Central Cardiac Audit Database Research Articles

Effects of endothelin receptor antagonism in an experimental model of renal transplantation

s / International Journal of Surgery 23 (2015) S15eS134 S21 Conclusion: Our results indicate the existence of a mitochondrial stress environment with a lasting negative impact on residual kidney-function at day 30 likely reflecting a renal-tubular dysfunction in the remaining kidney. Further biochemical analyses are ongoing to confirm the nature of this dysfunction allowing the targeting of timely interventions. 0598: EFFECTS OF ENDOTHELIN RECEPTOR ANTAGONISM IN AN EXPERIMENTAL MODEL OF RENAL TRANSPLANTATION K. Shah, S. Hosgood, M. Patel, M. Nicholson. University of Leicester, UK Aim: Uncontrolled Donation after Circulatory Death (uDCD) donors provide a large potential source of kidneys but there is reluctance to use them due to prolonged warm ischaemic times. Endothelin-1, a potent vasoconstrictor, is a major contributor to ischaemic injury. This study aimed to investigate the benefit of endothelin receptor blockade in an experimental model of uDCD transplantation. Methods: Porcine kidneys underwent 60 minutes warm ischaemia and 2 hours cold ischaemia followed by 3 hours of reperfusion with autologous blood without (control, n 1⁄4 6) and with (n 1⁄4 6) 500mg BQ-123, a selective ETA endothelin receptor antagonist. Markers of renal function and injury were analysed. Results: Renal blood flow was significantly higher in the experimental group at 15e30 minutes of reperfusion (29.6e37.7 vs. 13.1e18.2 ml/min/ 100 g, p 1⁄4 0.02), after which, although higher throughout, statistical significance was lost. Urine output, creatinine clearance and oxygen consumption were also higher in the experimental group throughout but statistical significance was only seen in the 1st hour urine output (83 vs. 32 ml/hr, p 1⁄4 0.01). Urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) levels were not different between the groups. Conclusion: Kidneys can recover from warm ischaemic injury. BQ-123 appeared to improve perfusion and function initially but did not have a sustained effect or significant overall benefit. Association of Surgeons of Great Britain & Ireland Short Paper Session 0002: SURGICAL AND TRANSCATHETER CLOSURE OF CONGENITAL CORONARY FISTULAE: OUTCOMES FROM A NATIONAL AUDIT D. Fudulu, D. Dorobantu, M. Caputo, S. Stoica. Bristol Children's Hospital, UK Aim: To report short and long term outcomes after surgical and transcatheter correction of congenital coronary fistulas (CCF). Methods: Using data from the UK Central Cardiac Audit Database we performed a retrospective analysis of all patients undergoing surgical or transcatheter correction of CCF between 2000 and 2012. Results: Out of 81 patients (48.2% Male, 51.8% Female), 34 (42%) underwent surgical repair and 47 (58%) had transcatheter procedures. The median ages were 12.6 years for surgery (range, 0.08e68.2) and 7.8 years (range, 0.01e77.8) in the catheterization group. Mean follow-up times were: 5.3 years (range, 0e13.0) for the surgical group and 4.6 years (range, 0e12.7) for the catheter group. Therewas no 30-daymortality in the entire cohort. One-year mortality for the surgical group was 7.41 % vs. 2.94 % for the catheter group (p 1⁄4 0.58). In the catheter group 4 patients (8.51%) required one or more reinterventions, compared to no reinterventions in the surgical cohort (p 1⁄4 0.13). Conclusions: CCF repair via transcatheter or surgical approach is attainable with no early mortality and good medium-term results. Careful patient selection would have to be partly responsible for these excellent national results Reintervention is overall infrequent and it appears to be higher after transcatheter embolisation. 0418: TRANS-VAGINAL DUPLEX ULTRASOUND FOR DETECTING PELVIC VEIN INCOMPETENCE IN WOMEN: A PILOT STUDY V. Hansrani, D. Kotecha, K. Norse, C. McCollum. University of Manchester, UK Aim: Pelvic vein incompetence (PVI) is diagnosed by reflux venography. This is invasive, nephrotoxic and involves ionizing radiation in young women. Trans-vaginal duplex ultrasound (TVU) is a non-invasive and entirely safe alternative. We compared TVUwith reflux venography for the detection of PVI. Methods: Womenwith clinical suspicion of PVI who attended for TVU and reflux venography were included in this study (n 1⁄4 20). Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for TVU with reflux venography as the ‘gold standard’. Results: 40-paired TVU and reflux venography images were analysed from 20women, mean (range) age 45 (25e55). PVI was detected in all 20 images with TVU and 19 of 20 (95%) images with reflux venography. The sensitivity and PPV of TVU to detect PVI was 100% and 95% respectively. TVU identified left ovarian vein incompetence with a sensitivity and specificity of 78.6% and 66.7%; right ovarian vein incompetence with sensitivity and specificity of 71.4% and 100%; left internal iliac vein incompetence with sensitivity and specificity of 91.7% and 100%, and right internal iliac vein incompetence sensitivity and specificity of 70% and 90% respectively. Conclusion: TVU is accurate and safe alternative to reflux venography in diagnosing of PVI. 0719: LIVING KIDNEY DONATION IN THE ELDERLY: THE UK EXPERIENCE R. Tamburrini, Z. Ahmed, A. Shafi, N. Kessaris, N. Mamode. Guy's Hospital,

