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Eur J Cardiothorac Surg 1998;13:500-503
© 1998 Elsevier Science NL

Surgery for congenital heart disease in Europe 1995

Department of Cardiac Surgery, The General Hospital, Southampton, UK

Received 2 March 1998; accepted 9 March 1998.

Tel.: +44 1703 796241; fax: +44 1703 796614.

	Abstract

Top Abstract Introduction 2. Materials and methods... Results Discussion References

 
Objective: An attempt was made to find out how many operations were performed in Europe in 1995 for congenital heart disease. Methods: Representatives from the 20 most active European countries which could supply reliable information were contacted. They were asked to contact all surgeons performing significant numbers of operations for congenital heart disease in their country. The numbers of operations on children under and over 1 year operated on with and without cardiopulmonary bypass were collected. No attempt was made to collect more detailed information such as operative mortality as it was felt that many surgeons would be reluctant to give their results and the data would be incomplete. Results: A total of 27 976 operations were recorded, of which 20 318 were performed with cardiopulmonary bypass and 7658 without. The total population of the 20 European countries was 448 million and the mean number of operations performed with cardiopulmonary bypass per million was 45.4. However, the rate varied from 9.1 to 70.1. The percentage of operations on cardiopulmonary bypass performed in the first year of life varied from 9.4% to 44.4%. Conclusions: The total of nearly 28 000 operations in 1995 is probably an underestimate, but it has been difficult to collect this data at all. Obviously many smaller countries have not been included, and some older patients undergoing operations such as atrial septal defect closure in adult units have been missed. The number of open heart operations per million vary in different countries and this presumably represents differing referral patterns. If their numbers are low in some countries, these results may be helpful in persuading their governments that more resources are needed for congenital heart surgery. It is also interesting to see the variation in the number of operations performed in the first year of life. Those countries with a lower rate may have a backlog of older patients who were previously palliated, or their surgeons may still prefer initial palliation and later correction in some conditions rather than early correction. It is hoped that with better prospective data collection, an assessment can be repeated in 2000.

Key Words: Congenital heart disease • Europe

	Introduction

Top Abstract Introduction 2. Materials and methods... Results Discussion References

 
In 1995 the Council of the European Association for Cardio-Thoracic Surgery set up a Subcommittee on Congenital Heart Disease under the chairmanship of the author. One of the aims of this subcommittee was to find out how much surgery for congenital heart disease was being performed in Europe. Information was therefore collected from the major countries in Europe and a table drawn up which it is hoped will be of interest to surgeons, paediatric cardiologists, administrators, governments and industry. It is appreciated that this table cannot be completely accurate and it has been extremely difficult and time consuming to collect the information at all. It is proposed to repeat this exercise for the year 2000 and it is hoped that with all contributors collecting data prospectively a full and more accurate table can be produced.

	2. Materials and methods

Top Abstract Introduction 2. Materials and methods... Results Discussion References

 
Considerable difficulty was encountered over definitions which one would have thought to be quite simple.

Europe
Many countries were contacted but some either performed little or no congenital heart surgery, or were unable (e.g. Russia) to give any meaningful figures. Ultimately 20 countries were included and it is thought that they perform the great bulk of congenital heart surgery in Europe.

Age
Different countries collect their statistics differently. Some countries do not collect data on patients over 16 having congenital heart surgery and some include all patients having surgery for congenital heart disease. Two countries were unable to give any breakdown into infants and those patients over 1 year. One country collected data on patients under 6 months and those over 6 months.

Nevertheless information was gathered as best possible on the numbers of patients under 1 year and the patients over 1 year undergoing surgery for congenital heart disease.

Year
Some countries collect data from 1 January to 31 December and other countries from 1 April to 31 March. Although this means that not every country is presenting data from exactly the same time frame, at least it is the same for each country each year and is a whole year's data.

National representative
A surgeon was selected from each of the 20 countries and was asked to contact all the surgeons undertaking surgery for congenital heart disease in his country. Each surgeon was asked to submit the total number of operations performed in infants, both on cardiopulmonary bypass (CPB) and without CPB, and the number of operations in patients over 1 year on CPB and without CPB. Although it would be very interesting to know the early mortality for these groups, it was felt that it was unlikely that this information would be forthcoming, or at least it would be very incomplete, and therefore just the total numbers were asked for.

Some countries only have one or two units performing congenital heart surgery and it was relatively easy to get their results. Other larger countries have national registers, e.g. Germany and Great Britain and the information was already collected.

Having selected the 20 representatives, letters were sent to each asking for the information described above. Some countries, particularly smaller ones where there were only a few units, replied very promptly and indeed some included a detailed breakdown including early mortality. However, in most other countries the representative had to work hard to collect the results from all the centres in his country. It is apparent that the methods and completeness of data collection vary very considerably from unit to unit.

A previous attempt to collect the results in 1994 was made and although the results were too incomplete to merit publication, the results were similar, with a slight increase to 1995 and the exercise to collect the 1994 data proved helpful in obtaining the 1995 data.

