procedures (19,242 transcatheter interventions included) it was 96.7 and 99.0% for the registered pacemaker and International Classification of Diseases (ICD) procedures (19,490), respectively. Concerning short- and long-term circulatory support, a total of 3,404 ECLS/ECMO implantations and 750 assist device implantations (L-/ R-/ BVAD, TAH), respectively were registered. In 2021 329 isolated heart transplantations, 254 isolated lung transplantations, and one combined heart–lung transplantations were performed.

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 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 in comparison 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 incl. minimally invasive cardiac surgery as well as all kinds of heart valve procedures, incl. 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 2021 whereby more than special circumstances, caused by the further ongoing COVID-19 pandemic, must necessarily be taken into account when interpreting the results.


#

Material 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, 2022, 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 2021 were all cardiac surgical procedures performed on patients from January 1 to December 31, 2021, 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, e.g. the death of a patient requiring a replacement of ascending aorta due to complication after CABG would only be attributed to coronary procedure.

The main reason for this structural set-up of the registry – established over four 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. Finally 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 hardware and software used locally.

In 2021, 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 surgical details, including unadjusted 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 possible. Due to unexpected technical problems very little data concerning some patients' origins were not available for the year 2021.

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 where developments are shown 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 September 30, 2021.

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


#

Registry Data 2021

[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 September 30, 2021. Concerning patients' origin it has to be considered that a very small amount of missing data (0.9%) influences the distribution of heart procedures per federal state. Taking this into account, the range of heart operations per 100,000 inhabitants shows a minimum of 96.3 (Baden-Württemberg, population: 11,123,393) and a maximum of 156.1 (Sachsen-Anhalt, population: 2,172,221), while the nationwide mean-value at the end of 2021 was 109.9 ([Table 1]). In addition, [Table 1] shows a state-by-state representation of confirmed COVID-19 cases/100,000 population with a median of 5,483.9 (range: 9,594), a minimum of 3,174 in Schleswig-Holstein and a maximum of 12,768 in Sachsen. Thus, the mean of confirmed COVID-19 cases was threefold higher than last year's and a much broader range among the federal states (range 2020: 2,504) could be observed.

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

11,123,393

10,716

96.3

774,223

6,960

Bayern

13,176,644

13,051

99.0

998,071

7,575

Berlin

3,669,811

3,704

100.9

230,966

6,294

Brandenburg

2,537,202

3,152

124.2

200,301

7,895

Bremen

675,171

685

101.5

33,606

4,977

Hamburg

1,853,049

2,186

118.0

101,845

5,496

Hessen

6,290,030

7,036

111.9

340,702

5,417

Mecklenburg-Vorpommern

1,612,466

1,228

76.2

87,764

5,443

Niedersachsen

8,025,848

9,479

118.1

333,592

4,156

Nordrhein-Westfalen

17,918,037

19,939

111.3

979,527

5,467

Rheinland-Pfalz

4,105,944

4,636

112.9

205,203

4,998

Saarland

983,070

1,034

105.2

53,790

5,472

Sachsen

4,046,699

4,860

120.1

516,664

12,768

Sachsen-Anhalt

2,172,221

3,391

156.1

194,547

8,956

Schleswig-Holstein

2,920,850

3,875

132.7

92,704

3,174

Thüringen

2,112,007

2,509

118.8

245,940

11,645

Deutschland

83,222,442

91,481

109.9

5,389,445

6,476

a Federal Office for Statistics of German Population; due date September 30st 2021.


b n = 529, foreign residences excluded.


c Robert Koch Institute: laboratory confirmed COVID-19 cases; due date December 30st, 2021.


Analyzing quantified categories of heart operations by department dimension, categorizes more than 66.7% of institutions into two clusters with 500 up to 1,499 procedures (2021: 52/78) and 21.8% into those with a minimum of 1,500 up to a maximum of 4,040 performed procedures, respectively ([Table 2]). Before the pandemic started in January 2020 the caseload of the heart surgery departments was considerably higher.

Table 2

Departments assorted by quantified categories (∑[a] [n = 92,838])

Procedures (quantity)

<500

500–999

1,000–1,499

1,500–1,999

2,000–5,000

Departments

9

32

20

6

11

Average

373

795

1,241

1,708

2,635

Range

157–491

551–975

1,036–1,493

1,565–1,982

2,057–4040

a CIED and extracardiac surgery without ECC are excluded.