TCT-183 Repeat Coronary Angiography in Patients with Previously Normal Coronary Arteries

Background: Coronary artery disease (CAD) is a major public and economic health problem. Coronary angiography is a gold standard for diagnosing CAD and is indicated in patients with 61–90% pre-test probability of the disease when the diagnosis cannot be made on clinical grounds alone and when revascularisation is being considered. The natural history of normal coronary angiogram is poorly understood. Objectives: To evaluate the progression of disease in patients with normal coronary angiography and to assess the overall survival and event-free survival from acute myocardial infarction (MI) in these patients. Methods: We interrogated the Central Cardiac Audit Database (CCAD) between November 2005 and December 2013 to identify patients with normal or ‘near-normal’ coronary angiography. Demographic, clinical and angiographic data was recorded. This database was linked with the Patient Episode Database for Wales (PEDW) and the datasets from the Office for National Statistics (for mortality) using the Secure Anonymised Information Linkage (SAIL) databank. This allowed for the extraction of information from all the sources above on the basis of the International Statistical Classification of Diseases (ICD-10) using the Structured Query Language (SQL). Results: Out of over 20,000 patients undergoing coronary angiography between November 2005 and December 2013, 5032 patients had normal coronaries and minor CAD. Of 5032 patients, 136 underwent repeat angiography, with 131 (96.3%) and 5 (3.7%) patients having two and three repeat investigations respectively. Mean time between procedures was 3.3 (±1.82) years. Of those 136 patients, at the median follow up of 6.8 years, no change in disease progression was demonstrated in 108 (79.4%) patients on the follow up studies. In the remaining 28 (20.6%) patients, normal coronaries progressed to minor CAD. No patients progressed beyond minor CAD. Patients with normal coronaries had significant better survival than patients with minor CAD (p 99.5% in both groups at the median of 5 years follow up. (p = 0.09) Conclusions: Normal coronary angiography and minor CAD is unlikely to progress to significant disease at 7 years and the incidence of MI in these patients is rare at 5 years. Therefore, repeating coronary angiography within at least 5 years is not indicated.

118 Repeat Coronary Angiography in Patients with Previously Normal Coronary Arteries

<h3>Background</h3> Coronary artery disease (CAD) is a major public and economic health problem. Coronary angiography is a gold standard for diagnosing CAD and is indicated in patients with 61–90% pre-test probability of the disease when the diagnosis cannot be made on clinical grounds alone and when revascularisation is being considered. The natural history of normal coronary angiogram is poorly understood. <h3>Objectives</h3> To evaluate the progression of disease in patients with normal coronary angiography and to assess the overall survival and event-free survival from acute myocardial infarction (MI) in these patients. <h3>Methods</h3> We interrogated the Central Cardiac Audit Database (CCAD) between November 2005 and December 2013 to identify patients with normal or ‘near-normal’ coronary angiography. Demographic, clinical and angiographic data was recorded. This database was linked with the Patient Episode Database for Wales (PEDW) and the datasets from the Office for National Statistics (for mortality) using the Secure Anonymised Information Linkage (SAIL) databank. This allowed for the extraction of information from all the sources above on the basis of the International Statistical Classification of Diseases (ICD-10) using the Structured Query Language (SQL). <h3>Results</h3> Out of over 20,000 patients undergoing coronary angiography between November 2005 and December 2013, 5032 patients had normal coronaries and minor CAD. Of 5032 patients, 136 underwent repeat angiography, with 131 (96.3%) and 5 (3.7%) patients having two and three repeat investigations respectively. Mean time between procedures was 3.3 (±1.82) years. Of those 136 patients, at the median follow up of 6.8 years, no change in disease progression was demonstrated in 108 (79.4%) patients on the follow up studies. In the remaining 28 (20.6%) patients, normal coronaries progressed to minor CAD. No patients progressed beyond minor CAD. Patients with normal coronaries had significant better survival than patients with minor CAD (p &lt; 0.05), but survival free from MI was &gt;99.5% in both groups at the median of 5 years follow up. (p = 0.09) <h3>Conclusions</h3> Normal coronary angiography and minor CAD is unlikely to progress to significant disease at 7 years and the incidence of MI in these patients is rare at 5 years. Therefore, repeating coronary angiography within at least 5 years is not indicated.

