Introduction

A letter has gone out to the SHA, explaining that all the Criteria have been fulfilled except for 1. as explained previously We are confident this will be accepted, so building will commence this September. The 3rd Theatre and additional ITU beds should be operational by the end of 2006. A seventh Surgeon will be appointed. All this is good news for patients, as the number of procedures will increase, reducing waiting times further (Currently 3 months).

 

 

Heart Surgery 2004-2005
Waiting List Initiative (WLI)

As previous year we fell short of the target

Patient Choice
All Elective patients needing Angioplasty+/-Stent ,CABG ,Valve Surgery

• Patients get the choice of Centre for Treatment.
  
• Not Consultant Specific until 2008
  
• Initially choice of two Centres (Wythenshawe and MRI) increasing to 4-5 Centres from December 2005 (Blackpool and CTC ?)
  
• Inclusion of Private Sector Providers is under discussion.
  
• The two centres will provide treatment for all patients, but individual Surgeons will be exempt from performing procedures they are not skilled at.
  A Surgeon will not be asked to operate on a very high risk patient if a Surgeon does not wish to do so.
  (Be assured that it is extremely rare for a patient to be turned down by all the Surgeons).

Total Number of Cases per Consultant per year

Overall reduction per Consultant with time probably due to an increase in the number of coated stent procedures done by the Cardiologists

 

 

Operation Priority

Sex Distribution

	Female	Male
2002-03	26%	74%
2003-04	29%	71%
2004-05	31%	69%

 

 

 

EuroSCORE
(European System for Cardiac Operative Risk Evaluation)

EuroSCORE is a simple, objective and up-to-date system for assessing the risk of heart surgery, based on one of the largest, most complete and accurate databases in European cardiac surgical history. We use the additive EuroSCORE which is by no means perfect in predicting non-survival, but probably currently the best available.

This is how the patients are scored to access their risk of non survival following the procedure
A score >6 is a high risk patient

 

 

Risk Stratification (previous year)

1st time CABG		Average Euroscore
		3.3	(3.1)
All Procedures		Average Euroscore
All Cases		4.5	(4.2)

We now operate on higher risk patients

 

Pure CABG vs. Total number of Procedures

2002-3	914/1225 =	75%
2003-4	660/1029 =	64%
2004-5	546/922 =	59%
The reduction in CABG’s is due to increased activity by the Cardiologists, doing the more straight forward cases, leaving the more complex cases for the Surgeons.

 

 

 

Pure Coronary Artery Bypass Grafts 540pts

	#	%	Average previous years
MIDCAB (ant/lat)
OFF PUMP STERNOTOMY CABG	153	28%	(36%)
ON PUMP	384	71%	(64%)
First time CABG	517	96%	(94%)
Redo CABG	22	}4%	(6%)
Reredo CABG	1

Reduction in off pump CABG (not using a heart lung machine)
probably due to more complex cases.
Only 4% of our patients have had previous Cardiac Surgery

 

 

Pure Coronary Artery Bypass Operations (CABG) 540

94% of patients had at least one arterial graft

Only 6% had pure vein grafts.

Arterial grafts last much longer than vein grafts
and patients with arterial grafts can therefore expect longer
relief of symptoms.

 

 

 

Average number grafts per patient

OPCAB	2.87 (3.15)
On pump CAB	3.56 (3.6)

Patients having operations using heart lung machine have more grafts,
partly due to more extensively diseased arteries.

 

 

 

Other than Pure CABG

We are now operating on more Valve patients than in the past.

 

 

 

CABG & Other

	#	Average previous years
CABG & LV Aneurysm	2	(3)
CABG & CAROTID	5	(5)
CABG & Radio freq Ablation	4
CABG & ASD	2	(3)
CABG & suture ligation of L Atrial appendage	2
CABG & Others	5
TOTAL	20

 

 

Number of Valves used
Valve insertion rate 0.33% (0.33%)


1/3 patients now receive a Valve

 

 

Pure Valve
Single Valve Surgery 137 (190)

	#	%	Average previous year
Aortic Valve Replacement				88
Male	43	49%	(60%)
Female	45	51%	(40%)
Mechanical Valve Replacement	35	40%	(65%)
Emergency/Urgent	28	23%	(21%)
Age 70 or over	35	40%	(25%)
Mitral Valve Replacement				18
Male	8	44%	(36%)
Female	10	56%	(64%)
Tricuspid Valve Replacement				0 (1)
Pulmonary Valve Replacement				0 (2)
Mitral Valve Repair				31 (31)
Aortic Valve Repair/Commisurotomy				0 (2)
Aortic Root Enlargement				2 (0)

