The Bluhm Cardiovascular Institute is co-directed by Robert O. Bonow, MD, chief of the Division of Cardiology at Northwestern Memorial Hospital and Patrick M. McCarthy, MD, chief of the Division of Cardiothoracic Surgery at Northwestern Memorial Hospital. Consistently, the cardiac surgical outcomes of Bluhm Cardiovascular Institute have been superior to recognized national performance benchmarks. This is particularly true for the most recently available information covering the period of January 1, 2006 to December 31, 2006 (calendar year 2006).
When available, we compare the Bluhm Cardiovascular Institute results to data from the Society of Thoracic Surgeons (STS).
These data allow us to determine how we are performing compared to aggregate (or combined) data from participating STS institutions across the country. The STS National Adult Cardiac Surgery Database receives outcome information from over 770 institutions across the country, with over 3 million patient records in the database. Unless otherwise indicated, the STS outcome data represented in this report were collected in calendar year 2006.
Society of Thoracic Surgeons "3 star" Rating
The STS recently developed a comprehensive rating system that allow for comparisons regarding the quality of cardiac surgery among hospitals across the country. Approximately 15 percent of hospitals received the "3 star" rating, which denotes the highest category of quality. In the current analysis of national data covering calendar year 2006, the overall cardiac surgery performance at the Bluhm Cardiovascular Institute was found to be in the highest quality tier, thereby receiving an STS "3 star" rating.
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Morbidity is defined as an adverse or unwanted effect caused by a treatment. In this particular instance, the STS defines morbidity to include the following adverse effects that may occur after cardiac surgery: reoperations, renal failure, deep sternal wound infection, prolonged ventilation, and stroke. The graph below shows that adverse effects were not seen in 92.3 percent of the patients at the Bluhm Cardiovascular Institute after cardiac surgery thereby receiving an STS "3 star" rating, compared to only 86.2 percent nationally.
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According to the American Heart Association/American College of Cardiology (AHA/ACC) 2004 Guideline Update for Coronary Artery Bypass Graft Surgery it is better to bypass a blocked coronary artery with arteries rather than veins from the body during coronary artery bypass surgery (CABG) because arterial grafts remain open longer than vein grafts. Arteries used in CABG surgery, include the internal mammary arteries located on either side of the chest or radial arteries located in the wrists. The longer the graft remains open, the better the clinical outcomes are for the patient as the need for repeat CABG is decreased. The graph below shows that internal mammary arteries were used in 97.6 percent of the patients at the Bluhm Cardiovascular Institute during CABG surgery (excludes patients with prior CABG surgery) thereby receiving an STS "3 star" rating, compared to only 92.9 percent nationally.
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Distribution of Cardiac Procedures
The Bluhm Cardiovascular Institute performed a large proportion of complex cases in comparison to the national distribution as reported by STS. As a major referral center, physicians from all over the United States send high-risk, complex patients to the Bluhm Cardiovascular Institute for innovative therapies, surgical expertise, and patient centered care.
Sixty-five percent of the surgical procedures performed at the Bluhm Cardiovascular Institute were complex heart valve operations. In this scenario, "complex" refers to more than one procedure performed during the same operation. Examples of these complex procedures include more than one valve being operated on during the same operation, heart valve procedures done in conjunction with CABG surgery, or heart valve procedures done in conjunction with atrial fibrillation ablation (Maze procedure). Twenty-five percent of the surgeries performed were isolated CABG. "Isolated" refers to when the CABG is the only procedure performed during the operation. "Other" procedures were responsible for 10 percent of the cases performed and include procedures such as but not limited to left ventricular aneurysm procedures, atrial septal defect repairs, isolated Maze procedures, and ventricular assist device implants.
In comparison, the STS reports that the majority or 60 percent of cardiac procedures performed nationally were "isolated CABG" procedures followed by only 21 percent "heart valve + other" procedures and 18 percent "other".
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Coronary Artery Bypass Graft Surgery Outcomes
Arteries -vs- Veins
The heart receives its blood supply from the coronary arteries. CABG surgery becomes necessary when plaque formation in the coronary arteries(coronary artery disease) inhibits blood flow, and blood is unable to reach and nourish the heart. In CABG surgery, arteries and veins are taken from other parts of the body and used to bypass (or re-direct) blood flow around the occluded (or blocked) coronary artery.
According to the American Heart Association/American College of Cardiology (AHA/ACC) 2004 Guideline Update for Coronary Artery Bypass Graft Surgery it is better to bypass a blocked coronary artery with arteries rather than veins from the body. Arteries used in CABG surgery, include the internal mammary arteries located on either side of the chest or radial arteries located in the wrists remain patent (or open) longer than vein grafts. The longer the arterial graft remains open, the better the clinical outcomes are for the patient as the need for repeat CABG is decreased.
