2021 Cardiac Surgery Annual Report

Annual Report 2021

Cardiac Surgery

SERT Institute

Contents

Cardiac Surgery Royal North Shore Hospital

Wide distribution of this document is encouraged. This work is copyrighted. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the Cardiothoracic Surgery Department at Royal North Shore Hospital. Published November 2022

Foreword

Snapshot

Executive summary

2021 Data summary

Yearly comparisons

Demographics

Overall surgical activity

Length of stay

Post-operative/morbidity/mortality indicators

Isolated CABG analysis

Isolated valve analysis

Aortic surgery

Acknowledgements

Glossary

Appendix

Foreword

Cardiac Surgery 2021 Snapshot

352 175 49% 67

I am pleased to present the Cardiac Surgery Annual Report for 2021. This is the second such report that has been produced by the Surgical Education Research & Training (SERT) Institute and the Data Analysis and Surgical Outcomes (DASO) Unit for Royal North Shore Hospital (RNSH). In 2021, our delivery of cardiac surgical cases was significantly disrupted by the ongoing COVID-19 pandemic which saw restrictions on elective surgery. The impact on our department and our hospital has been unprecedented in the history of modern cardiac surgery. However, this impact was somewhat alleviated by using services generously provided by North Shore Private Hospital. The small number of cases performed in the private hospital are not included in this report. The quality of the work within our department at RNSH remains high and is reflected in the excellent outcomes published here. None of this is possible without the dedication and commitment of our theatre, intensive care unit (ICU) and ward staff, who contribute so much to these outcomes. In particular, I would like to acknowledge the outstanding work of all the ICU nurses at RNSH. They, more than any group, have felt the impact of COVID-19 on their working conditions. It is widely recognised that one of the best tools available to improve patient outcomes and encourage excellence in surgery is to ensure data is collected, analysed and reported. Since being introduced at the RNSH Cardiothoracic Surgery Department in 2019, the Research Electronic Data Capture (REDCap) platform has resulted in significant improvements in data management, data validity, reporting and timely follow-up with patients, as evident in our unit-specific Key Performance

Indicators (KPIs).

Total cardiac surgery cases RNSH has been contributing to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) cardiac surgery database program since 2009 and in 2021, a total of 352 cases performed at RNSH met the ANZSCTS cardiac surgery database inclusion criteria. Emergency procedures performed In 2021, the team performed a total of 175 urgent/emergency procedures, accounting for just under 50% of the total workload.

In 2021, the database was again managed by our dedicated Data Manager (DM), Sharon Lum. The data is entered by the cardiothoracic surgery registrars to ensure clinical accuracy and to enable a 30-day patient follow-up by the department Clinical Nurse Specialist (CNS). The establishment of the SERT Institute and DASO Unit within the Division of Surgery and Anaesthesia at RNSH has continued to give surgeons ownership, responsibility, and the ability to use data to improve services. I commend this report to you and would like to thank our registrars, Susan Campbell (CNS) and Sharon Lum (DM), for their contributions.

Coronary artery bypass grafts (CABG) CABG surgery is the Australian and New Zealand standard procedure for benchmarking against all cardiothoracic surgery units. In 2021, isolated CABG surgery continued to be the highest volume cardiac procedure type at RNSH with 171 cases (49%).

Elective cardiac surgery cases performed at North Shore Private Hospital due to COVID-19

Dr Michael Harden Head of Cardiothoracic Surgery, RNSH

A total of 67 RNSH elective cardiac surgery cases took place at North Shore Private Hospital in 2021 due to the COVID-19 pandemic.

Cardiac Surgery Annual Report 2021

Executive Summary

2021 Data Summary

This report provides an overview of the RNSH Cardiac Surgery Department’s activity and achievements throughout 2021. The 2021 year was a mixed period for the department, particularly with the COVID-19 Delta outbreak halting elective surgery in early August. This resulted in 67 elective cardiac surgery patients being transferred to North Shore Private Hospital for surgery. The data collected and information available for this transferred patient cohort was limited and, therefore, has not been included in this report. The majority (77.2%) of RNSH cardiac surgery patients treated during the 12-month period were from either the Northern Sydney Local Health District (NSLHD) (31.2%) or Central Coast Local Health District (CCLHD) (46.0%). The remaining 22.8% of patients came from various locations across NSW, and interstate. Males aged between 60 and 79 years were the largest cohort of patients treated. In total, the department performed 352 cardiac surgery cases at RNSH. Of these, 49.7% were elective, 40.6% were urgent, 8.8% were emergency, and 0.9% were salvage cases. Isolated coronary artery bypass graft (CABG) surgery continued to be the most commonly performed procedure with 171 cases (48.6%), followed by 57 isolated heart valve repair/replacement procedures (16.2%), and 28 combination CABG/valve procedures (8.0%). The proportion of re-do operations was 6.8%, which is consistent with past reporting periods. The year saw the promising option of robotic cardiac and thoracic surgery being made available to RNSH patients at North Shore Private Hospital. The majority of patients underwent coronary artery bypass using the Left Internal Mammary Artery (LIMA). Thymectomy cases were also performed. A highlight for the department this year was Dr David Marshman being named an inaugural recipient of the Ray Hollings Surgical Excellence Award, which aims to encourage and support consultant surgeons to undertake quality improvement projects that support innovation and improve service delivery and patient care. The quality