Summarizing the departments by various heart surgical procedures, it can be asserted that heart operations in patients suffering from congenital heart disease or CHD (<1 year, with extracorporeal circulation [ECC]) are conducted in 21, isolated heart transplantations in 19 and combined heart–lung transplantations in one institution ([Table 3]).

Table 3

Departments summarized by heart surgery procedures 2021

Category

n

Coronary artery bypass grafting

77

Heart valve surgery

77

Pacemaker/ICD procedures

75/74

Surgery for CHD (pat, <1 y with ECC)

21[a]

Heart transplantation

19[b]

Heart-lung transplantation

1

a N = 2,061: thereof: 19–40 op. in three units, 50–85 op. in nine units, 109–207 op. in nine units.


b N = 329: thereof: 1–4 transpl. in five units, 5–9 transpl. in four units, 10–19 transpl. in five units, 33–63 transpl. in five units.


Overall, as shown in [Table 4], 161,261 procedures were reported to the registry for the year 2021, a difference of 0.3% compared to 2020 (161,817 procedures) but a remarkable decline to 2019 (175,705 procedures). In 2021 the total amount of 92,838 heart surgical procedures in the narrower sense remained almost unchanged to the previous year (92,809 procedures) while from 2020 to 2019 a COVID-19 influenced decrease of 7.6% (100.446 procedures) was seen. Regarding CABG procedures an ongoing decrease must be recorded while heart valve and thoracic aorta procedures increased. The remarkable increase of assist device procedures by 12.5% is caused by a rise of non-permanent systems, almost certainly an effect of the COVID-19 pandemic ([Table 4]).

Table 4

Frequency of cardiac procedures 2021

Category

With ECC

Without ECC

Total

Diff, 2020 (%)

CABG isolated

21,280[a]

6,667[a]

27,947

−5.1%

CABG combined

7,961[a]

214[a]

8,175

−4.3%

Heart valve procedures

17,665[a]

19,049[a]

36,714

+ 3.5%

Surgery of thoracic aorta

7,499[a]

704[a]

8,203

+ 4.7%

Surgery for CHD

4,645[a]

890[a]

5,535

−0.6%

Cardiac surgery, other

1,322[a]

1,210[a]

2,532

+ 0.1%

Assist device procedures

578[a]

2,832[a]

3,410

+12.5%

Extracardiac surgery

287[a]

48,968

49,255

+0.2%

Pacemaker and ICD procedures

35[a]

19,455

19,490

−3.7%

Total

61,272

99,989

161,261

−0.3%

a Sum: n = 92,838 (heart surgery procedures).


The number of procedures using ECC in Germany from 2012 to 2021 are illustrated in [Table 5]. Since 2012, a gradual reduction can be observed with the strongest decline in 2020. Presumably this reflects on one hand achievements of established innovations with minimally invasive heart surgical procedures, and on the other hand a relevant effect of the COVID-19 pandemic since 2020. In addition, the comparison of 2020 and 2021 shows a further decrease of 2,448 cardiac procedures using ECC during the ongoing pandemic situation.

Table 5

Cardiac procedures using extracorporeal circulation (2012–2021)

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

Departments

79

79

78

78

78

78

78

78

78

78

Operations

84,388

84,040

83,787

81,527

79,082

76,696

72,331

71,759

63,720

61,272

Average

1,068

1,064

1,074

1,045

1,014

983

927

920

817

786

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]). 10,560 (11.4%) operations were conducted as emergency procedures, and 6,783 (7.3%) were reoperations ([Table 7]). These proportions appear quite consistent over the past years.

