Cardiac Surgery Cases - Missouri Baptist Medical Center

Transcription

The Heart Center at Missouri Baptist
2012 Clinical Outcomes Report
10 Years of Data for Adult Cardiac Surgery
and Interventional Cardiology
Contents
Referral:
Introduction . . . . . . . . . . . . . . . . . . . . . . . 1
Thoracic Aortic Procedures . . . . . . . . . . . . . . . 18
Cardiac Surgery Cases: Overall Variety and Volume . . . 4
Treatment of Marfan Syndrome . . . . . . . . . . . . . 19
Quality Measures . . . . . . . . . . . . . . . . . . . . 6
Interventional Cardiology Overview . . . . . . . . . . . 20
Coronary Artery Bypass (CAB) . . . . . . . . . . . . . . 8
Electrophysiology Procedures for Arrhythmias . . . . . . 25
Aortic Valve Operations: 2003-2012 . . . . . . . . . . 12
Surgical Team, Interventional Cardiologists and
Mitral Valve Operations: 2003-2012 . . . . . . . . . . 16
Electrophysiologists . . . . . . . . . . . . . . . . . . . 26
To refer a patient to our
surgical team, please
call 314-996-5287.
To refer a patient
to an interventional
cardiologist on-staff,
please call 314-996-LIFE
(314-996-5433).
Members of the Cardiac Team include: (seated, from left) Stuart T. Higano, MD, FACC, FSCAI; Robert G. Kopitsky, MD, FACC; Lisa Schiller, MD; Karthik Ramaswamy, MD, FHRS; Nicholas Kouchoukos, MD, FACS; Linda L. Stronach, MD, FACC; John P. Hess, III, MD,
FACC; James R. Scharff, MD. Standing: Raffi K. Krikorian, MD; David Sewall, MD, FACC; William Reilly, MD; Marc Lewen, DO; K. Bryan Trimmer, DO; Howard S. Lite, MD, FACC, FASE. Robert Lehman, MD; Michael Mauney, MD; Martin W. Schwarze, DO; Michael
C. Murphy, MD, FACS; Jerome Dwyer, MD; Christopher Speidel, MD. Not pictured: Michael J. Fleissner, MD; Carey S. Fredman, MD; John Groll, MD; Edward J. Hurley, MD; Andrew Krainik, MD;
Leslie E. Mezel, MD;Tillet J. Mills, MD; Michael A. Missler, DO; Morton R. Rinder, MD; Hon Chi Suen, MD; Gary Vlahovich, DO
Introduction
Dear Colleagues:
Cardiac Surgery
To promote quality improvement, Missouri Baptist Medical
Center is publishing this 2012 Adult Cardiac Surgery
and Interventional Cardiology Clinical Outcomes Report.
Designed for a physician audience, this report contains a
summary of our surgical and medical trends, patient volumes
and outcomes.
Overall, the success of our cardiothoracic surgery program in the past decade reflects continuous
improvements and innovations in surgery performance, patient safety, and the environment of
a dedicated Cardiovascular and Thoracic surgery unit, committed to by both our experienced
surgical team and Missouri Baptist Medical Center.
In publishing our outcomes for the last four years, we realize
that studying this data always helps us learn and work to
improve clinical measures for our patients. The process has
prompted us to undertake new initiatives, like reducing the
amount of blood transfused and weaning patients sooner
post-operatively from ventilators. Such measures have further
improved the rate at which patients recover, while reducing
incidences of infection.
We believe it is important to study results over time, which
is why we share with you our outcomes as compared to
national data over a 10-year period. It is gratifying to be
able to report that patients undergoing cardiac surgery or
percutaneous coronary intervention (PCI) at Missouri
Baptist have benefited from our historically greater freedom
from morbidity and mortality compared to national averages.
Let me also take this opportunity to thank the entire team of
nurses, perfusionists, OR assistants and even the housekeeping
staff, whose attention to detail and patient advocacy makes a
huge difference to our patients.
The cardiac surgery data follows the guidelines issued by the Society of Thoracic Surgeons
(STS) National Adult Cardiac Database and is compared to STS national averages. For the
year ending 12/31/2012, 1,028 participating cardiac surgery programs submitted their results
to this national database, and more than 268,606 procedures were analyzed.
Interventional Cardiology
Missouri Baptist’s Interventional Cardiology Program has been recognized for its outcomes
by HealthGrades®, the leading independent healthcare ratings organization, which has given
Missouri Baptist 5-star ratings for treatment of heart attack, from 2005-2014.
Interventional cardiology outcome data reported here follow the guidelines issued by the
American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) Cath
PCI Registry® for hospitals that perform these procedures. For the year ending 12/31/2012,
1,398 participating cardiac catheterization programs submitted their results to this national
database, and more than 1.4 million procedures were analyzed.
Electrophysiology
In 2011, Missouri Baptist opened a dedicated Arrhythmia Center within its regionally
acclaimed Heart Center to meet the needs of an increasing population of patients suffering from
abnormal heart rhythms. In 2012, the Electrophysiology Program performed 961 ablations and
implants, up 24% over 2011.
Michael Mauney, MD
Cardiothoracic Surgeon
Missouri Baptist Medical Center 1
Introduction
Benchmarks
In this report, we focus on three benchmarks:
1. comparison of our procedure volumes to the national averages,
2. comparison of our “risk-adjusted” outcomes to the national averages,
and
3. comparison of our 2012 year results to our historic average
A volume/outcome relationship has been demonstrated for many treatments,
particularly those involving surgical techniques. Utilization of risk-adjusted
algorithms normalizes surgical difficulties and patient risk factors in the
underlying case mix, providing participants with direct outcome comparisons
across a broad spectrum of patients. For this measure, the goal is having a lower
risk-adjusted mortality rate when compared to the national averages.