improvement project application that Dr Marshman submitted on behalf of the Cardiothoracic Surgery Department was a study of perioperative blood product usage in RNSH cardiothoracic surgery. Dr Marshman received $4,600 in funding from the award, which will be used to support the project. In 2020, the department received two years’ sponsorship funding to establish a Cardiac Implantable Electronic Device (CIED) database. We continued work on this in 2021 and have now instituted a prospective Cardiac Electronic Devices (CIED) database using the Research Electronic Data Capture (REDCap) platform. In 2021, the RNSH Cardiac Surgery Department also continued contributing to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Database Program. The aims of this program are to standardise surgical and clinical data collection for cardiac surgery cases and to report on performance standards at the individual, unit, state and national level. While this report focuses on cardiac surgery provided at RNSH, the unit also provides a comprehensive thoracic surgery service including advanced surgical resection in thoracic oncology and managing complex thoracic infections and other pathologies. RNSH thoracic surgery currently contributes to trials in the management of early stage non-small cell lung cancer. Our new thoracic surgical database is in its inception, and will become established in 2022. The team of dedicated staff are very proud to present the data within this report, which demonstrates the high quality cardiac surgery service being provided by the RNSH Cardiothoracic Surgery Department to the local community and beyond. Despite a challenging year due to COVID-19, the department continued to remain engaged and productive. We look forward to continuing to lead the way in providing cardiac surgery in 2022.

Cardiac Surgery Annual Report 2021

Yearly comparisons

Demographics

Gender

COVID-19 continued to have an impact on the cardiac patient throughput at RNSH in 2021, as elective surgery was reduced. This resulted in 67 elective cardiac surgery patients being transferred to North Shore Private Hospital for surgery. These patients are not included in this report.

A total of 352 patients had a cardiac procedure at RNSH in 2021. The majority of cardiac cases were performed on male patients (n = 239) compared to female patients (n = 113) .

Figure 1 compares the number of cases for each procedure type in 2020 and 2021.

Male

113 Patients Female

239 Patients

67.9% Percentage of Total

32.1% Percentage of Total

Age

Figure 2 shows the overall age distribution (2A) and by gender (2B). Approximately 70.7% of cardiac surgery patients were aged 60 years or over at the time of surgery. Patients aged below 40 years represented the smallest proportion (2.0%) of cardiac surgery patients in 2021, which is consistent with national data.

Figure 1. Yearly comparisons for procedure type (not including public in-private cases)

Figure 2. Age Distribution. (A) Overall age distribution. (B) Age distribution split by gender.

Cardiac Surgery Annual Report 2021

Place of residence Many patients are referred from the Central Coast Local Health District (CCLHD) and are operated on by one of our six highly-skilled cardiothoracic surgeons.

Age Brackets

% of total

<40

2.0

Table 2 provides an overview of all patients presenting for cardiac surgery at RNSH in 2021 by place of residence.

40-49

8.0

The majority of patient referrals (77.2%) were from two NSW Health Local Health Districts (LHD): • 46.0% Central Coast • 31.2% Northern Sydney

50-59

19.3

60-69

108

30.7

70-79

106

30.1

The remaining 22.8% of patient referrals were from across NSW, ACT, QLD and TAS.

>79

9.9

Local Health District

% of total

Central Coast

162

46.0

Table 1. Age brackets

Northern Sydney

110

31.2

Aboriginal & Torres Strait Islander status In 2021, 16 patients (4.5%) identified as being either Aboriginal or Torres Strait Islander. The ratio of female to male patients in this group was 7:9.

Hunter New England

7.4

Western Sydney

3.7

Western NSW

2.6

The breakdown by case type for these patients was • 8 (50.0%) isolated CABG cases • 3 (18.8%) isolated valve cases • 1 (6.2%) combined valve and CABG case • 4 (25.0%) other cardiac cases

Sydney

2.3

South Western Sydney

2.0

Nepean Blue Mountains

1.1

Note: the Aboriginal and Torres Strait Islander people represent approximately 0.4% of the total NSLHD population (Aboriginal and Torres Strait Islander Health Services Plan 2017-2022, NSLHD 2017) .

South Eastern Sydney

0.9

Australian Capital Territory

0.6

Illawarra Shoalhaven

0.6

Queensland

0.6

Mid North Coast

0.3

Murrumbidgee

0.3

Northern NSW

0.3

Tasmania

0.3

Table 2. Patients in each LHD

Cardiac Surgery Annual Report 2021

Overall surgical activity

Figure 3 shows the geographic distribution of patients presenting to RNSH for cardiac surgery across NSW by Local Health District.

Cases by procedure type Table 3 and Figure 4 show the breakdown of cardiac surgery cases by procedure type at RNSH. A total of 48.6% of all major cardiac surgery cases were isolated coronary artery bypass grafting (CABG) procedures. This is the commonly performed procedure across the majority of hospitals that provide cardiac surgery, and is a key procedure used for national benchmarking standards.