Table 6

Gender distribution

Distribution

Female

Male

n

%

n

%

Heart valve procedures

15,523

42

21,191

58

Coronary procedures

7,592

21

28,530

79

CHD procedures

2,491

45

3,044

55

Surgery of thoracic aorta

2,746

33

5,457

67

Cardiac surgery, other

1,525

60

1,007

40

Assist device

885

26

2,525

74

Pacemaker and ICD

7,073

36

12,417

64

Extracardiac surgery

17,375

35

31,880

65

Total

55,210

34

106,051

66

Table 7

Additional data 2020 vs. 2019

Procedures with ECC

2021

2020

Emergency

10,560

11.4%

10,445

11.3%

Redo

6,783

7.3%

7,330

7.9%

As shown in [Table V1] 14,279 (38.9%) isolated heart valve procedures were performed as single, 2,792 as double (7.6%), and 323 (0.9%) as triple valve procedures. Further 2,834 (36.8%, n = 7,698) aortic valve and 3,369 (55.7%, n = 6,052) mitral valve operations were performed via a minimally invasive access ([Table V2]). The number of single heart valve procedures via transcatheter approach increased over the last 2 years concerning aortic, mitral and tricuspid valve. The unadjusted mortality of the surgical aortic valve procedures amounts to 2.9%, nearly consistent over the last 3 years. Concerning the transcatheter aortic valve implantations (TAVI), transferred by all heart surgery departments in Germany, the unadjusted mortality rate was 1.9% in 2021, a decrease of 0.5 percentage points compared to the two previous years (2020/2019: 2.4%).

Table V1

Isolated heart valve procedures

Procedure

N

%

Single valve

14,279

500

3.5

Double valve

2,792

259

9.3

Triple valve

323

51

15.8

Transcatheter access (single valve)

19,203

380

2.0

Transcatheter access (double valve)

39

3

7.7

Unspecified

78

5

6.4

Total

36,714

1,198

3.3

Notes: Transcatheter heart valve procedures: 16,903 aortic valve implantation; 230 mitral valve implantation; 1,542 mitral valve repair; six tricuspid valve implantation; 522 tricuspid valve repair; 39 double aortic and mitral valve procedure.


Table V2

Single heart valve procedures

Access path

N

%

Aortic valve

  Sternotomy

4,864

188

3.9

  Partial sternotomy

2,834

38

1.3

  Transvascular

15,992

275

1.7

  Transapical

911

47

5.2

Mitral valve

  Sternotomy

2,683

202

7.5

  Minimal invasive

3,369

33

1.0

  Transcatheter

1,772

52

2.9

Tricuspid valve

  Sternotomy

346

28

8.1

  Minimal invasive

127

10

7.9

  Transcatheter

528

6

1.1

Pulmonary valve

  Sternotomy

55

1

1.8

  Minimal invasive

0

0

  Transcatheter

0

0

Total

33,481

880

2.6

Note: Apical aortic conduits procedures (n = 1) are not included,


In 6,754 (87.7%) isolated aortic valve operations under ECC conditions, xenograft prostheses were implanted, a consistent distribution over the last 5 years ([Table V3], [Fig. 5]). Concerning the treatment of mitral valve disease, in 63.3% (3,828) of the isolated mitral valve operations a reconstruction with preservation of the native valve could be achieved ([Fig. 7]). In a total of 2,500 combined mitral valve repair procedures, 1,094 (43.8%) simultaneous CABG procedures, 765 tricuspid valve repairs (30.6%), 464 (18.6%) aortic valve procedures and 177 (7.1%) concomitant CABG and AVR were performed ([Table V4]).

Table V3

Isolated aortic/mitral valve operations

Prosthesis/native heart valve

Aortic

Mitral

n

%

n

%

Xenograft

6,754

209

3.1

1,798

168

9.3

Mechanical prosthesis

748

13

1.7

422

19

4.5

Repair

175

4

2.3

3,828

48

1.3

Homograft

21

0

0.0

4

0

0.0

Total

7,698

226

2.9

6,052

235

3.9

Note: Transcatheter procedures and apical aortic conduits procedures (n = 1) are not included.


Table V4

Isolated/combined mitral valve procedures—implantation/replacement vs. repair

Mitral valve procedures

Repair

Implantation/replacement

Total

n

%

N

%

n

%

Isolated

3,828

48

1.3

2,224

187

8.4

6,052

235

3.9

  + CABG

1,094

46

4.2

802

130

16.2

1,896

176

9.3

  + Tricuspid valve repair[a]

765

22

2.9

492

63

12.8

1,257

85

6.8

  + Aortic valve

464

27

5.8

786

120

15.3

1,250

147

11.8

  + CABG + Aortic valve replacement

177

19

10.7

245

53

21.6

422

72

17.1

Total

6,328

162

2.6

4,549

553

12.2

10,877

715

6.6

a 39 procedures (not specified mitral valve + tricuspid valve surgery) excluded. Mortality: 15% (6/39).