Long-Term Follow-Up of Elective Chronic Total Coronary Occlusion Angioplasty: Analysis From the U.K. Central Cardiac Audit Database

BackgroundChronic total occlusion (CTO) is common, being reported in 18% to 30% of patients undergoing coronary angiography. Percutaneous coronary intervention (PCI) is usually performed to relieve anginal symptoms, but data are emerging to suggest that there may also be a mortality benefit. ObjectivesThis study aimed to compare outcomes of patients with successful versus unsuccessful PCI to a CTO. MethodsWe analyzed the U.K. Central Cardiac Audit Database for all CTO PCI cases carried out in England and Wales between January 1, 2005, and December 31, 2009. Vital status in September 2010 was obtained from the Medical Research Information Service. ResultsA total of 13,443 patients (78.8% male) had a mean age of 63.5 years and underwent 14,439 CTO procedures. CTO PCI was successful in 10,199 cases (70.6%). During follow-up of 2.65 years (interquartile range: 1.59 to 3.83 years), successful PCI of at least 1 CTO was associated with improved survival (hazard ratio [HR]: 0.72; 95% CI: 0.62 to 0.83; p < 0.001). Complete revascularization was associated with improved survival compared with partial revascularization (HR: 0.70; 95% CI: 0.56 to 0.87; p = 0.002) or failed revascularization (HR: 0.61; 95% CI: 0.50 to 0.74; p < 0.001). ConclusionsSuccessful CTO PCI was associated with improved long-term survival. The improvement was greatest in patients when complete revascularization was achieved. The identity of the successfully treated occluded vessel was not associated with differences in outcome.

The Ross Operation in Children and Young Adults: 12-Year Results and Trends From the UK National Database.

To determine UK national trends and results of the Ross operation in relation to all aortic valve interventions. Examination of the UK Congenital Central Cardiac Audit Database for all aortic valve procedures performed between 2000 and 2011 in children (0-16 years) and young adults (16-30 years). A total of 2,206 aortic valve procedures were performed in children and 1,824 in young adults, the proportions in the two groups being: Ross operation (19% vs 15%, respectively), surgical valvoplasty (9.5% vs 4%), surgical valvotomy (9.5% vs 1%), aortic valve replacement (AVR; 11% vs 55%), aortic root replacement (4% vs 18%), and balloon valvoplasty (47% vs 7%). The 30-day and 1-year survival after Ross is 99.3% and 98.7%, respectively, in the last four years achieving 100%. In children, the proportion of balloon valvoplasty increased from an average of 43% in 2000 to 2006 to 53% in 2007 to 2011, whereas the Ross operation decreased from 22% to 16% (P < .001). In young adults, the figures are an increase from 49% to 58% for AVR compared to a decrease from 23% to 9% for Ross (P < .001). Our own single-center series of 91 patients also shows standard results for early- and long-term survival and freedom from reoperation, but gradually fewer Ross operations performed. The year-on-year changes show a significant decreasing trend locally and nationally. Despite an excellent track record, the Ross operation is performed less frequently in the United Kingdom. This report is a first step in comparing treatment modalities at national level.

Choice and Competition Between Adult Congenital Heart Disease Centers

Although concentrating adult congenital heart disease services at high-volume centers has been widely advocated, the potential beneficial effects of competition and patient choice have received relatively little attention. We aimed to assess the degree of patient choice and competition between adult congenital heart disease units and to investigate whether competition indices correlate with clinical quality or research output. Competition between the 10 major adult congenital heart disease units in England was evaluated based on the Herfindahl-Hirschman Index, representing the sum of squared market shares of individual units. In addition, to account for geography and feasible access, we calculated spatial indices of competition based on travel time by road. These indices were correlated with 30-day mortality postpulmonary valve replacement in adult patients (as obtained from the National Central Cardiac Audit Database) and the aggregate research impact factors of individual centers. On a national level, a high level of competition without obvious dominant players was found (Herfindahl-Hirschman Index between 0.107 and 0.013). When accounting for geography, however, important disparities in patient choice and competition faced by individual centers emerged. The degree of local competition was correlated significantly with clinical outcomes and research output. In contrast, no association between center volume and outcome could be established. Beyond the usual focus on concentrating services at high-volume centers, the potentially beneficial effects of competition should not be ignored. Therefore, policymakers should consider fostering a competitive environment for adult congenital heart disease centers or at least avoiding creating government-granted monopolies in the field.