Procedure type

% of total

Isolated CABG

171

48.6

Isolated valve

16.2

Valve + CABG

8.0

Aortic (± CABG/valve)

12.8

Other (± CABG/valve)

14.5

Table 3. Number of cases by procedure type (includes redo operations)

Figure 3. Geographic distribution of patients across NSW and the greater Sydney area

Figure 4. Number of cases by procedure type (includes redo operations)

Cardiac Surgery Annual Report 2021

Cases by procedure type and clinical status

The remaining cardiac surgery cases are divided into four other major subgroups – isolated valve, isolated valve combined with CABG, aortic procedures and ‘other cardiac’. Note: the ‘other cardiac’ procedure group included two transcatheter aortic valve implantation (TAVI) procedures performed by a cardiothoracic surgeon in the operating theatres. These cases were also included in the data set submitted to the ANZSCTS Cardiac Surgery Database Program for 2021. Breakdown by procedure type and clinical status Table 4 and Figure 5 show the breakdown of all cardiac surgery cases by procedure type and clinical status; grouped as elective and urgent/emergency. In 2021: • 49.7% of RNSH cardiac surgery cases were classified as elective surgery operations • 40.6% of RNSH cardiac surgery cases were classified as urgent surgery operations • 8.8% of RNSH cardiac surgery cases were classified as emergency surgery operations • 0.9% of RNSH cardiac surgery cases were classified as salvage surgery operations

Procedure type

Elective (% of total)

Urgent (% of total)

Emergency (% of total)

Salvage (% of total)

Isolated CABG

72 (20.5)

90 (25.6)

8 (2.3)

1 (0.3)

Isolated valve

40 (11.4)

16 (4.5)

1 (0.3)

0 (0.0)

Valve + CABG

18 (5.1)

10 (2.8)

0 (0.0)

Aortic (± CABG/valve)

17 (4.8)

7 (2.0)

19 (5.4)

2 (0.6)

Figure 5. Number of cases by procedure type and clinical status (includes redo operations)

Other (± CABG/valve)

28 (8.0)

20 (5.7)

3 (0.9)

0 (0.0)

Table 4. Number of cases by clinical status (further expanded) and procedure type

Cardiac Surgery Annual Report 2021

Proportion of redo operations Re-operations are relatively uncommon after a previous cardiac surgery procedure; however, for a small percentage of patients this is required. These procedures are classified in this report as a “re-do” operation and are defined as cases where a patient has returned or presented to RNSH for a repeat cardiac surgery procedure (regardless of where the first procedure was performed). The 352 RNSH cardiac surgery cases reported for 2021 included 24 re-do operations, accounting for 6.8% of total cardiac surgery cases (Figure 6). In previous analyses of RNSH cardiac data, re-do surgery was approximately 8–10% of all cases. The proportion of re-do operations in 2021 has remained relatively constant when compared to previous reporting periods before 2009.

Blood loss and transfusion The ANZSCTS Program reports on the cumulative blood products given within the intra-operative and postoperative period.

In 2021, 45.7% of all cardiac surgery cases received a blood product intra-operatively and/or post-operatively.

Table 5 and Figure 7 show the proportion of transfused cardiac cases by procedure type.

Procedure type

Transfused

Transfusion rate (%)

All

161

352 45.7

Isolated CABG

171

36.8

Isolated valve

57 45.6

Valve + CABG

28 57.1

Aortic (± CABG/valve)

45 82.2

Other (± CABG/valve)

37.3

Table 5. Transfusion rate for each procedure type. Transfusion rate is calculated by dividing the number of transfused cases by the number of cases in each procedure type (n).

Aortic (± CABG/valve) surgery cases had the highest transfusion rate, with 82.2% receiving a blood product intra-operatively and/or postoperatively. In comparison, isolated CABG cases had the lowest transfusion rate for at 36.8%.

Figure 6. Proportion of redo cases

Figure 7. Transfusion rate for each procedure type

Cardiac Surgery Annual Report 2021

Length of Stay (LOS)

Transfusion rate by procedure type and blood product type Data is collected for each specific blood product – red blood cells (RBC), platelets, cryoprecipitate (cryo) and fresh frozen plasma (FFP). Table 6 shows the transfusion rate for each blood product by procedure type in 2021.

Procedure type

RBC n (%)

Platelets n (%)

Cryo n (%)

FFP n (%)

Isolated CABG

171

55 (32.2)

21 (12.3)

30 (17.5)

10 (5.8)

Isolated valve

23 (40.4)

10 (17.5)

12 (21.1)

7 (12.3)

The length of stay (LOS) for each case has been measured and reported using the following time frames.

Valve + CABG

15 (53.6)

6 (21.4)

9 (32.1)

2 (7.1)

• Total LOS = from hospital admission to hospital discharge • Pre-operative LOS = from hospital admission to date of operation. This includes only the time before surgery at RNSH, and does not include inpatient waiting time at outside hospitals • Post-operative ICU LOS = from date of operation to end ICU care • Post-operative LOS = from date of operation to discharge from ICU

Aortic (± CABG/valve)

31 (68.9)

26 (57.8)

32 (71.1)

18 (40.0)

Other (± CABG/valve)

16 (31.4)

14 (27.5)

11 (21.6)

7 (13.7)

The different components of length of stay are presented in Figure 8.

Table 6. Transfusion rate for each blood product by procedure type

Table 7 shows the median and inter-quartile ranges (IQR) of the amounts used for each blood product in 2021.