The subgroup of 3,115 multiple heart valve procedures amounted to 2,546 (81.7%) double heart valve operations as a combination of mitral + tricuspid (n = 1,296) or mitral + aortic (n = 1,250) valve procedures ([Table V5]). Regarding the 16,903 transcatheter aortic valve implantations (TAVIs), an increase to 15,992 (94.6%) procedures performed by transvascular access and a lasting decrease to 911 (5.4%) by transapical access could be observed. In TAVI procedures without ECC the unadjusted mortality for those by transvascular access improved to 1.6% (255/15.917), respectively 4.9% (44/901) for the transapical approach. On the other hand, TAVI under use of ECC shows a remarkably high unadjusted mortality rate of 26.7% (20/75), respectively 30.0% (3/10) ([Table V6]), probably related to complications during the initial procedure.

Table V5

Multiple heart valve procedures

Combination

N

%

Mitral + tricuspid

1,296

91

7.0

Aortic + mitral

1,250

147

11.8

Aortic + mitral + tricuspid

320

51

15.9

Aortic + tricuspid

133

19

14.3

Aortic + pulmonary[a]

102

2

2.0

Tricuspid + pulmonary

11

0

0.0

Aortic + mitral + pulmonary

3

0

0.0

Total

3,115

310

10.0

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

16,818

299

85

23

16,903

322

1.9

  Transvascular

15,917

255

75

20

15,992

275

1.7

  Transapical

901

44

10

3

911

47

5.2

Mitral valve

1,666

40

106

12

1,772

52

2.9

  Repair

1,448

27

94

4

1,542

31

2.0

  Implantation

218

13

12

8

230

21

9.1

Tricuspid valve repair

527

6

1

0

528

6

1.1

  Repair

521

6

1

0

522

6

1.1

  Implantation

6

0

0

0

6

0

0.0

Aortic + mitral valve implantation

38

3

1

0

39

3

7.7

Aortic valve implantation[a] + CABG

24

1

13

2

37

3

8.1

Mitral valve implantation[b] + CABG

4

1

2

0

6

1

16.7

Aortic + mitral valve + CABG

0

0

0

0

0

0

Total

19,077

350

208

37

19,285

387

2.0

Notes: Pulmonary valve implantation for CHD excluded; 5% 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 the transmitted 36,122 CABG procedures, 77.4% were performed as isolated operations (n = 27,947), 11.8% (n = 4,267) combined with surgical aortic valve replacement (sAVR) and 5.2% (n = 1,896) with simultaneous mitral valve operations ([Table C1]). These numbers depict a minimal decline compared to the previous year. [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. While the total number of isolated CABG procedures showed a small decrease, the subgroup of isolated CABG without ECC increased to 6,667 (2020: 6,440). In addition, the unadjusted mortality rate of this subgroup decreased to 1.6% (2020: 2.0%), independent of the number of bypasses. In this context it has to be taken into account that conversions from off- to on-pump CABG are not captured. [Tables Con1] and [2] show data concerning congenital heart surgery procedures. In this subcategory the total number (n = 5,589) shows a small decline, meanwhile the unadjusted overall mortality rate changed to 2.1% ([Table Con1]) compared to 2020 (n = 5,637; 2.6%;) and 2019 (n = 5,834; 2.7%), respectively. [Tables Mis 1] [2] [3] [4] [5] demonstrate further compiled registry data under different aspects and for various categories like the Ross procedure, heart and lung transplantations, aortic surgery and heart rhythm procedures. With a total of 18,576 specified pacemaker and ICD procedures, the number declined by almost 3.2% (2020: 19,187) ([Fig. 11]), while the unadjusted mortality rate increased for pacemaker procedures to 0.9% (2020: 0.7%) and for ICD procedures to 1.2% (2020: 0.9%) ([Table Mis4]). As expected, the highest mortality rates for both CIED procedures were detected in the revision categories.