In 2011, STS started providing the public with access to its data on
cardiac surgical outcomes, launching STS Public Reporting Online
(www.sts.org/publicreporting). Participation in the STS Public Reporting
Online enables STS National Database participants to voluntarily report to each
other and the public their heart bypass surgery, overall composite star ratings
and the component ratings from which those are derived. Missouri Baptist
is one of only eight cardiac surgery programs in Missouri, and only one in the
St. Louis area to voluntarily participate in the STS Public Reporting Online.
STS Composite Quality Rating - Period Ending 12/31/2012
No star rating
CAB
CAB
★
CAB
★★
CAB
★★★
Total
AVR
7
11
73
2
93
AVR
★
0
6
23
0
29
AVR
★★
AVR
★★★
8
71
626
118
822
0
0
26
24
50
Total
15
88
747
144
994
About the STS Adult Cardiac Surgery Database
The STS Database has become the gold standard in cardiac surgery databases.
The STS data is the most objective rating of a cardiac surgery program due to
the large amount of real-time clinical data collected on each patient. Through
the development and rigorous validation of its risk-adjusted algorithms, the STS
database provides valuable research so that hospitals like Missouri Baptist can
review outcomes to improve our programs and the care we provide to patients
every day.
With more than 4.7 million surgical records, the STS National Adult Cardiac
Surgery Database has grown significantly from its start 23 years ago to become
the premier cardiothoracic surgery database in the world. The Society today
represents roughly 1,100 groups that perform cardiac surgery in the United
States. A small group of STS leaders, including Nicholas T. Kouchoukos, MD,
Missouri Baptist Medical Center cardiovascular surgeon, coordinated the first
efforts to collect the data.
2
No star rating
Of the 994 programs rated and publicly reported by STS, Missouri Baptist was one of 24
programs to receive the “3 star” rating for both Isolated CAB and Isolated AVR procedures.
For Isolated CAB procedures, 15% of participants scored received the “3 star” rating; 76%
received a “2 star” rating; and 9% received a “1 star” rating for the 2012 reporting period.
For Isolated AVR procedures, 6% of participants that were scored received the “3 star” rating;
91% received a “2 star” rating; and 3% received a “1 star” rating for the current reporting
period.
2012 Clinical Outcomes Report: 10 Years of Data for Adult Cardiac Surgery and Interventional Cardiology
Cardiac Surgery Cases: Overall Variety And Volume
In the 10-year period since 2003, Missouri Baptist cardiothoracic surgeons performed 6,786 open heart cases, of which 4,286 were major cases tracked in the
STS database for comparison against the national average. A substantial drop in
cases was noted in 2004 concurrent with the introduction of the drug-eluting
coronary stents and resulting decline in CAB volume. Since 2006, however, we
have seen a steady rise and maintenance of overall volume as national trends
show lower volume.
Our surgeons also treat patients with Marfan syndrome and provide surgical
management of individuals who require transfusionless surgeries, such as
members of the Jehovah’s Witnesses.
The bar graph below illustrates that the volume of cases at Missouri Baptist
repeatedly exceeds the STS national averages by substantial amounts for both
major cases, as well as for more complex cases. In 2012, Missouri Baptist
cardiothoracic surgeons performed more than 2.5 times the national average.
The volume gap is more exaggerated when comparing volumes of complex
cases performed. In 2012, complex case volume at Missouri Baptist was 235
cases, which is three times greater than the national average. In 2012, Missouri
Baptist was approved to be among the first non-academic heart centers in the
country to offer transcatheter aortic valve replacement (TAVR).
We offer a full spectrum of adult cardiac surgical procedures, including
common procedures, such as isolated coronary artery bypass grafting and valve
cases, and less common but usually more complex procedures for combined
coronary and valve disease, aortic aneurysms and dissections, cardiac tumors,
cardiac arrhythmias, multivalve disease, ventricular remodeling for heart failure
and redo heart surgeries.
All Procedures Volume vs. STS National Average
900
800
Missouri Baptist Medical Center
Complex Cases
766
743
700
# Cases
600
500
400
625
623
422
628
591
714
684
706
705
Major Cases
STS National
Complex Cases
382
350
335
300
315
302
301
284
266
261
Total Cases
200
100
0
4
STS National
Major Cases
STS Total Cases
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Cardiac Surgery Cases: Overall Variety And Volume
Volume For All Major Procedures vs. STS National Average
600
3500
10-Year Total # Cases
2500
1,927
2000
1500
1000
10-Year Total # Cases
2,996
3000
518
454
• 55% more CAB procedures over the last 10 years
400
• 130% more CAB procedures in 2012
300
233
191
200
0
Coronary Artery
Bypass (CAB)
Missouri Baptist Medical Center Major Cases
300
200
140
100
57
Mitral Valve
CAB +
Replacement Mitral Valve
Repair
92
32
• 185% more major valve procedures (183
compared to 64) in 2012
CAB +
Mitral Valve
Replacement
Population Demographics
All Cases: Age Distribution Over Last 10 Years
STS National Average Major Cases
68
80+ Years
16%
56
60
40
27
17
20
50
0
58
80
250
150
Mitral Valve
Repair
146
100
323
293
2011 Total # Cases
350
2012 Total # Cases
156
68
Aortic Valve
CAB +
Replacement Aortic Valve
Replacement
• 158% more major valve procedures (1648
compared to 639) over the last 10 years
212
100
500
0
500
Compared to the STS national average volume,
Missouri Baptist cardiothoracic surgeons performed:
588
8
Coronary Artery
Bypass (CAB)
0
Aortic Valve
CAB +
Replacement Aortic Valve
Replacement
Missouri Baptist Medical Center Major Cases
70-79 Years
28%
23
Mitral Valve
Repair
12
6
13
4
Mitral Valve
CAB +
Replacement Mitral Valve
Repair
STS National Average Major Cases
11
2
CAB +
Mitral Valve
Replacement
0-59 Years
26%
60-69 Years
30%
In the Missouri Baptist
case population,
approximately 44%
of patients were
70 years or older.