Procedure type

RBC median units (IQR)

Platelets median units (IQR)

Cryo median units (IQR)

FFP median units (IQR)

Isolated CABG

2 (1, 4)

1 (0, 5)

10 (9, 17)

0 (0, 1.5)

Isolated valve

4 (1.5, 4)

5 (1, 10)

10 (10, 10)

1 (0, 3)

Valve + CABG

4 (2, 5.5)

1.5 (0, 2.8)

10 (8.5, 13)

0 (0, 0)

Aortic (± CABG/valve)

4 (2, 6.5)

5 (1, 10)

20 (10, 30)

2 (0, 4)

Other (± CABG/valve)

3.5 (2, 9)

10 (5, 13.8)

10 (8.2, 17.5)

0.5 (0, 4)

Table 7. Blood product usage by procedure type

Figure 8. Length of stay diagram

Cardiac Surgery Annual Report 2021

Length of stay by clinical status Table 8 and Figure 9 show the distribution of each LOS type by clinical status.

Total LOS by procedure type

The median total length of stay for all cardiac surgery cases in 2021 was 13 days (IQR: 9–20 days).

The difference in pre-operative LOS between elective and urgent/emergent cases is expected due to the nature of these admissions. Elective cases are usually admitted the day before surgery for final pre-operative assessment. There is also variation in pre-operative LOS within the urgent/emergent category as some patients are dependent on transfer from outside hospitals and bed availability, and patients require completion of pre-operative investigations and workup.

Total length of stay

When examining the total length of stay by procedure type: • Aortic (± CABG/valve) surgery cases had the highest median total LOS of 16 days (IQR: 13–25 days) (Figure 10) • Isolated CABG cases had the lowest total LOS of 12 days (IQR: 8–18 days) (Figure 10)

Clinical status

Elective median days (IQR)

Urgent/emergency median days (IQR)

LOS type

Pre-operative

1 (1, 2)

4 (2, 7)

Post-operative ICU

2.9 (2, 4)

3 (2, 4.7)

Post-operative

8 (7, 12.5)

10 (7, 17)

Total

11 (8, 16.5)

16 (11, 22)

Table 8. Breakdown of LOS by LOS type and clinical status

Figure 10. Distribution of Total LOS by procedure type

Total LOS by procedure type

The median total length of stay for all cardiac surgery cases in 2021 was 13 days (IQR: 9-20 days).

Figure 9. Distribution of LOS by LOS type and clinical status

Figure 11. Distribution of pre-operative LOS by procedure type

Cardiac Surgery Annual Report 2021

Post-operative/ morbidity/ mortality indicators

Post-operative ICU LOS by procedure type In 2021, the median LOS in the ICU post-operatively for all cardiac surgery cases was three days (IQR: 2–4 days) (Figure 12).

Mortality

Table 9 details each mortality type by clinical status and procedure types. The values are expressed as frequencies and percentages, with percentages calculated by dividing the number of mortalities by the number of cases in each procedure type (n) .

Procedure type

In-hospital mortality n (% of procedure type)

Post-discharge mortality within 30 days n (% of procedure type)

Total mortality n (% of procedure type)

All

352

14 (4.0)

0 (0)

14 (4.0)

Figure 12. Distribution of ICU LOS by procedure type

Isolated CABG

171

2 (1.2)

0 (0)

2 (1.2)

Post-operative LOS by procedure type In 2021, the median LOS for all cardiac surgery cases post-operatively, including the ICU stay and time on ward 6B, was nine days (IQR: 7–14 days) (Figure 13).

Isolated valve

2 (3.5)

0 (0)

2 (3.5)

Valve + CABG

1 (3.6)

0 (0)

1 (3.6)

Aortic (± CABG/valve)

4 (8.9)

0 (0)

4 (8.9)

Other (± CABG/valve)

5 (9.8)

0 (0)

5 (9.8)

Table 9. Mortality by procedure types

Breakdown of deaths

Table 10 provides a breakdown of the primary cause of mortality. The most common cause was multisystem failure.

Mortality primary cause

n (%)

Multisystem failure

6 (42.9)

Infection

2 (14.3)

Neurologic event

2 (14.3)

Respiratory failure

2 (14.3)

Figure 13. Distribution of post-operative LOS by procedure type

Cardiac

1 (7.1)

Renal failure

1 (7.1)

Table 10. Breakdown of primary cause of mortality

Cardiac Surgery Annual Report 2021

Actual vs predicted risk mortality Table 11 and Figure 14 present the distribution and numerical comparison of actual mortality against the mortality risk scores at 30-days post-operation. Actual mortality is calculated by the number of mortalities observed in each procedure type divided by the number of cases in each procedure type. The actual mortality rate for cardiac cases in 2021 was within acceptable parameters for the MultiRisk and EuroSCORE II scoring systems. The large difference between the predicted and observed mortalities in the aortic (± CABG/valve) category is due to the two risk scoring systems used, which underestimate risk in aortic dissection patients (that make up 55.6% of this group). To address this issue, in the future, a risk score better calibrated to this specific cohort will be used. Similarly, the other (± CABG/valve) group includes a wide range of procedures, some of which were high risk and infrequent (e.g. pulmonary embolectomy), so the risk scoring systems are also not well calibrated for them. The most important comparator in Figure 14 is the isolated CABG group, as this procedure is performed in the highest numbers and the risk scores are considered the most accurate. That is why this is often used to benchmark performance.