Table C1

Isolated CABG and combined procedures with/without ECC

n

%

Isolated CABG

27,947

751

2.7

  + Aortic valve replacement

4,267

215

5.0

  + Other

1,468

69

4.7

  + Mitral valve repair

1,094

46

4.2

  + Mitral valve replacement

802

130

16.2

  + Aortic valve replacement + mitral valve repair

177

19

10.7

  + Aortic + mitral valve replacement

245

53

21.6

  + Aneurysmal resection

79

7

8.9

  + Transcatheter aortic valve implantation

37

3

8.1

  + Transcatheter mitral valve procedure

6

1

16.7

Total

36,122

1,294

3.6

Table C2

Isolated CABG on-/off-pump surgery

Grafts

On-Pump

Off-Pump

Total

n

%

n

%

n

%

Single

527

29

5.5

1,205

15

1.2

1,732

44

2.5

Double

4,194

145

3.5

1,783

35

2.0

5,977

180

3.0

Triple

9,456

267

2.8

2,515

38

1.5

11,971

305

2.5

Quadruple

5,374

140

2.6

912

17

1.9

6,286

157

2.5

Quintuple + more

1,729

60

3.5

252

5

2.0

1,981

65

3.3

Total

21,280

641

3.0

6,667

110

1.6

27,947

751

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

2,030

676

65

16

3.2

2.4

1–17

1,747

196

20

0

1.1

0.0

≥ 18

922

18

19

0

2.1

0.0

Total

4,699

890

104

16

2.2

1.8

Table Con2

Procedures for congenital heart disease with and without ECC

Lesion/Procedure

Age < 1 y

Age 1 to 17 y

Age ≥18 y

n

%

n

%

n

%

ASD

37

0

0.0

238

0

0.0

204

1

0.5

Complete AV-canal

173

0

0.0

103

1

1.0

5

0

0.0

VSD

288

2

0.7

104

1

1.0

12

0

0.0

Fallot's tetralogy

193

0

0.0

24

0

0.0

2

0

0.0

DORV

53

0

0.0

11

1

9.1

1

0

0.0

TGA

147

1

0.7

2

0

0.0

0

TGA + VSD

70

2

2.9

3

0

0.0

0

Truncus arteriosus

33

0

0.0

10

0

0.0

0

Fontan circulation

2

0

0.0

292

5

1.7

3

0

0.0

Norwood

133

22

16.5

1

0

0.0

0

Pulmonary valve

63

2

3.2

180

1

0.6

76

3

3.9

Transcatheter pulmonary valve implantation

0

7

0

0.0

4

0

0.0

Aortic valve

53

1

1.9

176

0

0.0

338

2

0.6

Ross procedure

5

0

0.0

20

1

5.0

31

0

0.0

Mitral valve

27

0

0.0

117

3

2.6

93

8

8.6

Tricuspid valve

103

2

1.9

87

0

0.0

44

3

6.8

PDA

153

8

5.2

18

0

0.0

2

0

0.0

Coarctation

238

3

1.3

26

0

0.0

3

0

0.0

Others

929

38

4.1

479

7

1.5

122

2

1.6

HTx

6

0

0.0

39

0

0.0

0

HLTx

0

0

0

LTx

0

6

0

0.0

0

Total

2,706

81

3.0

1,943

20

1.0

940

19

2.0

Table Mis1

Ross procedures (autologous AV and PVR)

Age (years)

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

<18

36

33

37

28

38

38

29

32

35

25

≥18

117

107

90

64

72

52

61

104

70

124

Total

153

140

127

92

110

90

90

136

105

149

Table Mis2

Heart and lung transplantation

Transplant

With ECC

Without ECC

n

%

n

%

HTx

329

26

7.9

HLTx

1

0

0.0

LTx

93

8

8.6

161

9

5.6

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


Note: Eurotransplant (ET) report 2021: 324 HTx, 2 HTx + kidneyTx, 1 HTx + liverTx, 2 HLTx, 264 DLTx, 16 SLTx, 0 LTx + kidneyTx and 1 LTx + liverTx.