In addition, 440 of
our patients had
undergone previous
cardiac surgery.
5
Quality Measures
2%
1.9%
1.6%
Risk-Adjusted Mortality For All Major Procedures vs. STS National Average
7%
6%
3%
2.5%
2.6%
2%
1.6%
2.5%
1.6%
2.6%
2.8%
2.5%
1.7%
1% 1.0%
0%
2003
2004
2005
Missou
STS National
STS Na
4%
1%
0%
5%
% Mortality
% Mortality
Risk-adjusted 30-day post-hospital
mortality
is justifiably the single
7%
most commonly used measurement
for 6%
comparative outcomes in cardiac
surgery. As illustrated in the following
two 5%graphs, our focus on patient
safety and continuous performance
4%
improvement
has resulted in perennially
low mortality rates for all major cardiac
2.8%
3% procedures.
surgical
2.6%
2.5% 2.6%
2006
2003
2007
2.6%
1.9%
2.5%
2.6%
2.4% 2.4%
2005
2008
2.4%
2.5%
2.3%
2006
2007
2010
2011
2008
2009
2012
2.4%
2.4% 2.4%
1.3%
1.0%
1.2%
2009
2.5%
2.5%
1.7%
1.6%
1.3%
2004
2.5%
2.3%
2.5%
1.2%
2010
2011
2012
Risk-Adjusted Mortality For Major Procedures vs. STS National Average
% Mortality
Mortality // 10-Year
10-Year Average
Average
%
12%
12%
10%
10%
STS
STSNational
National
8%
8%
6%
6%
5.5%
5.5%
2.9%
2.9%
2.2%
2.2%
2.0%
2.0%
2%
2% 1.4%
1.4%
1.3%
1.3%
5.1%
5.1%
4.8%
4.8%
4%
4%
0%
0%Coronary Artery Aortic Valve
Coronary
Coronary
Bypass (CAB) Replacement
Artery
ArteryBypass
Bypass
(CAB)
(CAB)
6
Missouri
MissouriBaptist
BaptistMedical
MedicalCenter
Center
10%
10%
9.2%
9.2%
3.4%
3.4%
2.9%
2.9%
Models for risk-adjusted outcomes
for mitral valve repair procedures
have only been available in the STS
database since 2008.
1.5%
1.5%
0.6%
0.6%
MitralValve
Valve
Valve
CAB+
Mitral
Mitral
CAB
++
Mitral
Valve Mitral
Mitral
CAB
Replacement
Repair
Aortic Valve
Replacement
Aortic
Valve
Replacement Valve
Valve
Aortic
Valve
Repair
Repair
Repair Replacement
Replacement
CAB+
CAB+
CAB
++
CAB
CAB
CAB++
Mitral Valve Mitral Valve
Mitral
Valve
Mitral
Valve
Mitral
Valve
Mitral
Replacement
RepairValve
Replacement
Replacement
Repair
Repair
Quality Measures
% Permanent Stroke / 10-Year Average
Stroke Rate in All Major Procedures vs. STS National
Average
Postoperative stroke is defined in the STS database as any confirmed
neurological deficit of abrupt onset caused by a disturbance in cerebral blood
supply that did not resolve within 24 hours.
7%
6%
5%
STS National
4.3% 4.6%
4%
3%
2%
0.8%
1%
0%
1.3%
1.7% 1.9%
2.7%
2.2%
1.3%
0.9%
2.1%
1.8%
1.1%
0.0%
Mitral Valve
Coronary
Aortic
Replacement
Artery Bypass Valve
(CAB) Replacement
Mitral
Valve
Repair
At Missouri Baptist, efforts to minimize the risk of stroke include preoperative
carotid Doppler ultrasound and thoracic aortic CT scans; intraoperative
epiaortic ultrasound; cerebral oximetry monitoring to assess blood flow to both
sides of the brain during surgery; alternative cannulation strategies (i.e. axillary
artery cannulation to avoid densely calcified aortas); and deep hypothermic
circulatory arrest to lower brain oxygen requirements in particularly
complex cases.
CAB +
CAB +
CAB +
Aortic Valve Mitral Valve Mitral Valve
Replacement Replacement
Repair
Stroke prevention protocols employed by Missouri Baptist
cardiothoracic surgeons have reduced this complication
in our patients versus the STS national average.
% Permanent Stroke / 10-Year Average
Deep Sternal Wound Infection In All Major Procedures
vs. STS National Average
7%
6%
5%
STS National
4%
3%
2%
1.1%
0.7%
0.7%
1% 0.6%
0.5%
0.5%
0.4%
0.4%
0.4%
0.2% 0.0%
0.0%
0.0%
0.0%
0%
Coronary
Aortic Mitral Valve
Mitral
CAB +
CAB +
CAB +
Artery Bypass Valve Replacement
Valve
Aortic Valve Mitral Valve Mitral Valve
(CAB) Replacement
Repair Replacement Replacement
Repair
Missouri Baptist Medical Center Deep sternal wound infection is defined in the STS database as an infection
within 30 days postoperatively, involving muscle, bone, and/or mediastinum
requiring operative intervention. By definition, it must have ALL of the following
conditions: 1) Wound opened with excision of tissue (I&D) or re-exploration
of mediastinum; 2) Positive culture; and 3) Treatment with antibiotics.
As a result of strict adherence to CDC antibiotic guideline protocols, we also
achieved a 100% compliance rate with timing and 100% on choice of antibiotic
administration.
7
Coronary Artery Bypass (CAB)
Missouri Baptist surgeons performed 3,688 coronary bypass grafting procedures, including 2,996 isolated CABs during the 10-year period, a substantially higher volume than the STS national average. Following the wide spread
adoption of drug-eluting stents in 2004, the number of CAB cases declined
nationwide. In 2007 and 2008, we began to see an increase again, as more
interventional cardiologists refer their complex coronary artery disease patients
to our institution.
