Anne-Kathrin Funkat

The German Aortic Valve Registry (GARY): in-hospital outcome

Background Aortic stenosis is a frequent valvular disease especially in elderly patients. Catheter-based valve implantation has emerged as a valuable treatment approach for these patients being either at very high risk for conventional surgery or even deemed inoperable. The German Aortic Valve Registry (GARY) provides data on conventional and catheter-based aortic procedures on an all-comers basis. Methods and results A total of 13 860 consecutive patients undergoing repair for aortic valve disease [conventional surgery and transvascular (TV) or transapical (TA) catheter-based techniques] have been enrolled in this registry during 2011 and baseline, procedural, and outcome data have been acquired. The registry summarizes the results of 6523 conventional aortic valve replacements without (AVR) and 3464 with concomitant coronary bypass surgery (AVR + CABG) as well as 2695 TV AVI and 1181 TA interventions (TA AVI). Patients undergoing catheter-based techniques were significantly older and had higher risk profiles. The stroke rate was low in all groups with 1.3% (AVR), 1.9% (AVR + CABG), 1.7% (TV AVI), and 2.3% (TA AVI). The in-hospital mortality was 2.1% (AVR) and 4.5% (AVR + CABG) for patients undergoing conventional surgery, and 5.1% (TV AVI) and AVI 7.7% (TA AVI). Conclusion The in-hospital outcome results of this registry show that conventional surgery yields excellent results in all risk groups and that catheter-based aortic valve replacements is an alternative to conventional surgery in high risk and elderly patients.

The German Aortic Valve Registry: 1-year results from 13 680 patients with aortic valve disease †

OBJECTIVES The German Aortic Valve Registry (GARY) seeks to provide information on a real-world, all-comers basis for patients undergoing aortic valve interventions. This registry comprises patients undergoing the complete spectrum of transcutaneous and conventional surgical aortic valve interventions. The aim of this study was to use the GARY registry to evaluate conventional and catheter-based aortic valve interventions in several risk groups. METHODS A total of 13 860 consecutive patients undergoing intervention for aortic valve disease [conventional aortic valve replacement (AVR) or transvascular/transapical TAVR (TV-/TA-TAVR)] were enrolled in 78 German centres in 2011. Baseline, procedural and outcome data, including quality of life, were acquired up to 1 year post-intervention. Vital status at 1 year was known for 98.1% of patients. RESULTS The 1-year mortality rate was 6.7% for conventional AVR patients (n = 6523) and 11.0% for patients who underwent AVR with coronary artery bypass grafting (n = 3464). The 1-year mortality rate was 20.7 and 28.0% in TV- and TA-TAVR patients, respectively (n = 2695 and 1181). However, if patients were stratified into four risk groups by means of the EuroSCORE and the German AV Score, the highest risk cohorts showed the same mortality at 1 year with either therapy. More than 80% of patients in all groups were in the same or better state of health at 1 year post-intervention and were satisfied with the procedural outcome. CONCLUSIONS Conventional AVR surgery yields excellent results after 1 year in lower-risk patients. Catheter-based AVR is a good alternative in high-risk and elderly patients.

Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.

Background:The authors compared the safety and efficacy of a newly developed fast-track concept at their center, including implementation of a direct admission postanesthetic care unit, to standard perioperative management. Methods:All fast-track patients treated within the first 6 months of implementation of our direct admission postanesthetic care unit were matched via propensity scores and compared with a historical control group of patients who underwent cardiac surgery prior to fast-track implementation. Results:A total of 421 fast-track patients were matched successfully to 421 control patients. The two groups of patients had a similar age (64 ± 13 vs. 64 ± 12 yr for fast-track vs. control, P = 0.45) and European System for Cardiac Operative Risk Evaluation–predicted risk of mortality (4.8 ± 6.1% vs. 4.6 ± 5.1%, P = 0.97). Fast-track patients had significantly shorter times to extubation (75 min [45–110] vs. 900 min [600–1140]), as well as shorter lengths of stay in the postanesthetic or intensive care unit (4 h [3.0–5] vs. 20 h [16–25]), intermediate care unit (21 h [17–39] vs. 26 h [19–49]), and hospital (10 days [8–12] vs. 11 days [9–14]) (expressed as median and interquartile range, all P < 0.01). Fast-track patients also had a lower risk of postoperative low cardiac output syndrome (0.5% vs. 2.9%, P < 0.05) and mortality (0.5% vs. 3.3%, P < 0.01). Conclusion:The Leipzig fast-track protocol is a safe and effective method to manage cardiac surgery patients after a variety of operations.

Cardiac Surgery in Germany during 2011: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

All cardiac surgical procedures performed in 78 German cardiac surgical units throughout the year 2011 are presented in this report, based on a voluntary registry which is organized by the German Society for Thoracic and Cardiovascular Surgery. In 2011, a total of 100,291 cardiac surgical procedures (implantable cardioverter defibrillator and pacemakers procedures excluded) have been collected in this registry. More than 13.4% of the patients were older than 80 years compared with 12.4% in 2010. Hospital mortality in 41,976 isolated coronary artery bypass graft procedures (14.7% off-pump) was 2.9%. In 26,972 isolated valve procedures (including 5,210 catheter-based procedures), an in-hospital mortality of 5.2% has been observed.This voluntary registry of the German Society for Thoracic and Cardiovascular Surgery will continue to be an important tool enabling quality control and illustrating current facts and the development of cardiac surgery in Germany.

