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273
What Are the Obstacles to Training in Surgery
for Congenital Heart Disease in Germany?
Ruediger Lange1
Juergen Hoerer1
Christian Schreiber1
1 Department of Cardiovascular Surgery, German Heart Center Munich
at the Technical University, Munich, Germany
Address for correspondence Christian Schreiber, MD, PhD, German
Heart Center Munich at the Technical University, Lazarettstrasse 36,
Munich 80636, Germany (e-mail: [email protected]).
Abstract
Keywords
► congenital heart
disease
► database
► mortality
► morbidity
► training
In recent years, several publications from German institutions have highlighted the need
for quality assessment, complexity and risk interpretation, and assurance of sustainable
structures in congenital heart surgery. In addition, there is a severe shortage of
congenital cardiac surgeons in Germany. To provide quality assurance, the German
Society for Thoracic and Cardiovascular Surgery (DGTHG, Deutsche Gesellschaft für
Thorax-, Herz- und Gefäßchirurgie) offers a Certificate for Congenital Cardiac Surgery,
which is awarded with proof of a minimal number of congenital procedures. We outline
that there are too many low-volume centers in Germany putting the cardiac surgeon
into the role of a “soloist.” In this situation, adequate training cannot be provided in the
majority of the centers in Germany. Furthermore, a considerable reduction of the
specifically required operations in the “Weiterbildungsordnung für die Ärzte” (WBO) will
be paramount for the future. There should be a stronger consideration for the specific
requirements for congenital heart surgeons, to make their training shorter and less
cumbersome. Also, the DGTHG’s Certificate for Congenital Cardiac Surgery should be
tailored to realistic needs in the field of congenital surgery. An adjustment of both the
WBO and the Certificate would be in line with the justified claim made in the
recommendations of the DGTHG.
Introduction
In recent years, several publications from German institutions have highlighted the need for quality assessment,
complexity and risk interpretation, as well as assurance of
sustainable structures in congenital heart surgery.1–6 In
addition, there is a severe shortage of congenital cardiac
surgeons in Germany. To provide quality assurance, the
German Society for Thoracic and Cardiovascular Surgery
(DGTHG, Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) offers a Certificate for Congenital Cardiac Surgery, which is awarded with proof of a minimal number of
congenital procedures. In detail, the surgeon must have
performed 100 procedures including 20 procedures with
cardiopulmonary bypass (CPB) in infants.
received
March 28, 2013
accepted
April 8, 2013
published online
May 13, 2013
Current Situation of Congenital Cardiac
Surgery in Germany
According to the most recent report from the German Heart
Foundation,7 5,599 operations were performed in 2011 on
patients with congenital heart disease (►Fig. 1).
However, this needs to be brought into perspective. The
report lists 31 German institutions that are dedicated not only
to diagnostic and interventional procedures but also to
surgical approaches on congenital patients.8 If we then turn
again to the already cited German report, this time looking at
the type of all procedures with and without CPB, we see the
first discrepancy (►Table 1). If the 5,599 congenital operations had been distributed equally among the 31 centers, then
each institution would have performed 181 operations. In the
© 2013 Georg Thieme Verlag KG
Stuttgart · New York
DOI http://dx.doi.org/
10.1055/s-0033-1345024.
ISSN 0171-6425.
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Thorac Cardiovasc Surg 2013;61:273–277.
Obstacles to Training in Surgery for Congenital Heart Disease
Lange et al.
Fig. 1 Development of congenital heart surgery in Germany over the past 10 years (taken with permission from Funkat et al7).
year 2011, 2,770 operations were performed solely on patients younger than 1 year. If these had been evenly distributed among the 31 centers, then each institution would have
performed 89 operations on patients younger than 1 year.