 

Multiple Valve Surgery 17 (22)

	#	Average of previous year
DOUBLE VALVE REPLACEMENT			16 (21)
AVR/MVR	13	(17)
Mitral & Tricuspid Repair/Replace	2	(4)
AV Replace & Tricuspid Repair	1
TRIPLE VALVE REPLACEMENT/REPAIR			1 (1)

 

 

Valve & Other excluding CABG 21

VALVE & other Non Congenital	16
VALVE & other Congenital	5

 

Valve & CABG +/- other
141 15% (10%)

	#	Prev Year
AVR & CABG	97/10%	(7%)
MVR/REPAIR & CABG	32/ 3%	(3%)
CABG & VALVE & LVA	4
CABG & VALVE & Radio freq ablation	3
AVR & CABG & Endarterectomy of asc aorta	2
OTHER VALVE COMBINATIONS & CABG	3	(0)

 

 

Miscellaneous operations 17 (12)

	#	Previous year
Congenital
ASD	5	(8)
MISC Adult	4	(2)
Acquired
Trauma	0	(1)
Pericardial patch/window	2	(1)
Atrial Myxoma	1
Myomectomy	1
Epi pacemaker	2
Pulm Embolectomy	1
Radio freq ablation	1

 

Major Aortic Surgery 25 (27)

Acquired
ROSS	5	(12)
Root Replacement	9	(9)
Root &Hemiarch	1	(1)
Ascending Aorta	9	(3)
Asc Hemi	1	(2)

 

 

Operations Performed by Specialist Registrar’s
with Consultant Assistance (No of months at MRI)

We at the MRI take training very seriously, to ensure our Trainees will one day become safe and competent Consultant Surgeons

 

 

Percentage of All Cases done
by Trainee’s - 35%

A trainer is one who delegates at least 30% of cases (The trainer as previously stated will assist the trainee).

 

 

Percentage of 1st time CABG
done by Trainee’s- 2004-05
Average 50%

 

 

Lost Theatre slots - 40    4.3%    (9%)
Fortunately only a small number of slots are lost
due to the reasons stated below

		#	Previous years
No CSU/PCU bed		23	(25)
No ITU bed		0	(2)
No Anaesthetist		2	(2)
No Surgeon No Theatre staff		0 2	(4)
Preceding Case ran over		4	(8)
Thoracic List Replaced Cardiac		0	(10)
Patient Medically unfit		6	(11)
Others		3	(8)

 

 

Cardiac Surgery (ITU) Unit Stay

Out in 24 hours	73%	77%
Out in 48 hours	85%	87%
Readmissions to CSU from HDU/Ward3	3%	2%

Longer stay this year likely due to higher risk patients

 

 

Complications

	#	%	Previous years
Full Tracheostomy	23	2.5%	(2%)
Sternal Rewiring	4	0.4%	(0.6%)
Mediastinitis req stern debridement	5	0.5%	(0.4%)
Pulmonary Embolism	1	0.1%	(0.1%)
Atrial Fibrillation	239	26%	(29%)
Hospital readmission rate.	47/889	5%

Pericardial/Pleural effusion accounted for 17% of the total. The dreaded complication of Mediastinitis (sternal bone infection) remains gratifyingly low

 

 

 

GI Complications

	#	%	Previous years
Ileus	5	0.5%	(0.3%)
Mesenteric Infarct (Both Died)	2	0.2%	(0.3%)
GI Bleed	7	0.7%	(0.7%)
Pseudo Obstruction	1	0.1%	(0.1%)
Ischaemic Bowel (All 5 Died)	5	0.5%	(0.2%)
Bowel Ischemia is a very serious but fortunately rare complication.

 

Complications - Stroke

	#	%	Previous Years
CVA (stroke)	6	0.7%	(1%)
TIA (transient Ischaemic attack)	9	1.0%	(0.6%)
Post op Incidence of Permanent stroke in 1st time CABG only		0.2%	(0.6%)
Once again the incidence of stroke is very low

 

 

 

Renal Failure

Mild/Moderate (Creatinine >200) Sternotomy	29 4)	3%	(2%)
Renal Failure (Req Dialysis/filtration)	29	3%	(2%)
1st Time CABG		1.4%	(1.6%)
The incidence of Renal complications is again low.