Use of arterial grafting is increasing at Missouri Baptist. Internal mammary
artery grafts (IMAs) are a national CAB quality metric, since arterial grafts have
been shown to provide longer durability and better performance. IMAs were
used in 98% of Missouri Baptist CAB patients in 2012 compared to only 74%
in 2001. Additionally in 2012, 11.5% of patients received a radial arterial graft
compared to a national average of approximately 4.6%
Recent initiatives also have focused on minimizing blood product utilization.
Our introduction of sophisticated intraoperative coagulation monitoring
via thromboelastograms (TEGs) has allowed us to tailor blood product
administration to each patient’s specific coagulation deficiencies. This has been
demonstrated to benefit those patients coming to the operating room urgently
or emergently with a coexisting coagulopathy or on anticoagulant or antiplatelet therapy.
Our focus is on complete revascularization and technically perfect bypass
grafting. In the vast majority of cases, we feel this is best accomplished in a
motionless, bloodless field “on pump” with the heart arrested. According to the
STS database, in 2012, 82% of all isolated CABs nationwide were performed
“on pump.” We reserve off-pump approaches for patients at extreme risk.
All Isolated Coronary Artery Bypass: Volume
500
STS National
400
378
# Cases
300
283
261
247
293
278
269
216
200
323
322
318
317
237
203
190
178
171
158
143
140
100
0
8
2003
2004
2005
2006
2007
2008
2009
2010
2011
Our center continues to perform
significantly more coronary bypass
procedures than the national
average as patients are referred to
us from across the St. Louis region.
2012
Coronary Artery Bypass (CAB)
Isolated Coronary Artery Bypass Procedures: Risk-Adjusted Mortality vs. STS National Average
7%
6%
STS National
% Mortality
5%
4%
3%
2%
2.5%
1.6%
2.0%
2.3%
2.2%
1.5%
2.1%
1.5%
1.3%
1.9%
1.9%
1.9%
1.3%
1.4%
2003
2004
2005
2006
2007
2.0%
1.9%
1.2%
0.8%
1%
0%
2.0%
0.8%
2008
2009
2010
2011
Risk-adjusted mortality for
coronary bypass procedures
compared favorably to the
national average.
2012
Coronary Artery Bypass First Operation, Non-Emergent: Internal Mammary Artery Use (2010)
In 2012, 98% of our isolated coronary bypass patients (first operation) received
an internal mammary artery (IMA) graft (a National Quality Forum quality
outcomes measure). Studies have shown that the use of the left internal Both IMAs
3.7%
mammary artery is associated with improved long-term results from coronary
artery bypass surgery.
In most instances where an IMA was not used, the absence of a left anterior
descending artery lesion, unstable emergencies, prior chest wall radiation,
and/or extremes of age, obesity and pulmonary insufficiency, precluded its use.
No IMA
1.7%
Single IMA
94.6%
IMA was used in 98%
of isolated CABG, first
operations in 2011.
9
Quality Measures
Isolated Coronary Artery Bypass: Mortality by Age
% Mortality / 10-Year Average
7%
Actual Mortality
6%
5.5%
5%
4%
3.3%
2.7%
3%
2%
1%
0%
Expected Mortality
1.7%
0.9% 1.1%
0-59
2.1%
0.8%
60-69
70-79
Age Group
80+
Emergent CAB and Re-Do Surgeries Increase
Due to the increasingly high volume of STEMI patients seen at Missouri
Baptist, especially those transported from rural hospitals through the Heart
LifeLine Alliance program, emergent CAB continues to run high at 3.7% of
CAB patients. The national average is 4.7%.
As a destination center for CAB re-do operations, Missouri Baptist showed
higher percentage of 5.6% of our CAB cases versus 3.0% for the national
average. CAB re-do mortality at Missouri Baptist in 2012 was at 0% compared
to 3.2% for the national average.
10
Aortic Valve Operations: 2003-2012
Our practice performed nearly 3,310 valve procedures in 2,950 patients over the
past 10 years. More than 35% of these cases required some degree of coronary
revascularization, approximately 20% required a redosternotomy, and 11.4%
involved more than one valve procedure.
As is the case nationally, more patients are choosing and receiving thirdgeneration tissue valve replacement versus mechanical valves, which require
lifelong anticoagulation. In 2012, 84% of isolated AVRs and 100% of AVR/
CAB patients received tissue valves at Missouri Baptist, up from 72% just five
years ago for AVR. Efforts to maximize valve area and therefore minimize AV
gradients have included aortic annulus enlargement in approximately 1.5%
of patients and use of newer stentless valve replacements, such as the 3F and
Freestyle valves.
In 2012, Missouri Baptist cardiothoracic surgeons performed 128 major
isolated aortic valve replacement procedures. In addition, another 70 patients
received AVR or AVr as part of other complex procedures, the most common
being AVR plus ascending aortic aneurysm resection.
