Creating transparency in UK adult cardiac surgery data

Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting

The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.

Trends and outcomes for cardiac surgery in the United Kingdom from 2002 to 2016

Objectives

Cardiac surgery has evolved significantly since the turn of the century. The objective of this study was to investigate trends in cardiac surgery activity and outcomes in the United Kingdom utilizing a mandatory national cardiac surgical clinical database in the context of a comprehensive public health care system (ie, the UK National Health Service).

Methods

Data for all cardiac surgery procedures performed between 2002 and 2016 were extracted from the UK National Adult Cardiac Surgery Audit database. Data are validated and cleaned using reproducible algorithms. Trends in activity and outcomes were analyzed by fiscal year using linear regression.

Results

A total of 534,067 procedures were performed during the study period with the number of cases per year peaking in 2008/2009 at 41,426. Despite an increase in patient age and mean logistic European System for Cardiac Operative Risk Evaluation score, the in-hospital mortality rate for all cardiac surgery has fallen from 4.0% to 2.8% (P < .001). The number of isolated coronary artery bypass graft procedures has steadily declined but the total number of valve procedures has steadily increased (both P values < .001). The number of thoracic aortic procedures performed each year has doubled (P < .001), but the incidence of redo procedures has steadily declined. The proportion of emergency and salvage procedures has remained stable.

Conclusions

This study, which covers all cardiac surgery procedures performed in the United Kingdom for fiscal years between 2002 and 2016, demonstrates that despite an increase in patient risk profile, there has been a consistent reduction in in-hospital mortality. A number of other markers associated with quality have also improved.

Coronary artery bypass surgery in the UK, trends in activity and outcomes from a 15-year complete national series

OBJECTIVES

The aim of this study was to review the UK national trends in activity and outcome in coronary artery bypass graft (CABG) over a 15-year period (2002-2016).

METHODS

Validated data collected (2002-2016) and uploaded to National Institute for Cardiovascular Outcomes Research were used to generate summary data from the National Adult Cardiac Surgery Audit Database for the analysis. Logistic European System of Cardiac Operative Risk Evaluation was used for risk stratification with recalibration applied for governance. Data were analysed by financial year and presented as numerical, categorical, %, mean and standard deviation where appropriate. Mortality was recorded as death in hospital at any time after index CABG operation.

RESULTS

A total of 347 626 CABG procedures (282 883 isolated CABG, 61 109 CABG and valve and 4132 redo CABG) were recorded. Over this period annual activity reduced from 66.6% of workload to 41.7%. The mean age for isolated CABG was 65.7 years. The mean log European System of Cardiac Operative Risk Evaluation was 3.1, 5.9 and 23.2 for elective, urgent and emergency isolated CABG, respectively. There was a decline in the observed mortality for all procedures. Overall mortality for isolated CABG surgery is now 1.0% and only 0.6% for elective operations.

CONCLUSIONS

Quality of care and risk-adjusted mortality rates have consistently improved over the last 15 years despite the increasing risk profile of patients. There have been a consistent decline in overall case volumes and a three-fold increase in elderly cases.

Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass

BACKGROUND

Corticosteroids are routinely given to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) in an attempt to ameliorate the inflammatory response. Their use is still controversial and the decision to administer the intervention can vary by centre and/or by individual doctors within that centre.

OBJECTIVES

This review is designed to assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with CPB.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Conference Proceedings Citation Index-Science in June 2020. We also searched four clinical trials registers and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included studies of prophylactic administration of corticosteroids, including single and multiple doses, and all types of corticosteroids administered via any route and at any time-point in the perioperative period. We excluded studies if steroids were administered therapeutically. We included individually randomised controlled trials (RCTs), with two or more groups (e.g. multi-drug or dose comparisons with a control group) but not 'head-to-head' trials without a placebo or a group that did not receive corticosteroids. We included studies in children, from birth up to 18 years of age, including preterm infants, undergoing cardiac surgery with the use of CPB. We also excluded studies in patients undergoing heart or lung transplantation, or both; studies in patients already receiving corticosteroids; in patients with abnormalities of the hypothalamic-pituitary-adrenal axis; and in patients given steroids at the time of cardiac surgery for indications other than cardiac surgery.