Additional information on the MultiRisk and EuroSCORE II risk evaluation methods can be found in the Appendix.

Procedure type

Actual mortality %

EuroSCORE II % median (IQR)

MultiRisk % median (IQR)

All

1.9 (1, 3.6)

1.6 (0.8, 2.9)

Isolated CABG

1.2

1.2 (0.9, 2)

0.9 (0.6, 1.6)

Isolated valve

3.5

2.3 (1.4, 3.7)

2.5 (1.7, 4.1)

Aortic (± CABG/valve)

8.9

3.7 (2.2, 8.3)

2.1 (1.1, 4.1)

Figure 14. Comparison of the actual mortality rate against various mortality risk scores

Other (± CABG/valve)

9.8

3.4 (1.7, 6.4)

3.2 (1.9, 4.9)

Valve + CABG

3.6

3.2 (2.5, 5.3)

2.5 (1.9, 4.3)

Table 11. Numerical summary of the comparison of actual mortality against various mortality risk scores. Values for each mortality risk score are displayed as medians and interquartile ranges (IQR). Actual mortality is calculated by the number of mortalities observed in each procedure type divided by number of cases in each procedure type.

Cardiac Surgery Annual Report 2021

Morbidity Table 12 provides an outline of all complications and the incidence of each complication type for all RNSH cardiac surgery cases in 2021. Notes: • Each case can have multiple complications and returns to theatre (RTT) in the postoperative period. • Each complication within the table has been counted as a separate incident. • Patients can have multiple reasons for cardiac inotrope or vasopressor use. Of the 220 patients who experienced cardiac inotrope or vasopressor use, almost all used it for >4 hours post-operatively. Of those patients, 65.0% used it for low SVR syndrome and 50.0% used it for low cardiac output syndrome.

Complication

% of total

New pulmonary

22.2

Ventilation prolonged (>24 hrs)

11.1

Pulmonary embolism

0.9

Pneumonia

10.2

New infection

13.1

Deep sternal wound

2.0

Complication

% of total

Superficial access wound infection

7.4

Return to theatre (RTT) total

15.3

Donor site deep wound

1.1

Re-op bleeding / tamponade

4.8

Deep access wound of parasternal site

0.3

Re-op deep sternal wound infection

1.7

Septicaemia

2.3

Re-op deep thoracotomy wound infection

0.3

New vascular

1.4

Re-op insertion of pacemaker/AICD

4.3

New other

6.8

Re-op other cardiac

1.7

Anticoagulant complications

1.7

Re-op other non-cardiac

7.1

Gastrointestinal tract complications

1.7

New renal insufficiency

7.1

Multi-system failure

3.4

Pre-/post-operative MI

0.9

New neurologic

5.1

Pre-/post-operative cardiogenic shock

4.3

Table 12. Overall complications (continued)

Cardiac inotrope or vasopressor use

220

62.5

>4 hours post-operatively

219

62.2

For low cardiac output syndrome

110

31.2

For low SVR syndrome

143

40.6

New cardiac arrhythmia

116

New neurologic

5.1

Stroke permanent

2.8

Stroke transient

0.9

Continuous coma ≥ 24hrs

1.4

Table 12. Overall complications

Cardiac Surgery Annual Report 2021

Isolated CABG analysis Isolated coronary artery bypass graft (CABG) surgery was the highest volume cardiac procedure type for 2021 with 171 cases performed at RNSH, inclusive of re-do operations.

Post-operative indicators

Table 13 summarises the median and IQR for ventilation time (hours) and blood loss (mls).

Post-operative Variables

All median (IQR)

Isolated CABG median (IQR)

Isolated valve median (IQR)

Ventilation (hours)

10.5 (6.3, 18.5)

8.4 (6, 13.3)

11.7 (6.1, 19.9)

Blood Loss (mls)

227.5 (140, 330)

230 (150, 320)

190 (115, 310)

Demographics Figure 16 shows the distribution of all 171 isolated CABG cases in 2021 by age and gender.

Table 13. Post-operative indicators

The largest age cohort of patients for this procedure category was 60—69 years (39.2%) and overall, there was a higher number of male patients with 130 (76.0%) cases compared to only 41 female patients (24.0%).

Discharge

30 day follow-up outcomes data was collected for each case (Figure 15). For 2021: • 287 (81.5%) patients were discharged home • 39 (11.1%) patients were discharged to a local or referring hospital • 14 (4.0%) hospital mortalities were reported • 12 (3.4%) patients were discharged to a rehabilitation unit/hospital

Figure 16. Age distribution for isolated CABG cases. (A) Overall age distribution. (B) Age distribution split by gender.

Figure 15. Discharge location for all patients

Cardiac Surgery Annual Report 2021

Pre-operative cardiac status

Risk factors Table 14 outlines the patient risk factors and pre-operative cardiac status for CABG surgery cases. In total, 71.3% of the patients undergoing isolated CABG surgery had a diagnosis of hypertension, which was the most common risk factor, followed by hypercholesterolaemia and diabetes. These remain the three highest contributing risk factors for CABG surgery.