Table Mis3

Aortic surgery

Replacement[a]

With ECC

Without ECC

N

%

n

%

Supracoronary replacement of ascending aorta

1,173

85

7.2

Supracoronary ascending + aortic valve replacement

1,133

45

4.0

Infracoronary replacement of ascending aorta

 Mechanical aortic valve conduits

309

16

5.2

 Biological aortic conduits

1,023

102

10.0

 David procedure

502

7

1.4

 Yacoub procedure

108

5

4.6

 Other

292

21

7.2

Aortic arch replacement[b]

2,815

400

14.2

Replacement of descending aorta

65

3

4.6

6

1

16.7

Thoraco-abdominal aortic replacement

75

12

16.0

20

1

5.0

Endostent descending aorta

4

3

75.0

678

21

3.1

Total

7,499

699

9.3

704

23

3.3

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: 442 abdominal procedures and 34 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

12,443

118

0.9

8

1

12,435

117

 Implantation

8,478

75

0.9

4

0

8,474

75

 Battery exchange

1,706

3

0.2

0

0

1,706

3

 Revision procedures

2,259

40

1.8

4

1

2,255

39

ICD

6,133

72

1.2

18

5

6,115

67

 Implantation

2,445

11

0.4

1

0

2,444

11

 Battery exchange

1,499

2

0.1

1

0

1,498

2

 Revision procedures

2,189

59

2.7

16

5

2,173

54

Miscellaneous

914

10

1.1

9

0

905

10

Total

19,490

200

1.0

35

6

19,455

194

Table Mis5

Surgical procedures for tachyarrhythmia

Energy source

Endocardiac

Epicardiac

Total

n

n

 Unipolar radio frequency

55

244

299

 Unipolar cooled radio frequency

57

102

159

 Bipolar radiofrequency

234

1,598

1,832

 Cryothermy

1,331

324

1,655

 Microwave

0

0

0

 Focused ultrasound

2

98

100

 Laser

0

0

0

 Other

6

3

9

Total

1,685

2,369

4,054

Note: 223 procedures are unspecified with regard to endo-/epicardiac ablation.


Compared to the data of previous years, some significant changes can be seen on one hand, while several developments remained almost unchanged in 2021 on the other hand. The number of CABG procedures, isolated or combined, shows a further decrease of 4.9% in 2021, considerably less than the decline of the previous year (13.9%). The number of isolated heart valve procedures rose to the level of 2019 (increase of 3.5%) ([Fig. 1]). However, unadjusted mortality rates for CABG, AVR vary just slightly over the last decade ([Fig. 2]). The age distribution of patients continues to evolve toward a higher percentage of elderly patients (≥80 years) as well as a continuous increase of adults ≤69 years (49.5%) ([Fig. 3]). Presently, 29.8% of the cardiac procedures are performed in patients from 70 to 79 years of age, and 20.7% in octo-/nonagenarians. The relative amount of isolated off-pump CABG increases steadily, reaching 23.9% in 2021 (2020: 21.9%) ([Fig. 4]).

Zoom Image
Fig. 1 Selected heart surgical categories (2012–2021). 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 (2012–2021).
Zoom Image
Fig. 3 Age distribution of cardiac procedures (2012–2021). Notes: Patients <20 years and CIED procedures were excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2012–2021)

With regard to heart valve prostheses distribution, in 90.0% (n = 6,754) sAVR was performed using a xenograft ([Fig. 5]), whereas in 10.0% (n = 748) a mechanical prosthesis was implanted: a consistent proportion over the past 5 years. The unchanged development of transcatheter heart valve procedures in Germany led to a total of 19,285 transferred procedures in 2021 ([Table V6]). Focused on the distribution of aortic valve procedures for 2021, 16,903 (69.2%) TAVI and 7,523 (30.8%) sAVR were reported to the registry ([Fig. 6]). It must be emphasized that exclusively the German departments for cardiac surgery contribute to these data. Therefore, the registry cannot reach completeness of TAVI data due to the fact that procedures documented by cardiology departments are incompletely included. On the basis of and in addition to the recommendations of international scientific guidelines and expert consensus on the management of valvular heart disease, respectively,[8] [9] [10] the German Federal Joint Committee (G-BA) implemented a quality assurance directive[11] for “minimally invasive heart valve interventions (TAVI, transcatheter mitral clip reconstruction)” in 2015, which is still 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),[12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] provide various important findings and thus also contribute to an exceptional patient benefit.