Contemporary clinical outcomes of patients treated with or without rotational coronary atherectomy — An analysis of the UK central cardiac audit database

IntroductionRotational atherectomy (RA) is widely used for treating calcified coronary lesions. Clinical data however remain limited. MethodsWe assessed outcome and survival among patients undergoing percutaneous coronary intervention (PCI) with or without RA in the UK between September 2007 and March 2011. ResultsData from 221,669 percutaneous coronary intervention (PCI) procedures were analysed; 2152 patients (0.97%) underwent RA (RA+); the remainder underwent conventional PCI (RA−). RA+ patients were older (71.7±9.6 vs. 64.1±12.8year; p<0.001), and had a higher incidence of diabetes (26.4% vs. 18.0%; p<0.001), hypertension, (61.9% vs. 49.4%; p<0.001), peripheral vascular disease (9.9% vs. 4.2%, p<0.001), cerebrovascular disease (5.5% vs. 3.4%, p<0.001), renal impairment (3.4% vs. 1.5%, p<0.001) and poor left ventricular function (11.4% vs. 4.3%,p<0.001). Procedural success was lower among RA+ patients (90.3% vs 94.6%; p<0.001) and procedural complications were more frequent (9.7% vs 5.4%; p<0.001). After 2.4±1.2 years follow-up, unadjusted Cox proportional hazard modeling demonstrated poorer survival for RA+ patients (HR 2.21, 95%CI 1.97–2.49; p<0.0001). This disadvantage remained after adjustment for adverse variables (HR 1.26, 95%CI 1.11–1.44; p=0.0004) and following propensity analysis. There was evidence however of improved survival for RA+ patients with left main stem disease (HR 0.52, 95%CI 0.35–0.75, p<0.0001), and peripheral vascular disease (HR 0.65, 95%CI 0.43–0.98, p<0.0005). ConclusionsRotational atherectomy was undertaken in patients with higher pre-procedural risk. Medium term survival was worse among patients undergoing rotational atherectomy, and this survival disadvantage remained after correction for available adverse factors. Rotational atherectomy however remains clinically useful for patients with calcified coronary lesions.

A mortality risk model to adjust for case mix in UK paediatric cardiac surgery

BackgroundCongenital heart disease (CHD) is a relatively common disorder in childhood, affecting approximately 8–9 per 1000 live-born infants annually in the UK. CHD often involves serious abnormalities and is an important cause of childhood mortality, morbidity and disability. It is generally recognised that it is important and valuable to monitor outcomes in cardiac surgery and that, to do so fairly and effectively, one needs to risk stratify the case load of each unit. There is evidence that, since outcome monitoring in adult cardiac surgery became mandatory and routine, outcomes have improved. At present, no process for routinely monitoring risk-adjusted outcomes in paediatric cardiac surgery exists.ObjectivesTo establish whether or not a risk model can be developed that is fit for the purpose of adjusting for case mix severity to facilitate routine monitoring of outcomes for paediatric cardiac surgery in the UK and to assess whether or not and how diagnostic information can augment procedural information in risk adjustment.MethodsData from the Central Cardiac Audit Database (CCAD) for all cardiac surgery procedures, excluding reoperations within 30 days, performed in the UK for patients &lt; 16 years between 2000 and 2010 (38,597 patient episodes) were included: 70% for model development and 30% quarantined for validation. The outcome was 30-day survival, as supplied to CCAD through the Central Register of NHS patients (now the Medical Research Information Service). The CCAD defines 36 ‘specific procedures’. Nine of these were merged as a ‘low-volume specific procedure’ group (&lt; 90 cases each in the entire development set). Unassigned cases were grouped as ‘not a specific procedure’. Twenty-four ‘primary’ cardiac diagnoses and separately a categorisation of ‘univentricular’ status were defined using a hierarchical algorithm developed by the study team based on International Paediatric and Congenital Cardiac codes. Comorbidities considered included prematurity (&lt; 37 weeks' gestation), Down syndrome, constellations of features that constitute a recognised syndrome, congenital structural defects of organs other than the heart and acquired conditions. Other candidate variables included use of bypass and patient age, weight and sex. Data were analysed using logistic regression.ResultsIn the development set, there were 25,665 episodes that resulted in survival to 30 days, 693 episodes for which the vital status at 30 days was unknown and 854 episodes that resulted in death within 30 days in the development set (mortality 3.2% overall). The risk model developed includes the following factors: specific procedure, primary cardiac diagnosis grouped into low-, medium- and high-risk categories, univentricular heart status, age band (neonate, infant, child), continuous age, continuous weight, presence of a comorbidity other than Down syndrome and use of bypass. To account for decreasing mortality over time in the development set, a binary indicator for operations performed after 1 January 2007 is also included in the model. We were able to calculate a risk score for 95% of cases in the test set: weight was missing in 5% of cases. Data completeness improved over time. The proposed model discriminated well: the area under the receiver operating characteristic curve (AUC) for the test set was 0.77 (0.81 for post-2007 data). Removal of all but procedural information gave a reduced AUC of 0.72. The model performed well across the spectrum of predicted risk in the entire data set, but there was underestimation of mortality risk in the test set among neonates operated from 2007.LimitationsAn important limitation is that the model pertains to short-term 30-day outcomes (not long-term outcomes) and is designed for the purpose of routine monitoring for quality assurance rather than bedside-type predictions for individual patients. Over the recent period in the validation set (since 2007), the model was found to underestimate risk at the very high-risk end (&gt; 10% risk), in particular among neonates. This indicates that risk adjustment based on the current parameterisation of the model will potentially give an unduly negative impression of outcomes at those centres with a high proportion of high-risk cases. Finally, any risk model used for ongoing quality improvement initiatives needs to be regularly updated as data quality improves and clinical practice evolves.ConclusionsFor the first time diagnostic information has been successfully incorporated into risk adjustment for short-term outcomes in this patient group, which added discriminatory power. The risk model is fit for purpose, although the underestimation of risk in recent neonates is an important caveat. Several centres have expressed an interest in piloting the risk model and the accompanying monitoring tool. Future work includes developing software to generate variable life-adjusted display charts within units using the risk model; using the risk model to explore trends in case mix over time; and informing future work in evaluating long-term outcomes for children with CHD.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Use of diagnostic information submitted to the United Kingdom Central Cardiac Audit Database: development of categorisation and allocation algorithms