Major Isolated Aortic Valve Replacement Procedures
150
AVR + CAB
47
51
120
56
# Cases
41
90
41
42
39
52
37
91
48
73
60
55
46
48
30
42
46
AVR Only
76
68
43
A total of 312 valve cases were performed,
including 230 AVR procedures (68 AVR only, 56
AVR + CAB, and 105 other AVR, which includes
TAVR cases) Of the total major valve cases:
• 25% required coronary revascularization
0
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
• 17.5% required redosternotomy
• 9.4% involved multiple valve procedures
12
Isolated Aortic Valve Replacement: Risk-Adjusted Mortality vs. STS National Average
7%
6%
STS National
% Mortality
5%
4.7%
4%
3.3%
3%
4.0%
3.6%
2.8%
2.3%
2.8%
3.1%
1.9%
2%
3.1%
3.0%
2.5%
3.0%
3.0%
2.6%
2.1%
1.6%
1.3%
0.9%
1%
0%
0%
2003
2004
2005
2006
2007
2008
2009
2010
2011
12%
12%
10%
10%
8%
6%
4%
Isolated Aortic Valve Replacement Mortality by Age
6.9%
6%
4.4%
4%
2.8%4.4%
2% 1.6% 1.7%
0%
2% 1.6% 1.7%
0%
Expected Mortality
6.9%
0-59
2.8%
0-59
0%
60-69
• 31% were over 80 years old
• 18.5% had prior heart surgery
Actual Mortality
Actual
Mortality
8%
2012
In 2012, many of our aortic valve
replacement patients had multiple
complicating factors:
Expected Mortality
• 15.7% had a prior stroke or TIA
• 4.9% had creatinine levels 2.
• 29% had preexisting diabetes
5.2%
5.2%
1.7%
0%
60-69
1.7%
70-79
70-79
80+
80+
13
New catheter-based aortic valve replacement (TAVR)
More than 1.5 million people in the U.S. suffer from aortic stenosis, and
some 250,000 of these patients are considered severe. Surgical replacement
has been used with great success in younger, low risk patients; however, a
large patient population exists that have been considered ineligible for
surgery due to age, left ventricular dysfunction and co-morbidities.
Part II of the PARTNER trial (The Placement of Aortic Transcatheter Valves)
addressed this high-risk patient population with an investigation comparing
standard therapy to transcatheter aortic-valve implantation (TAVI). The
study found that less-invasive catheter-based aortic valve replacement has a
greater survival rate for patients, 20 percent greater after a TAVR procedure
versus standard therapy one year later.
Using the recently FDA-approved transcatheter aortic heart valve, Edwards
SAPIEN, our cardiac team replaces the diseased aortic heart valve through
a small incision in the groin without open-heart surgery or the use of the
heart-lung machine.
MoBap also offers an alternative valve replacement option through an
incision in the ribs. This method may require a larger incision, but is still less
invasive than bypass and could benefit patients with very small blood vessels.
From June-December 2012, the MoBap team of interventional cardiologists
and cardiac surgeons performed 22 TAVR cases; 70 patients were referred
for consideration.
Missouri Baptist Medical
Center was one of the first in
the region to offer transcatheter
aortic valve replacements.
15
26
004
Isolated mitral valve repair has now become our single most common major
mitral valve operation, exceeding mitral valve replacement, mitral valve
replacement + CAB, and mitral valve repair + CAB over the last five years.
Over the past 10 years, our average risk-adjusted mortality rate for mitral valve
replacement is 1.3%, with near-zero mortality reported during the last seven years.
Mitral Valve Complex Cases
In addition to the 59 major mitral valve cases, we also performed an additional
41 complex MVr procedures in 2012. Whenever the valve pathology permits,
we strive for repair over replacement.
MVr/ASCENDINGAORTA/ASD/MAZE
Repair “Other”
1
n=15
Replacement is typically reserved for severe cases of endocarditis, advanced
ischemic mitral regurgitation, rheumatic valve disease, difficult re-dos and
some emergencies, such as papillary muscle rupture, where the valve cannot
sustain repair.
MVr/TVr/CAB +/- MAZE
2
MVr/MAZE
5
3
MVr/AVr/CAB
3
Major Mitral Valve Operations: Repair Replacement +/– CAB
MVr/TVr +- MAZE
4
Repair
120
Repair
80
34
36
60
26
20
2005
2006
0
Replacement
n=26
46
38
30
37
39
35
40
28
Replacement “Other”
Replacement
100
# Cases
39
Mitral Valve Operations: 2003-2012
28
24
26
16
34
29
28
36
27
26
36
30
27
21
28
46
38
35
23
29
27
2008
2004
2009
2005
2010
2006
2011
2007
2012
2008
21
MVR/MAZE/TVr
1
MVR/CAB/TVr
1
1
1
MVR/ROOT
2
MVR/AVR
6
MVR/AVR/CAB +/- TVr
2
27
16
2007
2003
36
MVR/CAB/CAROTIDENDART
MVR/CAB/ROOT
23
MVR/MAZE
3
MVR/AVR/MAZE +/- TVr
2
2
2009
2010
2011
2012
MVR/CAB/MAZE
2
MVR/TVr/MAZE
3
MVR/TVr
16
Mitral Valve Operations: 2003-2012
Isolated Mitral Valve Repair: Observed Mortality vs. STS National Average
12%
10%
STS National Average
% Mortality
8%
6% 5.6%
2%
0%
Isolated mitral valve repair has now become one of our
most common – and safest – major valve operations.
During the last seven years (2006-2012), we have
recorded only one mortality at Missouri Baptist related
to an isolated mitral valve repair.
4.2%*
4%
1.9%
1.3%
0%
1.8%
0%
1.6%
0%
2005remove
200620022007
1.4%
1.3%
0%
2008
0%
2009
add 2012
2010
1.4%
1.0%
0%
2011
2012
* Represents one mortality
0.0% blue
Isolated Mitral
Valve Replacement: Risk-Adjusted Mortality vs. STS National Average
5.0% green
12%
10%
STS National
% Mortality
8%
6.8%*
6.0%
6%
5.6%
5.2%
5.0%
6.0%
6.0%
5.0%
5.7%
5.4%
5.0%
3.6%*
4%
2.8%
2%
0%
0%
2003
0%
2004
0%
2005
0%
2006
0%
2007
0%
2008
0%
2009
2010
2011
Over the past 10 years, our
average risk-adjusted mortality
rate for isolated mitral valve
replacement is 1.3%.