Zoom Image
Fig. 5 Isolated aortic valve (AV) replacement (2012–2021). 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) (2012–2021) + additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V. TAVI, transcatheter heart valve intervention.

In 2021, the rate of isolated mitral valve reconstructions remains almost unchanged on a remarkable level of 63.3% (2020: 64.1%) ([Fig. 7]). Based on the fact that all isolated mitral valve procedure are 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) like in other publications, e.g., Gammie et al.[26] Therefore, other published rates of mitral valve repair have to be interpreted with caution if compared to this registry.

Zoom Image
Fig. 7 Isolated mitral valve surgery (2012–2021).

In 2021 almost half (48.5%; n = 2,685) of cardiac operations for CHD were performed in neonates/infants <1 year, 34.6% in children between 1 and 17 years and 16.9% in patients at least 18 years of age ([Fig. 8]). These numbers show a quite steady level over the past decade.

Zoom Image
Fig. 8 Age distribution for congenital heart disease (CHD) (2012–2021). 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).

Concerning ventricular assist device (L-/ R-/ BVAD, TAH) implantations (n = 750) a further significant decrease of 11.0% compared to 2020 (n = 843) ([Fig. 9]) could be observed, while the total number of heart transplantations decreased to 329, a decline of 3.2% compared to the previous year ([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. 9 Mechanical circulatory support devices (2012–2021).
Zoom Image
Fig. 10 Heart transplantation (2012–2021).
Zoom Image
Fig. 11 Pacemaker and ICD procedures (2012–2021).

#

Discussion

Even under the exceptional conditions of the further ongoing COVID-19 pandemic, the registry of the GSTCVS enables a comprehensive overview of all heart surgical procedures performed in German cardiac surgery departments in 2021. 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.[27] As observed in recent years, heart surgery in Germany is 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 could be always enabled (24/7/365) nationwide, even under COVID-19 conditions. These aspects are especially important in the context of various developments in the German health care policy and considering the background of demographic trends of the German population, leading to more patients at increased age combined with a higher proportion of related comorbidities and an accordingly complex perioperative risk profile.

Compared to 2020, the number of cardiac surgery procedures showed a smaller decrease for isolated/combined CABG and sAVR than in 2019 to 2020, an ongoing trend in the view of the German population characteristics and in the context of application of scientific guidelines.[10] [28] [29] Despite this, for the years 2020 und 2021 it must be taken into account that the care of patients with heart disease was affected by the consequences of SARS-CoV-2 pandemic with shutdowns and restrictions, respectively. Due to limited intensive care resources in all German cardiac centers, provision of elective/urgent heart surgical procedures was affected substantially. Otherwise, the low level in heart transplantations needs more efforts for a positive development in the future, even when the COVID pandemic will have been overcome.

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 German Society for Thoracic and Cardiovascular Surgery and all German cardiac surgical departments. 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: extracorporeal life support
ECMO: extracorporeal 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
Tx: transplantation
VAD: ventricular assist device
VSD: ventricular septal defect


#

Conflict of Interest

None declared.

Acknowledgement

The German Society for Thoracic and Cardiovascular Surgery would like to thank all heads of the German cardiac surgical departments 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   
Email: gf@dgthg.de

Publication History

Received: 20 June 2022

Accepted: 20 June 2022

Article published online:
10 August 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Selected heart surgical categories (2012–2021). 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 (2012–2021).
Zoom Image
Fig. 3 Age distribution of cardiac procedures (2012–2021). Notes: Patients <20 years and CIED procedures were excluded.
Zoom Image
Fig. 4 Isolated coronary artery bypass grafting (CABG) (2012–2021)
Zoom Image
Fig. 5 Isolated aortic valve (AV) replacement (2012–2021). 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) (2012–2021) + additional TAVI procedures calculated from the German legal quality assurance program, §§ 135a/ 136/ 137 SGB V. TAVI, transcatheter heart valve intervention.
Zoom Image
Fig. 7 Isolated mitral valve surgery (2012–2021).
Zoom Image
Fig. 8 Age distribution for congenital heart disease (CHD) (2012–2021). 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 (2012–2021).
Zoom Image
Fig. 10 Heart transplantation (2012–2021).
Zoom Image
Fig. 11 Pacemaker and ICD procedures (2012–2021).