DATA COLLECTION AND ANALYSIS

We used the Covidence systematic review manager to extract and manage data for the review. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We resolved disagreements by consensus or by consultation with a third review author. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We found 3748 studies, of which 888 were duplicate records. Two studies had the same clinical trial registration number, but reported different populations and interventions. We therefore included them as separate studies. We screened titles and abstracts of 2868 records and reviewed full text reports for 84 studies to determine eligibility. We extracted data for 13 studies. Pooled analyses are based on eight studies. We reported the remaining five studies narratively due to zero events for both intervention and placebo in the outcomes of interest. Therefore, the final meta-analysis included eight studies with a combined population of 478 participants. There was a low or unclear risk of bias across the domains. There was moderate certainty of evidence that corticosteroids do not change the risk of in-hospital mortality (five RCTs; 313 participants; risk ratio (RR) 0.83, 95% confidence interval (CI) 0.33 to 2.07) for children undergoing cardiac surgery with CPB. There was high certainty of evidence that corticosteroids reduce the duration of mechanical ventilation (six RCTs; 421 participants; mean difference (MD) 11.37 hours lower, 95% CI -20.29 to -2.45) after the surgery. There was high-certainty evidence that the intervention probably made little to no difference to the length of postoperative intensive care unit (ICU) stay (six RCTs; 421 participants; MD 0.28 days lower, 95% CI -0.79 to 0.24) and moderate-certainty evidence that the intervention probably made little to no difference to the length of the postoperative hospital stay (one RCT; 176 participants; mean length of stay 22 days; MD -0.70 days, 95% CI -2.62 to 1.22). There was moderate certainty of evidence for no effect of the intervention on all-cause mortality at the longest follow-up (five RCTs; 313 participants; RR 0.83, 95% CI 0.33 to 2.07) or cardiovascular mortality at the longest follow-up (three RCTs; 109 participants; RR 0.40, 95% CI 0.07 to 2.46). There was low certainty of evidence that corticosteroids probably make little to no difference to children separating from CPB (one RCT; 40 participants; RR 0.20, 95% CI 0.01 to 3.92). We were unable to report information regarding adverse events of the intervention due to the heterogeneity of reporting of outcomes. We downgraded the certainty of evidence for several reasons, including imprecision due to small sample sizes, a single study providing data for an individual outcome, the inclusion of both appreciable benefit and harm in the confidence interval, and publication bias.

AUTHORS' CONCLUSIONS

Corticosteroids  probably do not change the risk of mortality for children having heart surgery using CPB at any time point. They probably reduce the duration of postoperative ventilation in this context, but have little or no effect on the total length of postoperative ICU stay or total postoperative hospital stay. There was inconsistency in the adverse event outcomes reported which, consequently, could not be pooled. It is therefore impossible to provide any implications and policy-makers will be unable to make any recommendations for practice without evidence about adverse effects. The review highlighted the need for well-conducted RCTs powered for clinical outcomes to confirm or refute the effect of corticosteroids versus placebo in children having cardiac surgery with CPB. A core outcome set for adverse event reporting in the paediatric major surgery and intensive care setting is required.

Has Publishing Surgeon-Specific Outcomes Had an Impact on Training in Cardiac Surgery?

BACKGROUND

Surgeon-specific outcome data are now published for most surgical specialties in the United Kingdom. There are concerns that this initiative has had a negative impact on training. The primary objective of this study was to assess whether training activity has changed since the publication of surgeon-specific outcomes in cardiac surgery.

METHODS

Prospectively collected data for cardiac surgical procedures performed at a single center from 2004 to 2016 were analyzed. The cohort was split into two halves according to operation date. Multivariable logistic regression was used to assess whether training activity had increased from the first to the second part of the study and to identify whether trainee first operator was associated with adverse outcomes.