2012
* Represents one mortality
17
Thoracic Aortic Procedures
Thoracic aortic disease encompasses a broad spectrum of pathologies (including
aneurysms, penetrating ulcers, intramural hematomas, and acute or chronic
dissections) involving multiple, distinct anatomic regions from the aortic root,
through the ascending aorta and aortic arch, to the descending thoracic and
thoracoabdominal aorta. It often presents with urgent or emergent indications,
and usually requires complex anesthesiology and cardiopulmonary bypass
support due to altered cerebral and end-organ perfusion. Successful therapy
of thoracic aortic disease depends on a team of experienced surgeons, RNs,
anesthesiologists and perfusionists.
In 1997, Dr. Nicholas Kouchoukos greatly expanded the aortic surgical
program at Missouri Baptist. As a result, he and his partners have performed
more than 1,000 thoracic aortic procedures since 2000, including nearly 100
cases each year in the last seven years.
Thoracic Aortic Procedures: Case Volume
Thoracic Aortic Procedures: Types (2003-2012)
120
111
111
97
100
106
107
106
97
96
Hemi Arch + Descending
4.5%
102
# Cases
88
Arch
0.4%
Descending
8.9%
80
Ascending +
Arch + Descending
8.9%
60
Thoracoabdominal
15.5%
40
0
Ascending +
Hemi Arch
40.0%
Ascending
21.8%
20
18
Thoracic aortic stenting has emerged as a viable alternative for some aneurisms
with ideal anatomy or in patients at high risk for open surgery. To date,
43 patients have been treated this way in collaboration with our vascular
surgical colleagues.
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Treatment Of Marfan Syndrome
Marfan syndrome is a connective tissue disorder that can affect the heart, blood
vessels, lungs, eyes, bones and ligaments. In Marfan syndrome, the protein
necessary for strengthening the connective tissue, fibrillin 1, does not work
properly, affecting the growth and development of the body.
Approximately 90% of patients with Marfan syndrome experience changes in
their heart or blood vessels. The most serious problem associated with Marfan
syndrome is weakness of the aorta (the body’s largest artery). People with Marfan
syndrome often develop thoracic aortic aneurysms, typically at the aortic root,
and without treatment, they are at risk of death from dissection or tearing of
the aorta.
Aortic Root Surgeries: Case Volume
Dr. Nicholas Kouchoukos is well known for his expertise in the diagnosis
and surgical treatment of Marfan syndrome. In total, he and his colleagues
have performed 417 procedures involving the aortic root during a 10-year
period, utilizing composite mechanical roots, porcine roots, homograft root
replacements and valve-sparing procedures.
Aortic Root Surgeries: Types (2003-2012)
60
Root + Ascending + Arch + Descending
2%
54
50
50
# Cases
43
49
45
42
40
42
Aortic Root Only
16%
37
27
30
28
Root + Ascending
17%
20
Other
19%
10
0
Root + Ascending
+ Hemi Arch
46%
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
19
Interventional Cardiology Overview
Overall Volume and Outcomes
5-Star Rating for Treatment of Heart Attacks
Cardiac Catheterization Laboratory Procedures
Missouri Baptist was the only hospital in the St. Louis region to receive 5-star
ratings for the treatment of heart attack for 10 years in a row, 2005-2014.
Missouri Baptist Medical Center is a regional referral center for percutaneous
coronary intervention (PCI). In 2012, physicians in the catheterization
laboratory performed 5,903 procedures for patients with simple and complex
ischemic heart disease.
Over the past 10 years, volume has remained relatively consistent, with more
than 900 PCI procedures per year.
Patients who underwent PCI procedures at Missouri Baptist in 2012 had
an overall lower complication rate than the national average.
Some 22% of our PCI patients have had a prior heart attack, and one in four
are over age 75, while one in three have diabetes and 39% multi-vessel disease.
One-third of our patients travel more than 50 miles to be treated at Missouri
Baptist, and many are transported by helicopter from regional hospital ERs
to the Missouri Baptist Cath Lab.
Interventional Cardiology Volume
8000
7000
Procedures Volume
6000
5937
6281
6488
5735
5682
5661
6010
6191
5826
5903
5000
4000
3000
2000
Diagnostic
Coronary Intervention (PCI)
Implants
1000
EP
Peripheral
Other
0
20
6110
Over the past 10 years, volume has remained
relatively consistent, with more than 900 PCI
procedures per year.
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Total Volume
2012
Risk Factors Among Patients Undergoing PCI Procedures (N=916)
50%
45.2%
% Cases in 2011
40%
30%
38.8%
36.4% 37.4%
Comparison Group
31.0%
24.0% 23.1% 22.4%
20%
Patients who underwent PCI procedures at Missouri
Baptist in 2012 had an overall lower complication rate
than the national average.
18.1% 19.1%
14.2%12.7%
10%
1.7%
0
Age > 75 yrs
Prior
Heart Failure
Heart Attack
Diabetes
5.0%
Prior Bypass Severe LV Multivessel
Surgery
Dysfunction
Disease
PCI Complications (N = 916)
8%
% Complications in 2011
7%
6.5%
6%
7.1%
5.3%
5%
Comparison Group
All Hospitals
4%
3%
2%
1%
0%
2.5% 2.6%
1.9%
2.04%
1.64%
0.1% 0.3% 0.3%
Risk
Adjusted
Mortality
Emergency
CABG
1.6%1.6%
0.7%
Composite:
Bleeding Events
Death,
within 72 hours
emergency CABG,
of procedure
stroke or repeat target
vessel revascularization
1.2% 1.2%
0.4%
Major
Vascular
Complications
Any
Adverse
Event
21
Case Review with Cardiac Cath and Surgery Teams
At Missouri Baptist, the cardiothoracic surgeons and interventional cardiologists
convene weekly for peer case review. Such collaboration between surgeons and
cardiologists is the hallmark of our program and has led to improved outcomes,
better coordination of treatment planning, an increasingly higher quality of
care and top decile patient satisfaction.