 

 

 

Intra Aortic Balloon Pump (IABP)
(A device used to help a failing heart)

TOTAL	32	3.5%	(3.3%)
MORTALITY	12	38%	(36%)
IABP POST OP	18	2.0%	(1.9%)
MORTALITY	7	38%	(45%)
IABP PRE OP	14	1.5%	(1.4%)
MORTALITY	5	36%	(14%)
Fortunately we have not had to use this device very often

 

 

Specialist Registrar Reopening for bleeding/tamponade
(No of months at MRI)

 

 

 

Reopen Bleeding/Tamponade
5.5% ( 5.5%)

Reopening rate too high. Fortunately no harm comes to the vast majority of patients.

 

 

Elderly Patients Aged 70 or over

	#	%	Previous Years
TOTAL	346/920	38%	(34%)
Female	128	37%	(40%)
Male	218	63%	(60%)
Non Elective	115	33%	(33%)
PURE CABG	178	51%	(56%)
Non Elective CABG	69	20%	(22%)
AVR	35	10%	(13%)
AVR&CABG	63	18%	(13%)
AVR,CABG or Both	276	80%	(82%)
Age 80 or over	72	7.8%	(4.6%)
Average Euroscore	8.1		(8.2)
Our patients are getting older all the time.
Mortality Elderly Group	18/346	5%	(6%)
Mortality Elderly Pure CABG	3/178	1.7%	(3.5%)
Elderly 80 and over		11%	(8%)
Very acceptable mortality we feel.

 

 

Mortality
Death within Base Hospital on that Admission

OVERALL	31/920	3.4%	(3.2%)
Elective operations	7/646	1.1%	(2.1%)
Non elective operations	24/274	8.7%	(6.2%)
First time CABG	7/517	1.4%	(1.8%)
Elective 1st time CABG	1/341	(0.3%)	(0.1%)
Non Elective 1st time CABG	6/176	(3.4%)
Redo CABG	0/23		(0%)
Mortality Opcab	0/156	0%	(1.2%)
Mortality Oncab	7/384	1.8%	(1.9%)
Mortality Males	14/638	2.2%	(2.1%)
Mortality Females	17/282	6%	(5.7%)
AVR	5/88	6%	(0%)
MVR /repair	3/49	6%	(1.6%)
CABG & AVR	7/97	7%	(9%)
CABG & MVR/Repair	4/32	13%	(7%)
A Summary table of all the mortalities at the MRI. Please note non elective (urgent/emergency and salvage operations) carried a mortality 8x that of elective ops.

 

 

Cusum Curves

Cusum Curves are means of analysing a Unit’s or an individual Surgeon’s performance over time. We have used the Euroscore to construct these curves.
Essentially they show crude versus risk adjusted (predicted) Mortalities, using a complex formula.

• Y axis = Cumulative Deaths.
  
• X axis = Cumulative No of operations.
  
• The Yellow line represents cumulative predicted mortality
  
• The Light Blue line represents cumulative observed mortality
  
• The Pink and Dark Blue lines represent Upper and Lower 95% confidence limits of observed mortality.
  
  A Unit or a Surgeon is under performing if the yellow line drops below the dark blue line. Neither the Unit as a whole nor individual Surgeons are under Performing. Therefore on the following slide (see arrows) the first Cusum shows that 130 patients were predicted not to survive. As there were only 100 deaths we performed better than predicted.

 

 

All Surgeons All Operations 2002-2005

	01 April 2002 - 31 March 2005

 

 

All Surgeons All Operations 2004-2005

	01 April 2004 - 31 March 2005

 

 

G J Grotte

	01 April 2004 - 31 March 2005

 

 

D J M Keenan

	01 April 2004 - 31 March 2005

 

 

N J Odom

	01 April 2004 - 31 March 2005

 

 

R I R Hasan

	01 April 2004 - 31 March 2005

 

 

B Prendergast

	01 April 2004 - 31 March 2005

 

 

K E McLaughlin

	01 April 2004 - 31 March 2005

 

 

Remember! Surgeons can have both good, bad and indifferent years, and any Surgeons performance should be assessed over a period of no less than three years.