At the Bluhm Cardiovascular Institute, multiple arterial grafts are routinely used for CABG procedures and far exceed national standards. Specifically, bilateral (or both) internal mammary arteries were used in 18.9 percent of all isolated (one procedure performed during operation) CABG procedures, compared to 4.4 percent nationally. Likewise, the radial artery was used in 21.7 percent of all isolated CABG procedures, compared to 7.7 percent nationally.
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Endoscopic Harvesting Technique
Arteries and veins used to bypass occluded (or blocked) coronary arteries may need to be harvested (or removed) from the body to be used for CABG surgery. When an open harvest technique is used, a large incision is necessary. When an endoscopic harvest technique is used for the same purpose, only a small incision is necessary. The endoscopic harvesting technique results in less pain, less incisional complications such as infections, and a quicker recovery for the patient.
At the Bluhm Cardiovascular Institute, endoscopic harvesting of saphenous vein and radial artery conduit is routine, being performed 97 percent of the time for saphenous veins and 100 percent of the time for radial arteries.
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Heart Valve Surgery Outcomes
Minimally Invasive Procedures
The majority of isolated heart valve operations at the Bluhm Cardiovascular Institute were performed through a minimally invasive incision. An isolated valve refers to when only one valve is operated on during the operation. Minimally invasive procedures are defined as a surgery performed on a beating heart and/or when the surgery is performed through a two to three inch incision compared to a six or eight inch incision. Minimally invasive procedures allow for a faster recovery, shorter length of stay in the hospital, lower infection rates, and less bleeding and trauma.
At the Bluhm Cardiovascular Institute, minimally invasive procedures are being performed 56 percent of the time for mitral valve surgery and 75 percent of the time for aortic valve surgery.
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Repair -vs- Replacement
The cardiac surgeons at the Bluhm Cardiovascular Institute know that it is in the best interest of the patient to repair a damaged heart valve rather than to replace it with an artificial valve. Heart valve repair often provides the best long-term clinical outcome for restoring proper valve function and does not require the patient to be placed on blood-thinning medication like Coumadin® (warfarin) for the rest of their lives. Blood-thinning medication increases the risk of bleeding and stroke.
At the Bluhm Cardiovascular Institute 90 percent of mitral valves were repaired rather than replaced. In comparison, STS data indicates that isolated mitral valve repair was only performed in 53 percent of patients undergoing mitral valve operations nationwide.
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Bioprosthetic - vs - Mechanical
If a heart valve is damaged beyond repair, surgery is required to replace the diseased valve. The diseased valve is replaced with either a bioprosthetic (tissue) valve or a mechanical valve. Although there are advantages and disadvantages, mechanical valves require blood-thinning medication like Coumadin® (warfarin) for the rest of your life and may result in lifestyle modifications such as sports or activity restrictions and dietary constraints. There is an increased risk of stroke with mechanical valves, which is cumulative with each year after surgery.
Valve replacement with bioprosthetic valves at the Bluhm Cardiovascular Institute far exceeds national standards. Specifically, bioprosthetic valves were used in 98.1 percent of all aortic valve replacement procedures at the Bluhm Cardiovascular Institute, compared to 77.5 percent nationally. Likewise, bioprosthetic valves were used in 100 percent of all mitral valve replacement procedures at the Bluhm Cardiovascular Institute, compared to 54.3 percent nationally.
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Mitral Valve Disease and Atrial Fibrillation
Patients with mitral valve disease have a higher risk of developing atrial fibrillation. Atrial fibrillation is a common, potentially harmful arrhythmia (irregular heartbeat) that occurs in the atria (top portion of the heart).
Cardiac surgeons at the Bluhm Cardiovascular Institute understand the significant relationship between severe mitral valve disease and atrial fibrillation. They also have the technology and experience to treat both during the same operation. Of mitral valve disease patients at the Bluhm Cardiovascular Institute, 35 percent were diagnosed with atrial fibrillation before surgery. According to the 2006 STS data, atrial fibrillation was present in 30.5 percent of patients nationally before all types of mitral valve surgery. At the Bluhm Cardiovascular Institute, atrial fibrillation ablation surgery was performed in 89 percent of patients with a previous history of atrial fibrillation that were undergoing surgery for mitral valve disease. By comparison, the STS average was only 55.9 percent.
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Valve Surgery Operative Mortality
There are risks with every cardiac surgery. The amount of risk varies with each patient and is dependent on the patient's age, overall health, cardiac function, and the specific surgery being performed. One of the risks for any surgical procedure, is mortality (or death) of the patient. Operative mortality is defined as a patient death that occurs during the same hospitalization as the cardiac surgery or after discharge from the hospital but within 30 days of the cardiac surgery.
Overall, the operative mortality at the Bluhm Cardiovascular Institute was very low for both aortic valve replacement and mitral valve repair procedures. Operative mortality for isolated aortic valve replacement at the Bluhm Cardiovascular Institute was zero percent, compared to 3.1 percent nationally. Operative mortality for isolated mitral valve repair surgery was zero percent at the Bluhm Cardiovascular Institute, compared to 1.9 percent nationally.
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