Door-to-Balloon Time
The American College of Cardiology/American Heart Association (ACC/
AHA) practice guidelines strongly recommend that patients with ST-elevated
acute myocardial infarction (STEMI) receive PCI balloon inflation within
90 minutes of arrival in the Emergency Department to reduce mortality
and morbidity.
In 2012, Missouri Baptist achieved a mean door-to-balloon time of 56.5
minutes, with 100% of cases meeting the 90-minute threshold.
Heart LifeLine Alliance
In 2008, Missouri Baptist cardiologists and emergency medicine physicians
teamed to develop an effective, regional system of protocols for the diagnosis,
stabilization, transport and treatment of patients presenting with STEMI
in rural emergency departments. The protocols allow local health providers
to activate the Missouri Baptist Cardiac Cath Lab at the same time they are
calling for transport by medical helicopter. EKG results are transmitted to the
Emergency Department and Cardiac Cath Lab at Missouri Baptist. Upon
arrival, the patient is met by the Cardiac Cath Lab team for immediate transport
to the Cath Lab.
Door-to-Balloon Time Comparisons
100
Mean
Median
Minutes
ACC/AHA National Guideline recommends a
90 door-to-balloon interval of no more than 90 minutes.
80
73.5
70
71.5
74.1
69.0
60.8
60
50
22
60.0
2008
2009
2010
56.4
52
2011
57
56.5
2012
Heart LifeLine Alliance Transport Zone
Electrophysiology Procedures for Arrhythmias
In 2011, Missouri Baptist opened a dedicated Arrhythmia Center within its
regionally acclaimed Heart Center to meet the needs of an increasing population
of patients suffering abnormal heart rhythms. In 2012, the Electrophysiology
program performed 961 ablations and implants, up 24% over 2011.
Electrophysiologists at Missouri Baptist are performing cutting-edge procedures,
often using robotic magnetic navigation, to map the heart and guide ablations
in areas of the heart previously inaccessible with manual ablation.
help the heart perform more efficiently by synchronizing the left and right
ventricles of the heart through timed electrical pulses.
The team also was first in the St. Louis region to provide CryoAblation Balloon
Catheter, a new technology to treat atrial fibrillation. Using a new balloon
catheter system, doctors are able to freeze the small sections in the heart that
cause the erratic and irregular heart rhythm, offering the potential to cure
patients with this life-disrupting arrhythmia.
In 2012, the team was the first in Missouri to implant a new type of cardiac
resynchronization therapy defibrillator (CRT-D), designed to better manage
heart failure in patients. CRT-Ds regulate the heart’s pumping function and
Frequency and Types of Ablations Performed
WPW Syndrome
2%
Atrial
Flutter
27%
Atrial
Fibrillation
35%
Super
Ventricular
Tachycardia
30%
Ventricular
Tachycardia
5%
25
Cardiothoracic Surgeons
Nicholas T. Kouchoukos, MD, FACS
Specialty: Cardiothoracic Surgery
Medical School: Washington University School of Medicine
Training: Barnes Hospital (combined internship/residency in general surgery),
University of Alabama (fellowship in thoracic surgery)
Board Certification: Thoracic and general surgery
Michael C. Mauney, MD
Medical School: Duke University School of Medicine
Training: University of Virginia Health Sciences Center (residency in general
and thoracic surgery)
Board Certification: Thoracic surgery
James R. Scharff, MD
Medical School: Wake Forest University School of Medicine
Training: St. Louis University Hospital (internship, residency and fellowship
in cardiothoracic surgery)
Hon C. Suen, MD
Medical School: University of Hong Kong
Training: Queen Mary Hospital/Princess Margaret Hospital (internship/residency
in surgery); Grantham Hospital (residency in cardiothoracic surgery);
Massachusetts General Hospital (fellowship in thoracic/pediatric surgery);
Beth Israel Deaconess Medical Center, Needham, MA (residency/fellowship
in cardiothoracic surgery); Washington University School of Medicine
(residency in cardiothoracic surgery)
Michael C. Murphy, MD, FACS
Director, Division of Cardiothoracic Surgery
Medical School: University of Virginia
Training: University of Virginia Health Sciences Center (residency in general
surgery) and Texas Heart Institute (residency in thoracic surgery)
Board Certification: Thoracic surgery
26
Interventional
Cardiologists
On Staff On Staff
Interventional
Cardiologists
Stuart T. Higano, MD
Linda L. Stronach, MD
Robert G. Kopitsky, MD
Zia M. Ahmad, MD
David Sewall, MD, FACC
Michael J. Fleissner, MD
Christopher M. Speidel, MD
John R. Groll, MD
Medical Director, Heart LifeLine AllianceSM
Specialty: Interventional and Cardiovascular Disease
Medical School: University of Massachusetts Medical School
Training: Mayo Clinic (combined internship/residency in internal medicine
and fellowship in cardiovascular disease)
Board Certification: Cardiovascular disease, interventional cardiology,
internal medicine
Medical Director, Cardiac Cath Lab
Medical School: Duke University School of Medicine
Training: Washington University School of Medicine (internship and residency
in internal medicine and fellowship in cardiology)
internal medicine
Medical Director, CHF Clinic
Specialty: Interventional Cardiology
Medical School: Boston University School of Medicine
Training: Washington University School of Medicine (internship and
residency in internal medicine and fellowship in cardiology)
Board Certification: Cardiovascular disease, interventional cardiology
Medical Director, Cardiac Diagnostics
Medical School: Washington University School of Medicine
Training: Washington University School of Medicine (combined internship/
residency in internal medicine and fellowship in cardiovascular disease)
internal medicine
Missouri Baptist Medical Center Medical Director, Advanced Cardiac Care Unit
Medical School: Brown University Medical School
Training: University of North Carolina (residency in internal medicine),
University of Pittsburgh (fellowship in critical care and cardiology)
Board Certification: Cardiovascular disease, internal medicine