Cardiac Surgery in Germany during 2014: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

Based on a voluntary registry of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), data of all heart surgery procedures performed in 78 German cardiac surgical units during the year 2014 are presented. In 2014, a total of 100,398 cardiac surgical procedures (implantable cardioverter-defibrillator and pacemaker procedures excluded) were submitted to the registry. More than 14.2% of the patients were older than 80 years, describing an increase of 0.4% compared with the previous year. The unadjusted in-hospital mortality for 40,006 isolated coronary artery bypass grafting procedures (84.7% on-pump, 15.3% off-pump) was 2.6%. In 31,359 isolated valve procedures (including 9,194 catheter-based procedures), an in-hospital mortality of 4.4% was observed. This annual updated registry of the GSTCVS is published since 1989. It is an important tool for quality assurance and voluntary public reporting by illustrating current standards and actual developments for nearly all cardiac surgical procedures in Germany.

Cardiac Surgery in Germany during 2012: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery

On the basis of a voluntary registry of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), data of all cardiac surgical procedures performed in 79 German cardiac surgical units during the year 2012 are presented. In 2012, a total of 98,792 cardiac surgical procedures (ICD and pacemaker procedures excluded) were submitted to the registry. More than 13.8% of the patients were older than 80 years, which is a further increase in comparison to previous years. In-hospital mortality in 42,060 isolated coronary artery bypass grafting procedures (84.6% on-pump and 15.4% off-pump) was 2.9%. In 28,521 isolated valve procedures (including 6,804 catheter-based procedures), an in-hospital mortality of 4.8% was observed. This long-lasting registry of the GSTCVS will continue to be an important tool for quality control and voluntary public reporting by illustrating current facts and developments of cardiac surgery in Germany.

Isolated tricuspid valve surgery in patients with previous cardiac surgery

OBJECTIVES Few studies have been published in literature on outcomes of isolated tricuspid valve (TV) surgery when performed as a reoperation. Hence, we analyzed our early and midterm results of TV surgery in this unique group of patients. METHODS We performed a retrospective analysis of 82 consecutive patients who underwent isolated TV surgery as a reoperation at our institution between 1997 and 2010. Symptomatic TV regurgitation (84.2%), acute endocarditis (14.6%), and valve thrombosis after TV repair (1.2%) were the indications for surgery. A minimally invasive access through a right anterolateral thoracotomy was the preferred approach in 60% of the patients. Previous cardiac operations included mitral, aortic, and TV surgery in 60%, 29%, and 27% and coronary bypass surgery in 18%, usually performed as combined procedures. Elective surgery was performed in 67.1% of the patients. Mean patient age was 64.1 ± 11.9 years, 28% being male with an average logistic EuroSCORE of 16.4% ± 14.3%. Follow-up was 96% complete, with a mean duration of 2.6 ± 2.4 years. RESULTS Overall thirty-day mortality was 14.6%; for patients without and with endocarditis, it was 12.9% and 25%. Thirty-day mortality for patients undergoing elective surgery was 4.0%. Overall 2-year survival was 63.0% ± 5.5%. The 2-year freedom from TV-related reoperation was 93.5% ± 3.3%. CONCLUSIONS Postoperative results of isolated TV surgery as a reoperation are acceptable when performed electively but dismal in patients undergoing nonelective surgery. Thus, redo TV surgery, when indicated, should be performed sooner rather than later. Minimally invasive surgery through a right lateral minithoracotomy is a safe approach for patients with elective surgery.

Isolated reoperative minimally invasive tricuspid valve operations.

BACKGROUND Tricuspid valve (TV) regurgitation has recently been identified as a major risk factor for long-term mortality. Isolated reoperative tricuspid valve repair/replacement (TVR/r) carries an excessively high operative risk. Currently, isolated TVR/r with minimally invasive access through a right lateral thoracotomy is being used increasingly in our institution to treat progressive TV pathologic processes after previous cardiac operations. We analyzed our early and midterm results with reoperative TVR/r in this unique patient cohort. METHODS Forty-eight consecutive patients underwent isolated TV operations after previous cardiac operations with minimally invasive access through a right lateral thoracotomy at our institution between September 2000 and December 2011. Previous cardiac operations included 26 patients (54.2%) with mitral valve replacement/repair, 18 patients (37.5%) with an aortic valve replacement, 10 patients (20.4%) with a TVR/r, and 8 patients (16.7%) with coronary artery bypass grafting. Operations were performed electively in 79% of patients (n=38). Mean patient age was 63.8±13.4 years, with an average log EuroSCORE of 13.9%±11.3%; 67% of patients were women. Follow-up was 94% complete, with a mean duration of 2.8±2.3 years. RESULTS Thirty-day mortality for patients undergoing elective surgery was zero. For all patients early mortality was 4.2%. Five-year survival for patients after elective reoperative TVR/r through minimally invasive access was 72.2%±10.0%, and 5-year freedom from TV-related reoperations was 88.1%±6.7%, respectively. CONCLUSIONS Minimally invasive access through a right thoracotomy provides a safe option for reoperative TVR and offers excellent early outcome, particularly in elective cases. Surgical intervention should be performed earlier rather than later.

Leipziger „Fast-track“-Protokoll in der Kardioanästhesie

BACKGROUND In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs. METHOD A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs. RESULTS The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group. CONCLUSIONS The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.

[Leipzig fast-track protocol for cardio-anesthesia. Effective, safe and economical].

BACKGROUND In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs. METHOD A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs. RESULTS The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group. CONCLUSIONS The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.