Pre-op cardiac status

% of isolated CABG

Previous MI

45.6

MI type

Risk factors

% of isolated CABG

NSTEMI

33.3

STEMI

10.5

Hypertension

122

71.3

Unknown

1.8

Hypercholesterolaemia

111

64.9

MI timing

Diabetes

35.1

≤ 6hrs

1.2

Smoking (history)

33.3

1 to 7 days

18.7

Obesity (BMI>30)

32.2

8 to 21 days

20.5

PVD

6.4

>21 days

5.3

Chronic renal failure

1.2

Unstable angina

136

79.5

Angina classification

Table 14. Risk factors for isolated CABG cases

Prolonged extertion

14.6

Slight limitation of ordinary activity

43.9

Marked limitation of ordinary activity

14.0

IV GTN

8.8

Angina treatment IV Heparin

27.5

Therapeutic heparinoids

1.2

Inability to carry out any physical activity 12

7.0

Table 15. Pre-operative cardiac status breakdown for isolated CABG cases

Cardiac Surgery Annual Report 2021

Pre-operative haemodynamics

Operative data On- or off-pump

Pre-op haemodynamics

% of isolated CABG

A total of 126 isolated CABG procedures performed at RNSH used the heart-lung bypass machine (i.e. were ‘on-pump’), representing 73.7% of all isolated CABG cases. This is in comparison to 45 isolated CABG cases (26.3%) that did not use the heart-lung bypass machines (i.e. were ‘off-pump’) (Table 17).

Ejection fraction <50%

19.9

LVEF median (IQR)

56 (50, 61)

On- or off-pump

% of isolated CABG

LVEF estimate

On-pump

126

73.7

Normal (>60%)

38.0

Off-pump

26.3

Mild impairment (46-60%)

42.1

Table 17. On- and off-pump proportions

Moderate impairment (30-54%)

15.8

Severe impairment (<30%)

4.09

Table 18 summarises the use of bilateral mammary arteries, number of arterial grafts, and total number of grafts performed in the two methods of CABG. These factors have been associated with better long term outcomes.

Left main disease >50%

25.1

Number of diseased coronary systems 1

On- vs off- pump

Total LIMA n (%)

RIMA n (%)

Number of distal

Number of distals using arterial conduits median (IQR)

Number of distals using radial conduits median (IQR)

Number of distals using vein conduits median (IQR)

3.51

anastomses median (IQR)

21.6

128

74.8

116 (92.1)

On-pump 126

8 (6.3) 3 (2, 3.8)

1 (1, 2)

1 (1, 1)

2 (1, 2)

Table 16. Pre-operative haemodynamic status breakdown for isolated CABG cases

44 (97.8)

29 (64.4)

Off-pump 45

3 (3, 4)

3 (1, 3)

1 (1, 2)

2 (1, 2.2)

Table 18. Conduit selection on- or off-pump comparisons

Ischaemic time Perfusion time refers to the amount of time a patient spends on the heart-lung bypass machine. Cross clamp time is the length of time the heart is not perfused but protected by cardioplegia and hypothermia during the operative case.

Ichaemic time variables

On-pump median (IQR)

Cross clamp time (mins)

53.5 (42, 68)

Perfusion time (mins)

91 (71.25, 117.5)

Table 19. Summary of ischaemic time variables. Values are expressed as medians and interquartile ranges (IQR).

Cardiac Surgery Annual Report 2021

Morbidity Table 22 provides an outline of all complications and the incidence of each complication type for all RNSH isolated CABG surgery cases in 2021. Factors to note include: • Each case can have multiple complications and returns to theatre (RTT) in the postoperative period. • Each complication within the table has been counted as a separate incident.

Transfusion rate

The transfusion rate for on-pump and off-pump isolated CABG cases was calculated by dividing the number of transfusions by the number of on-pump and off-pump cases.

• For all isolated CABG cases, 63 (36.8%) patients were transfused • For on-pump isolated CABG cases, 50 (39.7%) patients were transfused • For off-pump isolated CABG cases, 13 (28.9%) patients were transfused

Complication

% of isolated CABG

On- or off-pump

Transfused

Transfusion rate (%)

Return to theatre (RTT) total

8.2

Re-op bleeding / tamponade

1.8

All

171

36.8

Re-op deep sternal wound infection

2.3

On-pump

126 39.7

Re-op insertion of pacemaker/AICD

1.2

Off-pump

45 28.9

Re-op other cardiac

1.2

Table 20. On- and off-pump comparisons for transfusion rate. Transfusion rate was calculated by dividing the number of transfused by the number of on- and off-pump cases (n).

Re-op other non-cardiac

2.3

New renal insufficiency

1.8

Post-operative indicators

Pre-/post-operative MI

1.2

Pre-/post-operative cardiogenic shock

1.8

Post-operative variables

Median (IQR)

Cardiac inotrope or vasopressor use

103

60.2

>4 hours post-operatively

102

59.6

Post-op ICU LOS (hours)

65.9 (47.1, 90.8)

for low cardiac output syndrome

20.5

Ventilation (hours)

8.4 (6, 13.3)

for low SVR syndrome

40.4

Blood loss (mls)

230 (150, 320)

New cardiac arrhythmia

26.3

Table 21. Post-operative indicators for all isolated CABG cases in ICU. Values are expressed as medians and interquartile ranges (IQR).

New neurologic

1.8

Stroke permanent

0.6

Blood loss

Stroke transient

0.6

Median blood loss within the first four hours post-operatively for all isolated CABG cases was 230 mls (IQR: 150, 320 mls).