Medical School: Dow Medical College, University of Karachi
Training: State University of New York at Buffalo (internship), University of
Kentucky Chandler Medical Center (residency in internal medicine), Bowman
Gray School of Medicine, NC (fellowship in cardiology)
Board Certification: Cardiovascular disease
Medical School: Medical College of Wisconsin
Training: University of Illinois Hospitals & Clinics (residency in internal medicine),
Medical College of Wisconsin (fellowship in cardiology)
Specialty: Cardiovascular Disease
Medical School: University of Illinois Abraham Lincoln School of Medicine
Training: Jewish Hospital of St. Louis (combined internship/residency in
internal medicine and fellowship in cardiology)
27
Interventional Cardiologists On Staff
John P. Hess, III, MD
Marc K. Lewen, DO
Edward J. Hurley, MD
Tillet J. Mills, MD
Medical School: University of Missouri School of Medicine – Columbia
Training: Mayo Clinic (combined internship/residency in internal medicine),
University of Louisville School of Medicine (fellowship in cardiology), St. Vincent’s
Hospital (fellowship in interventional cardiology)
internal medicine
Medical School: University of North Carolina School of Medicine
Training: Mayo Clinic (internship, residency and fellowship in cardiology)
Board Certification: Cardiovascular disease
Raffi K. Krikorian, MD
Michael A. Missler, DO
Robert B. Lehman, MD
William R. Reilly, MD
Medical School: Kirksville College of Osteopathic Medicine
Training: Normandy Osteopathic Hospital (internship and residency in internal
medicine), St. Louis University School of Medicine (fellowship in cardiology)
Board Certification: Cardiovascular disease, interventional cardiology, internal
medicine
Medical School: Tulane University School of Medicine
Training: Charity Hospital of Louisiana (combined internship/residency
in internal medicine), University of Virginia Medical Center (fellowship
in cardiovascular disease)
internal medicine
Training: Genesys Regional Medical Center Health Park (internship and
residency in internal medicine), Deborah Heart & Lung Center-Brown Mills,
New Jersey (fellowship in interventional cardiology and cardiovascular disease)
Board Certification: Cardiovascular disease, interventional cardiology, internal
medicine
Medical School: Higher Institute of Medicine, Bulgaria
Training: Oakwood Hospital and Medical Center, Dearborn, MI (internship), St.
Louis University School of Medicine (residency in internal medicine),Truman
Medical Center-West (fellowship in cardiovascular disease), Mid-America
Rehabilitation Hospital, Kansas City (fellowship in interventional cardiology),
Board Certification: Cardiovascular disease, interventional cardiology
Medical School: Texas Tech University
Training: Texas Tech University Health Sciences Center (combined internship/
residency in internal medicine), University of Oklahoma (fellowship in cardiology)
28
Medical School: Southern Illinois University-Carbondale
Training: University of Illinois Urbana-Champaign (residency in
internal medicine), Barnes-Jewish Hospital (fellowship in cardiovascular disease)
Electrophysiologists On Staff
Morton R. Rinder, MD
Speciality: Interventional Cardiology
Medical School: University of Maryland
Training: University of Maryland Medical System (residency
internal medicine), Washington University School of Medicine
(fellowship in cardiovascular disease and interventional cardiology)
internal medicine
Karthik Ramaswamy, MD, FHRS
Medical Director, Electrophysiology Lab
Specialty: Cardiac Electrophysiology
Medical School: University of Miami School of Medicine
Training: University of Texas Southwestern Medical Center
Board Certification: Cardiovascular disease, clinical cardiac electrophysiology,
Fellow of the Heart Rhythm Society
Carey S. Fredman, MD
K. Bryan Trimmer, DO
Medical School: Texas College of Osteopathy
Training: Pontiac Osteopathic Hospital (combined internship and
residency in internal medicine), Detroit Osteopathic Hospital (fellowship
in cardiology)
Board Certification: Interventional cardiology
Gary Vlahovich, DO
Training: Normandy Osteopathic Hospital (combined internship and
residency in internal medicine), University of Oklahoma (fellowship in
cardiology)
Board Certification: Interventional cardiology
Medical School: New York University School of Medicine
Training: St. Louis University School of Medicine (internship and residency in
internal medicine, fellowship in cardiology, fellowship in electrophysiology), Ichilov
Medical Center, Tel Aviv (fellowship in cardiac electrophysiology)
Board Certification: Internal medicine, cardiovascular disease, cardiac
electrophysiology
Andrew J. Krainik, MD, MPH
Medical School: University of Illinois College of Medicine
Training: Washington University School of Medicine (residency in Internal
Medicine); Washington University and Barnes-Jewish Hospital (fellowships in
Cardiology and Clinical Cardiac Electrophysiology)
Board Certification: Internal medicine, cardiovascular disease
Board-eligible: Clinical Cardiac Electrophysiology
Lisa Schiller, MD
Medical School: Rush University Medical College
Training: Washington University School of Medicine (combined internship and
residency in internal medicine), University of Minnesota (fellowship in cardiac
electrophysiology and cardiovascular disease)
Board Certification: Cardiology, clinical cardiac electrophysiology
Michael L. Shapiro, MD
Medical School: New York University School of Medicine
Training: Wilford Hall U.S.A.F. Medical Center (internship and residency in internal
medicine, fellowship in cardiology), Washington University School of Medicine
(fellowship in cardiac electrophysiology)
Board Certification: Internal medicine, cardiovascular disease, cardiac electrophysiology
Missouri Baptist Medical Center 29
Cardiothoracic and Vascular Surgery
at Missouri Baptist Medical Center
3015 N. Ballas Road
St. Louis, MO
(314) 996-5287
www.missouribaptist.org
MBM17303_3.14

Cardiac Surgery Cases - Missouri Baptist Medical Center

Transcription

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