To categorise records according to primary cardiac diagnosis in the United Kingdom Central Cardiac Audit Database in order to add this information to a risk adjustment model for paediatric cardiac surgery. Codes from the International Paediatric Congenital Cardiac Code were mapped to recognisable primary cardiac diagnosis groupings, allocated using a hierarchy and less refined diagnosis groups, based on the number of functional ventricles and presence of aortic obstruction. A National Clinical Audit Database. Patients Children undergoing cardiac interventions: the proportions for each diagnosis scheme are presented for 13,551 first patient surgical episodes since 2004. In Scheme 1, the most prevalent diagnoses nationally were ventricular septal defect (13%), patent ductus arteriosus (10.4%), and tetralogy of Fallot (9.5%). In Scheme 2, the prevalence of a biventricular heart without aortic obstruction was 64.2% and with aortic obstruction was 14.1%; the prevalence of a functionally univentricular heart without aortic obstruction was 4.3% and with aortic obstruction was 4.7%; the prevalence of unknown (ambiguous) number of ventricles was 8.4%; and the prevalence of acquired heart disease only was 2.2%. Diagnostic groups added to procedural information: of the 17% of all operations classed as "not a specific procedure", 97.1% had a diagnosis identified in Scheme 1 and 97.2% in Scheme 2. Diagnostic information adds to surgical procedural data when the complexity of case mix is analysed in a national database. These diagnostic categorisation schemes may be used for future investigation of the frequency of conditions and evaluation of long-term outcome over a series of procedures.

OP71 Discriminating Clinical Outcome Models May Drift Unacceptably: Example of Cardiac Surgery Mortality

BackgroundClinical prediction models are used for different purposes, but purpose-specific validation is not usually carried out. The ability of a model to discriminate between true positives and false positives has...

Development of a diagnosis- and procedure-based risk model for 30-day outcome after pediatric cardiac surgery

The study objective was to develop a risk model incorporating diagnostic information to adjust for case-mix severity during routine monitoring of outcomes for pediatric cardiac surgery. Data from the Central Cardiac Audit Database for all pediatric cardiac surgery procedures performed in the United Kingdom between 2000 and 2010 were included: 70% for model development and 30% for validation. Units of analysis were 30-day episodes after the first surgical procedure. We used logistic regression for 30-day mortality. Risk factors considered included procedural information based on Central Cardiac Audit Database "specific procedures," diagnostic information defined by 24 "primary" cardiac diagnoses and "univentricular" status, and other patient characteristics. Of the 27,140 30-day episodes in the development set, 25,613 were survivals, 834 were deaths, and 693 were of unknown status (mortality, 3.2%). The risk model includes procedure, cardiac diagnosis, univentricular status, age band (neonate, infant, child), continuous age, continuous weight, presence of non-Down syndrome comorbidity, bypass, and year of operation 2007 or later (because of decreasing mortality). A risk score was calculated for 95% of cases in the validation set (weight missing in 5%). The model discriminated well; the C-index for validation set was 0.77 (0.81 for post-2007 data). Removal of all but procedural information gave a reduced C-index of 0.72. The model performed well across the spectrum of predicted risk, but there was evidence of underestimation of mortality risk in neonates undergoing operation from 2007. The risk model performs well. Diagnostic information added useful discriminatory power. A future application is risk adjustment during routine monitoring of outcomes in the United Kingdom to assist quality assurance.