Continuous coma ≥ 24hrs

0.6

Ventilation

New pulmonary

8.2

Median ventilation within the first four hours post-operatively for all isolated CABG cases was 8.4 hours (IQR: 6, 13.3 hours).

Ventilation prolonged (>24 hrs)

2.3

Pulmonary embolism

0.6

Post-operative ICU LOS

Pneumonia

5.3

Median post-operative LOS in ICU for all isolated CABG cases was 65.9 hours (IQR: 47.1, 90.8 hours).

Table 22. Complications observed in isolated CABG cases

Cardiac Surgery Annual Report 2021

Isolated valve analysis There were 57 isolated valve cases performed in the 2021 reporting period, including re-do operations and infective endocarditis cases.

Complication

% of total

New infection

14.6

Deep sternal wound

2.3

Superficial access wound infection

10.5

Donor site deep wound

1.2

Demographics Figure 18 shows the distribution of all 57 isolated valve cases in 2021 by age and gender. There were slightly more isolated valve cases performed on female patients (30, 52.6%) compared to the male patients (27, 47.4%), with the 70–79 age group representing the largest age cohort (40.4%).

Septicaemia

0.6

New other

0.6

Gastrointestinal tract complications

0.6

Table 22. Complications observed in isolated CABG cases (continued)

Discharge 30 day follow-up outcomes data was collected for each case (Figure 17). For 2021: • 151 (88.3%) patients were discharged home • 15 (8.8%) patients were discharged to a local or referring hospital • 3 (1.8%) patients were discharged to a rehabilitation unit/hospital • 2 (1.2%) hospital mortalities were reported

Figure 18. Age distribution for isolated valve cases. (A) Overall age distribution. (B) Age distribution split by gender.

Figure 17. Discharge location for isolated CABG cases

Cardiac Surgery Annual Report 2021

Pre-operative cardiac status

Risk factors Table 23 outlines the patient risk factors and pre-operative cardiac status for isolated valve surgery cases.

Pre-op cardiac status

% of isolated valve

The two highest contributing risk factors in this patient cohort are: • Hypertension (45.6%) • Hypercholesterolarmia (38.6%)

History of congestive heart failure

35.1

Congestive heart failure at admission

21.1

Risk factors

% of isolated valve

NYHA

I (no limitation of activity)

14.0

Hypertension

45.6

II (slight limitation of activity)

33.3

Hypercholesterolaemia

38.6

III (marked limitation of activity)

45.6

Obesity (BMI>30)

31.6

IV (inability to carry out any activity)

7.0

Diabetes

14.0

Arrhythmia

22.8

Smoking (history)

10.5

Atrial fibrillation or flutter

19.3

PVD

5.3

Atrial fibrillation type Paroxsysmal

Chronic renal failure

3.5

12.3

Permanent

5.26

Table 23. Risk factors for isolated valve patients

Unknown

1.75

Complete heart block

1.75

Table 24. Pre-operative cardiac status breakdown for isolated valve cases

Cardiac Surgery Annual Report 2021

Pre-operative haemodynamics

Figure 19 summarises the various valve procedures performed.

Pre-op haemodynamics

% of isolated valve

Ejection fraction <50%

14.0

LVEF median (IQR)

61 (55, 65)

LVEF estimate

Normal (>60%)

56.1

Mild impairment (46-60%)

29.8

Moderate impairment (30-54%)

7.0

Severe impairment (<30%)

7.0

Left main disease >50%

0.0

Number of diseased coronary systems 0

93.0

3.5

1.8

Table 25. Pre-operative haemodynamics status breakdown for isolated valve cases

Figure 19. Valve procedures performed

Cardiac Surgery Annual Report 2021

MV only procedures

% of isolated valve

AV only procedures

% of isolated valve

Procedures

Replacement

54.4

Replacement

12.3

Root reconstruction with valved conduit (Bentall procedure)

3.5

Repair/reconstruction with annuloplasty

12.3

Prosthesis

Repair of paravalvular leak

1.8

CE Perimount Aortic Magna Ease with Thermafix -3300TFX

56.1

Prosthesis

Perceval S Sutureless Valve ICV 12xx

21.1

Epic mitral porcine-E100-xxM

12.3

INSPIRIS RESILIA Aortic Valve - 11500A

17.5

CE physio II mitral ring - 5200R

10.5

CoreValve Evolut R - EVOLUT R

8.8

Simulus semi-rigid mitral annuloplasty ring - 800SCxx

7.0

CE Perimount Aortic Magna - 3000

7.0

Cosgrove-edwards mitral annuloplasty band - 4600

5.3

Mechanical Heart Valve Aortic - ONXA-xx

5.3

CE physio mitral annuloplasty ring - 4450

3.5

CE Perimount Aortic Magna with Thermafix - 3000TFX

5.3

Mechanical heart valve mitral - ONXM

3.5

Perceval (sutureless) PVSxx

1.8

Simulus semi-rigid annuloplasty ring - 800SRxx

3.5

Open Pivot Standard Aortic Heart Valve -500FA-xx

1.8

Medtronic mosaic mirtal porcine

1.8

Supra-Annular Aortic (Top Hat) - S5-0xx

1.8

Edwards geoForm mitralannuloplasty ring

1.8

Open Pivot AP Aortic Heart Valve -505DA-xx

1.8

Edwards etlogix annuloplasty ring - 4100

1.8

Mechanical Heart Valve Aortic - Conform-X Sewing Cuff - ONXAC-xx 1

1.8

Standard series mitral - 500DMxx

1.8

Graft

Mechanical heart valve mitral - Conform-X sewing cuff - ONXMC

1.8

Valved Graft Prosthesis - 502AGxx

3.5

Mechanical heart valve aortic - Conform-X sewing cuff - ONXAC-xx 1

1.8

Masters VAVGJ (Valsalva graft) - xxVAVGJ-515

1.8

Table 27. Breakdown of all procedures and prostheses used in MV only procedures

Table 26. Breakdown of all procedures,prostheses and grafts used in AV only procedures