RESULTS

A total of 14,054 cardiac surgical procedures were included, of which 1,777 (12.6%) had a trainee as first operator. Despite an increase in the risk profile of patients undergoing surgical procedures, the proportion of cases performed by trainees increased from 11.7% (786 of 6,708) in the first half of the study to 13.5% (991 of 7,346) in the second half of the study (p = 0.002). This effect remained after adjustment for confounding variables. Trainee first operator was not significantly associated with an increased risk of any adverse short-term outcome.

CONCLUSIONS

Since surgeon-specific outcome publication began in United Kingdom, cardiac surgical training activity has significantly increased at the study center despite an increase in the risk profile of patients. This study demonstrates that it is possible to maintain or even increase training activity with good outcomes in the era of surgeon-specific outcome publication.

Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine a Safe Threshold

OBJECTIVE

To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery.

DATA SOURCE

Hospital data on all publicly funded CABG in five European countries, 2007-2009 (106,149 patients).

DESIGN

Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold.

FINDINGS

The 30-day in-hospital mortality rate was 3.0 percent overall, 5.2 percent (95 percent CI: 4.0-6.4) in low-volume hospitals, and 2.1 percent (95 percent CI: 1.8-2.3) in high-volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year.

CONCLUSIONS

There is a clear relationship between hospital CABG volume and mortality in Europe, implying a "safe" threshold volume of 415 cases per year.

Surgical Quality Predicts Length of Stay in Patients with Congenital Heart Disease

Historically, the primary marker of quality for congenital cardiac surgery has been postoperative mortality. The purpose of this study was to determine whether additional markers (10 surgical metrics) independently predict length of stay (LOS), thereby providing specific targets for quality improvement. Ten metrics (unplanned ECMO, unplanned cardiac catheterization, revision of primary repair, delayed closure, mediastinitis, reexploration for bleeding, complete heart block, vocal cord paralysis, diaphragm paralysis, and change in preoperative diagnosis) were defined in 2008 and subsequently collected from 1024 consecutive index congenital cardiac cases, yielding 990 cases. Four patient characteristics and 22 case characteristics were used for risk adjustment. Univariate and multivariable analyses were used to determine independent associations between each metric and postoperative LOS. Increased LOS was independently associated with revision of the primary repair (p = 0.014), postoperative complete heart block requiring a permanent pacemaker (p = 0.001), diaphragm paralysis requiring plication (p < 0.001), and unplanned postoperative cardiac catheterization (p < 0.001). Compared with patients without each metric, LOS was 1.6 (95 % CI 1.1-2.2, p = 0.014), 1.7 (95 % CI 1.2-2.3, p = 0.001), 1.8 (95 % CI 1.4-2.3, p < 0.001), and 2.0 (95 % CI 1.7-2.4, p < 0.001) times as long, respectively. These effects equated to an additional 4.5-7.8 days in hospital, depending on the metric. The other 6 metrics were not independently associated with increased LOS. The quality of surgery during repair of congenital heart disease affects outcomes. Reducing the incidence of these 4 specific surgical metrics may significantly decrease LOS in this population.

Standards for heart valve surgery in a 'Heart Valve Centre of Excellence'

Surgical centres of excellence should include multidisciplinary teams with specialist expertise in imaging, clinical assessment and surgery for patients with heart valve disease. There should be structured training programmes for the staff involved in the periprocedural care of the patient and these should be overseen by national or international professional societies. Good results are usually associated with high individual and centre volumes, but this relationship is complex. Results of surgery should be published by centre and should include rates of residual regurgitation for mitral repairs and reoperation rates matched to the preoperative pathology and risk.

Towards transparency in cardiac radiology: should CT coronary angiography radiation doses be published?

This is a commentary on the use of radiation dose as a quality marker in CT coronary angiography.