Editorial Comment: Re: Evaluation of the Aristotle complexity models in adult patients with congenital heart disease

With an increasing number of adult congenital heart (GUCH) surgery patients, a suitable risk stratification model should be available for outcome evaluation, but it would tend to be incomplete due to the very heterogeneous and often complex patient groups with multiple measured as well as unmeasured risk factors. The paper by Horer et al .[ 1] contained valuable data concerning the procedural factors associated with early death and the complications following GUCH surgery. In addition to identifying the associations between early death and procedural factors, the authors looked for associations between items contained within the Aristotle comprehensive complexity (ACC) score. They commented that some of the items in the ACC ‘did not achieve statistical significance’ in terms of an association with early death, putting this down to the low prevalence of these factors within the dataset or to the small number of deaths. However, the lack of inclusion of complex patients who were not offered high-risk surgical options might skew the analysis. A third possibility is the lack of an association between all items in the ACC (developed primarily for paediatric cardiac patients) and early death in adult patients. Having found that the ACC score had a fairly good discrimination in the GUCH patient population, the authors discussed the appropriateness of the ACC for predicting outcome. Some care is required here. The authors talked of predictive accuracy, but no assessment of the accuracy of ACC was presented. To be very clear, discrimination (the extent to which a model can discern between low-risk and high-risk cases) is not a measure of predictive accuracy for individual patients or patient sub-groups. As we may remember, the Aristotle score was not created to predict mortality [2]. The score would give an average value of mortality for a given paediatric cardiac procedure which every centre or surgeon could use for performance evaluation. The authors also commented on the potential utility of adding diagnostic information such as ‘univentricular status’ to augment procedural information in risk stratification schemes such as the ACC. We certainly see the value in this and have recently completed an analysis of the UK Central Cardiac Audit Database (CCAD) to develop a risk model for paediatric cardiac surgery that incorporates such information on diagnosis [3]. In risk modelling for paediatric cardiac surgery, the trend is towards systems based on the analysis of data rather than expert opinion [4]. Nevertheless, the authors’ vision of their work stimulating the collection and publication of larger series of data is one we fully endorse.

Subtle changes in renal function are associated with differences in late survival following adult cardiac surgery

To determine the predictors of post-operative renal function following adult cardiac surgery, and to assess the influence of this on late survival. Prospectively collected data were analysed on 8032 patients who underwent coronary artery bypass grafting, valve surgery or combined procedures from 1 January 1998 until 31 December 2008, who did not require preoperative renal replacement therapy. The estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease formula accounting for ethnicity pre-operatively, post-operatively on the fourth post-operative day, and the post-operative nadir based upon the peak post-operative creatinine within 30 days of surgery. Late survival data were obtained from the UK Central Cardiac Audit Database (CCAD). Appropriate frailty analyses were conducted in R and model fit was compared using Aikaike's Information Criterion. Initial analysis intended to determine predictors of post-operative renal function including pre-operative eGFR, EuroSCORE and surgical procedure including the operative procedure and bypass time. Further analysis examined its influence on late survival. Median follow-up was 72 months (IQR 48-105) during which there were 904 late deaths. The most powerful predictor of the day 4 eGFR was the pre-operative eGFR but other factors contributed including increasing EuroSCORE and bypass time. The pre-operative eGFR was shown to be a strong and independent predictor of late outcome (P = 0.0001, HR 0.497 95%CI 0.434-564); however, model fit was significantly improved using the day 4 eGFR (P = 0.0001, HR 0.43 95%CI 0.385-0.482). No specific change in individual renal function was identified as a predictor of adverse late survival, and neither the pre-operative nor day 4 eGFR was predictive of the nadir of renal function. Subtle early changes in renal function at the time of surgery are powerful predictors of adverse late outcome and can be predicted by pre-operative renal function.