Cardiac Surgery Annual Report 2021

Operative data Ischaemic time

Blood loss

Median blood loss within the first four hours post-operatively for all isolated valve cases was 190 mls (IQR: 115, 310 mls).

Ichaemic time variables

Median (IQR)

Ventilation

Cross clamp time (mins)

94 (64, 125)

Median ventilation within the first four hours post-operatively for all isolated valve cases was 11.7 hours (IQR: 6.1, 19.9 hours).

Perfusion time (mins)

128 (88, 192)

Post-op ICU LOS

Median post-operative LOS in ICU for all isolated valve cases was 3.2 days (IQR: 2.1, 5 days).

Table 28. Summary of ischaemic time variables. Values are expressed as medians and interquartile ranges (IQR).

Transfusion rate

Procedure type

Transfused

Transfusion rate (%)

Isolated valve

45.6

Table 29. Transfusion rate for the isolated valve procedure type. Transfusion rate is calculated by dividing the number of transfused cases by the number of cases in each procedure type.

Post-operative indicators

Post-operative variables

Median (IQR)

Post-op ICU LOS (days)

3.2 (2.1, 5)

Ventilation (hours)

11.7 (6.1, 19.9)

Blood loss (mls)

190 (115, 310)

Table 30. Post-operative indicators for isolated valve cases. Values are expressed as medians and interquartile ranges (IQR).

Cardiac Surgery Annual Report 2021

Morbidity Table 31 provides an outline of all complications and the incidence of each complication type for all RNSH isolated valve surgery cases in 2021.

Discharge 30 day follow-up outcomes data was collected for each case (Figure 28). For 2021: • 47 (82.5%) patients were discharged home • 8 (14.0%) patients were discharged to a local or referring hospital • 2 (3.5%) hospital mortalities were reported

Complication

% of isolated valve

Return to theatre (RTT) total

19.3

Re-op bleeding / tamponade

3.5

Re-op deep sternal wound infection

1.8

Re-op insertion of pacemaker/AICD

12.3

Re-op other cardiac

3.5

Re-op other non-cardiac

7.0

New renal insufficiency

8.8

Pre-/post-operative MI

3.5

Cardiac inotrope or vasopressor use

64.9

>4 hours post-operatively

64.9

for low cardiac output syndrome

31.6

for low SVR syndrome

42.1

New cardiac arrhythmia

42.1

New neurologic

1.8

Stroke permanent

0.6

New pulmonary

24.6

Figure 20. Discharge location for isolated valve cases

Ventilation prolonged (>24 hrs)

14.0

Pneumonia

10.5

New infection

8.8

Deep sternal wound

1.8

Superficial access wound infection

3.5

Septicaemia

3.5

New other

10.5

Anticoagulant complications

3.5

Gastrointestinal tract complications

1.8

Multi-system failure

5.3

Table 31. Complications observed in isolated valve cases

Cardiac Surgery Annual Report 2021

Aortic surgery

Post-operative indicators

Post-operative variables

Median (IQR)

There were a total of 45 aortic procedures in 2021.

Post-op ICU LOS (days)

5.3 (3.6, 8.5)

Ventilation (hours)

36.4 (14.3, 71.2)

Blood loss (mls)

250 (130, 340)

Aortic pathology/aetiology

Table 32 summarises the presenting diagnoses for all aortic surgery cases.

Table 34. Post-operative indicators for aortic cases

Aortic pathology/aetiology

% of aortic procedures

Blood loss

Median blood loss within the first four hours post-operatively for all aortic cases was 250 mls (IQR: 130, 340 mls).

Aortic aneurysm

44.4

Aortic dissection

55.6

Ventilation

Acute (< 2 weeks)

53.3

Median ventilation within the first four hours post-operatively for all aortic cases was 36.4 hours (IQR: 14.3, 71.2 hours).

Non-acute (> 2 weeks)

2.2

Post-operative ICU LOS

Ascending (Stanford A)

53.3

Median post-operative LOS in ICU for all aortic cases was 5.3 hours (IQR: 3.6, 8.5 hours).

Descending only (Stanford B)

2.2

Table 32. Aortic pathology/aetiology

Aortic procedure type

Table 33 outlines the number of cases for each aortic procedure type performed in 2021.

Aortic pathology/aeitiology

% of aortic procedures

Direct aortoplasty

11.1

Patch repair

2.2

Replacement

95.6

Ascending

88.9

Arch

13.3

Descending

4.4

Thoraco-abdominal

2.2

Table 33. Aortic procedure type Note: Patients can have multiple types of replacements

Cardiac Surgery Annual Report 2021

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