	Results

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The results are shown in Table 1 which lists the 20 selected countries in alphabetical order together with their population in 1995 (columns 1 and 2). Austria and Spain were unable to give a breakdown of their figures but their totals are included.

In the case of Italy, the national registry gives details for patients under 6 months and over, rather than under and over 1 year, as for the rest of the table. Therefore figures used from the representative from Italy who personally contacted all the main Italian units were used, as comparative figures under and over one year could be obtained. Therefore the total given for Italy maybe as much as 500 less than the real total of operations performed in 1995.

Column 10 shows the number of open heart operations per million of population with a mean of 45.4. Column 11 shows the percentage of open heart operations in each country that were performed under 1 year. This was obtained by calculating what percentage column 4 was of column 5. Columns 10 and 11 therefore provide data that allow comparison between countries, thus assessing different practices.

	Discussion

Top Abstract Introduction 2. Materials and methods... Results Discussion References

 
What seemed a simple exercise in its conception, became a more difficult and lengthy process than had been anticipated. The difficulty with definitions as described above under Section 2 remains somewhat unsatisfactory, but despite this a reasonably accurate and hopefully truthful table has been produced. Little other information is available about the amount of surgery for congenital heart disease being performed in Europe [1].

Clearly many surgeons, at least at that time did not collect the data on the operations they perform in a satisfactory manner. It took a great deal of prompting to obtain these results, and I am very grateful to all the national representatives who put so much time and effort into obtaining these figures. There were some misgivings as to the reasons for being asked for this information and in all cases permission from each country was granted to publish the figures. There was some concern that the figures could be used by governments to close units, or in some way reduce the numbers of surgeons.

It is likely that the total of nearly 28 000 operations is an underestimate. Firstly, as mentioned above, extra cases were performed in Italy – their national register for 1995 quotes a total of 2765 as compared with the total in the table of 2185. Secondly, some countries have not included patients over 16, whereas undoubtedly many older patients are operated on above this age.

Thirdly, some private operations may not have been included. This is particularly likely in Great Britain where operations performed outside National Health Hospitals are not included in the National Register.

The numbers of open heart operations per million vary considerably from country to country. Greece with 9.1% presumably refers patients abroad, and Switzerland probably operated on patients referred from abroad. There must be many reasons why some countries are lower than others, but if the numbers are lower in some countries for financial reasons, this table may be of some help in persuading governments that more resources are needed for congenital heart surgery.

The final column in the table listing the percentage of operations performed on cardiopulmonary bypass in the first year of life gives some insight into the varying practices in different countries. Presumably those countries with a lower percentage tend to palliate more infants requiring surgery with later correction, but also it is possible that these countries have a larger number of adults or a backlog of older patients. It will be interesting to see how this column compares with the table for 2000. The trend is certainly for earlier correction and one would expect to see the percentages rise in this column. The European Cardiac Surgical Registry (ECSUR) which has been set up under the auspices of the European Association for Cardiothoracic Surgery is also trying to collect data for all cardiac surgery in Europe and hopefully this information will be available for the year 2000.

As this was a first attempt and there was considerable difficulty in getting even this information, no attempt was made to ask for early mortality. Although some countries have this data in their National Registers and some surgeons are very willing to give this information, many others would be reluctant and indeed there is suspicion that even the present information could be used to try to close or amalgamate units.

The ultimate aim of the subcommittee is to improve the lot of children undergoing surgery for congenital heart disease and it is hoped that this table will be of some help.

	Acknowledgments

 
I am very grateful to the following surgeons for their help in collecting the data which has made this paper possible.

Professor A. Beitzke, Graz, Austria

Professor P. Sergeant, Leuven, Belgium

Professor A. Todorov, Sofia, Bulgaria

Professor B. Hucin, Prague, Czech Republic

Dr P. Lauridsen, Copenhagen, Denmark

Dr H. Sairanen, Helsinki, Finland

Dr F. Lacour-Gayet, Paris, France

Professor P. Kalmar, Hamburg, Germany

Mr J.L. Monro, Southampton, Great Britain

Dr I. Stinios, Athens, Greece

Dr L. Kiraly, Budapest, Hungary

Mr A. Wood, Dublin, Ireland

Dr G. Stellin, Padua, Italy

Professor T. Ebels, Groningen, Netherlands

Dr H. Lindberg, Oslo, Norway

Dr B. Maruszewski, Warsaw, Poland

Professor P. Bastos, Porto, Portugal

Professor M. Murtra, Barcelona, Spain

Professor A. Berggren, Göteborg, Sweden

Professor M. Turina, Zurich, Switzerland

	References

Top Abstract Introduction 2. Materials and methods... Results Discussion References

 

1. Unger F. Open heart surgery in Europe 1993. Eur J Cardiothorac Surg 1996;10:120-128.[Abstract]

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