163 The United Kingdom transcatheter aortic valve registry - outcomes to December 2009 and update

<h3>Introduction</h3> The United Kingdom Transcatheter Aortic Valve (TAVI) Registry was established to define the clinical and procedural details of all patients being treated by TAVI, regardless of access route or technology used, and to assess their outcomes. The registry has captured all cases in England and Wales. <h3>Methods</h3> For every TAVI performed, all centres complete an agreed dataset. The data are encrypted and sent electronically to servers at the Central Cardiac Audit Database (CCAD) for analysis. A unique patient identifier (the NHS number) is used to link with the NHS Central Register to track mortality. This analysis is based on all procedures performed up to 31st December 2009. <h3>Results</h3> 25 centres in England and Wales performed a total of 877 procedures in 870 patients; 66 in 2007, 273 in 2008 and 538 in 2009. Median number of cases per centre was 24. Median (IQR) age was 82 (78–87) yrs. 52% were male, and mean logistic Euroscore (LES) was 22.2%. 68% were transfemoral, the remainder being mainly transapical. 90% of CoreValve implants and 46% of Edwards used a transfemoral approach. Patients needing a transapical route had more comorbid conditions than those treated by a transfemoral route (LES 25.2% vs 20.9%). Mortality tracking was successful in 100% of patients. Survival at 30 days was 93.1%, 78.9% at 1 year (443 at risk) and 72.3% at 2 years (114 at risk). Survival was significantly poorer in those needing non-transfemoral approaches (1 year survival 73.5% vs 81.4%). Survival was also poorer in those with poorer LV ejection fraction, with moderate or severe post procedural aortic regurgitation and with a LES&gt;40. Survival was not associated with age, NYHA class, or the presence of concomitant coronary artery disease, and not different between those with a LES&lt;21 compared with LES 21–40. There was also no difference in survival between patients treated with CoreValve or Edwards technologies, or between proctored and non proctored cases. There was a significant improvement in survival over the 3 years of the registry, and a change in demographics with the proportion of patients with prior CABG rising from 16.4% in 2007 to 29.9% in 2009. The total number of cases in the UK TAVI registry has risen to 1490 as of 29 Nov 2010. More details of the 2010 cohort will be available at the time of presentation (Abstract 163 figure 1). <h3>Conclusions</h3> The UK TAVI Registry has successfully captured the entire TAVI activity of England and Wales incorporating the learning curves of every centre. Outcomes following TAVI are excellent in a high risk patient population. Outcomes are better in the population who are suitable for a transfemoral approach (with less comorbidity) than those treated with the transapical approach. These data suggest that careful proctoring allows the introduction of a new treatment method without an adverse effect on patient outcome, and we have demonstrated no systematic difference in outcome between the two commercially available technologies.

097 Surgical aortic valve replacement in high risk octogenerians vs transcatheter aortic valve implantation

<h3>Introduction</h3> Transcatheter aortic valve implantation (TAVI) is considered to subject less immediate procedural risk than surgical aortic valve replacement (AVR) in high risk elderly patients. Therefore high risk Octogenarians are now being considered for TAVI in preference to AVR. The evidence for this strategy and methods for patient selection are not established. The use of the Logistic Euroscore (LES) in this context has been questioned. We have prospectively compared our TAVI patient characteristics and outcomes with retrospective analysis of high risk Octogenarians who underwent AVR. <h3>Methods</h3> The records of 273 patients aged 80 and over who underwent AVR at the Bristol Heart Institute between 1996 – 2008 were analysed. Patients with a Logistic Euroscore of 15 and above were identified as high risk including those that had concomitant bypass grafting. All TAVI procedures were performed with the Medtronic Corevalve system between Jan 2008 and Oct 2009. Data was collected prospectively as per the Central Cardiac Audit Database (CCAD) TAVI dataset and all patients were included for comparison. <h3>Results</h3> Abstract 097 Table 1 80 AVR patients and 41 TAVI procedures were identified. The median LES was 20.7 (average age 83.5, male 51.2%) and 16.4 (average age 83.9, male 48%) respectively. More TAVI patients had previous cardiac surgery (19.5% vs. 15%). The postoperative stroke rate was 4.8% in the TAVI group vs. 6% for AVR. The rate of pacemaker implantation was greater in the TAVI group (24.4% vs. 11%). Mortality rates were significantly lower in the TAVI group (30 day mortality 2.4% vs. 14%, 90 day mortality 2.4% vs. 19%). There was a shorter median postoperative recovery for the TAVI patients prior to discharge (7 days vs. 11 days) and more patients were discharged directly home to indepedence (90.2% vs. 44%). <h3>Conclusion</h3> In this historical, clinically selected group of Octogenarians the LES appears to correlate well with subsequent surgical risk of AVR. In our current cohort of high risk elderly patients undergoing TAVI there are comparatively lower mortality rates, shorter recovery times and earlier discharges home to independence. However, Corevalve patients are requiring more post-procedure permanent pacemakers. In elderly patients with symptomatic aortic stenosis it is appropriate to use LES as a factor to identify those who are likely to have a better outcome with TAVI compared to traditional AVR.

Cardiac registers: the adult cardiac surgery register

Aims of the scts adult cardiac surgery databaseTo measure the quality of care of adult cardiac surgery in GB and Ireland and provide information for quality improvement and research.Quality of...

Retrospective study of neonatal ligation during 2002 in the United Kingdom of persistently patent arterial ducts

Our aim was to ascertain the number of neonatal ligations of the patent arterial duct performed in the United Kingdom in 2002, and to determine the survival of the neonates after 30 days. A postal questionnaire was sent to the lead paediatician in every hospital in the United Kingdom possessing a special care or neonatal intensive care unit, requesting information on the number of babies referred for ligation of a persistently patent arterial duct. A separate questionnaire was sent to the paediatric cardiothoracic centres for information on babies who underwent the procedure. Cross-referencing the responses identified neonates who were not reported in the separate questionnaires. Additional information was requested from the central cardiac audit database. The overall response rate was 74%, with 172 forms returned of 234 distributed. From the combined responses, we ascertained that ligation has been performed in 244, with survival at 30 days of 94%. There were problems in identifying some babies because of the incomplete nature of the information received from both referring hospitals and specialist cardiothoracic centres. We would recommend a joint prospective study is conducted by paediatricians and paediatric cardiologists to determine the short and long term outcomes in this population known to be at high risk.

The Ethics of Transparency: Publication of Cardiothoracic Surgical Outcomes in the Lay Press

he Congenital Heart Institute of Florida, Division of Thoracic and Cardiovascular Surgery, All Children’s Hospital and Children’s ospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida, Saint Petersburg and ampa, Florida; Section of Thoracic Surgery at University of Alabama at Birmingham, Division of CardioThoracic Surgery, epartment of Surgery, Birmingham, Alabama; Division of Cardiothoracic Surgery, Department of Surgery, Institute of Human alues in Health Care, Medical University of South Carolina, Charleston, South Carolina

Verification of data in congenital cardiac surgery

Accurate, complete data is now the expectation of patients, families, payers, government, and even media. It has become an obligation of those practising congenital cardiac surgery. Appropriately, major professional organizations worldwide are assuming responsibility for the data quality in their respective registry databases. The purpose of this article is to review the current strategies used for verification of the data in the congenital databases of The Society of Thoracic Surgeons, The European Association for Cardio-Thoracic Surgery, and The United Kingdom Central Cardiac Audit Database. Because the results of the initial efforts to verify data in the congenital databases of the United Kingdom and Europe have been previously published, this article provides a more detailed look at the current efforts in North America, which prior to this article have not been published. The discussion and presentation of the strategy for the verification of data in the congenital heart surgery database of The Society of Thoracic Surgeons is then followed by a review of the strategies utilized in the United Kingdom and Europe. The ultimate goal of sharing the information in this article is to provide information to the participants in the databases that track the outcomes of patients with congenitally malformed hearts. This information should help to improve the quality of the data in all of our databases, and therefore increase the utility of these databases to function as a tool to optimise the management strategies provided to our patients. The need for accurate, complete and high quality Congenital Heart Surgery outcome data has never been more pressing. The public interest in medical outcomes is at an all time high and "pay for performance" is looming on the horizon. Information found in administrative databases is not risk or complexity adjusted, notoriously inaccurate, and far too imprecise to evaluate performance adequately in congenital cardiac surgery. The Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery databases contain the elements needed for assessment of quality of care provided that a mechanism exists within these organizations to guarantee the completeness and accuracy of the data. The Central Cardiac Audit Database in the United Kingdom has an advantage in this endeavour with the ability to track and verify mortality independently, through their National Health Service. A combination of site visits with "Source Data Verification", in other words, verification of the data at the primary source of the data, and external verification of the data from independent databases or registries, such as governmental death registries, may ultimately be required to allow for optimal verification of data. Further research in the area of verification of data is also necessary. Data must be verified for both completeness and accuracy.

Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease – the perspective of cardiac surgery

This review includes a brief discussion, from the perspective of cardiac surgeons, of the rationale for creation and maintenance of multi-institutional databases of outcomes of congenital heart surgery, together with a history of the evolution of such databases, a description of the current state of the art, and a discussion of areas for improvement and future expansion of the concept. Five fundamental areas are reviewed: nomenclature, mechanism of data collection and storage, mechanisms for the evaluation and comparison of the complexity of operations and stratification of risk, mechanisms to ensure the completeness and accuracy of the data, and mechanisms for expansion of the current capabilities of databases to include comparison and sharing of data between medical subspecialties. This review briefly describes several European and North American initiatives related to databases for pediatric and congenital cardiac surgery the Congenital Database of The European Association for Cardio-Thoracic Surgery, the Congenital Database of The Society of Thoracic Surgeons, the Pediatric Cardiac Care Consortium, and the Central Cardiac Audit Database in the United Kingdom. Potential means of approaching the ultimate goal of acquisition of long-term follow-up data, and input of this data over the life of the patient, are also considered.