This would translate, for example, into 10 ventricular septal
defect (VSD) operations per year, 4 transpositions of the great
arteries (TGA), 2 TGA þ VSD, 5 Norwood, and 1 common
arterial trunk. These numbers show that training for
Table 1 Procedures for congenital heart disease with and without cardiopulmonary bypass7
n
Deaths
%
n
Deaths
%
n
Deaths
%
ASD
74
0
0.0
279
0
0.0
271
6
2.2
Complete AV canal
180
5
2.8
76
0
0.0
14
1
7.1
VSD
303
1
0.3
121
0
0.0
26
1
3.8
Fallot’s tetralogy
206
5
2.4
36
1
2.8
6
0
0.0
DORV
65
1
1.5
14
0
0.0
0
0
–
TGA
132
4
3.0
7
0
0.0
0
0
–
TGA þ VSD
65
2
3.1
7
0
0.0
0
0
–
Truncus arteriosus
27
2
7.4
8
0
0.0
0
0
–
Fontan
5
0
0.0
275
1
0.4
10
2
20.0
Norwood type
162
21
13.0
4
1
25.0
0
0
–
Pulmonary valve
70
1
1.4
238
1
0.4
75
2
2.7
Transcatheter pulmonary valve implantation
0
0
–
7
1
14.3
7
0
0.0
Aortic valve
55
4
7.3
185
1
0.5
305
5
1.6
Ross procedure
12
2
16.7
28
0
0.0
25
1
4.0
Mitral valve
39
4
10.3
77
0
0.0
74
7
9.5
Tricuspid valve
66
0
0.0
47
0
0.0
44
0
0.0
PDA
282
5
1.8
20
0
0.0
5
0
0.0
Coarctation
184
2
1.1
45
0
0.0
4
0
0.0
Heart transplantation
4
0
0.0
18
0
0.0
0
0
–
Heart–lung transplantation
0
0
–
0
0
–
0
0
–
Lung transplantation
0
0
–
9
0
0.0
0
0
–
Others
839
30
3.6
371
11
3.0
91
2
2.2
Total
2,770
89
3.2
1,872
17
0.9
957
27
2.8
Abbreviations: ASD, atrial septal defect; AV, atrioventricular; DORV, double outlet right ventricle; PDA, patent ductus arterious; TGA, transposition at
the great arteries; VSD, ventricular septal defect.
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Obstacles to Training in Surgery for Congenital Heart Disease
Lange et al.
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congenital cardiac surgery cannot be provided in most centers in Germany due to the limited number of patients who
are eligible for training operations and the limited number of
patients who are required to maintain the expertise of the
mentor. In addition, the question arises if such a low caseload
per center would be compatible with the respective quality
that is requested by international standards.
On the basis of the Society of Thoracic Surgeons database,
it has been well documented that the mortality of surgery for
most congenital defects is highly dependent on the number of
cases performed in an institution.9 According to this report,
low-volume centers with less than 100 procedures per year
exhibited a higher mortality rate than medium-volume centers with 100 to 250 procedures per year. The lowest mortality was noticed in high-volume centers with more than 250
operations per year. Accordingly, the consensus statement of
the Congenital Heart Disease Committee of the European
Association of Cardio-Thoracic Surgery (EACTS) on the optimal structure of a congenital heart surgery department in
Europe10 requires more than 250 procedures per year, including more than 100 operations in infants. These departments should be headed by at least two fully trained
congenital cardiac surgeons. The report mentions that “… it
is usually recognized that a surgeon needs to perform a
minimum of three surgical procedures a week. Considering
a 42-week annual activity, the total surgical output is 126
operations.” Interestingly, a few years later, the DGTHG also
agreed on “ideal” requirements concerning structures of an
institution dedicated to the care of congenital patients.11 The
DGTHG also states a minimum of 250 operations per year and
at least 100 operations on patients younger than 1 year.
This brings us back to the current situation in Germany.
According to the report of the German Heart Foundation, only
seven institutions “qualify” for the standards of the EACTS
and DGTHG, as they perform more than 250 operations per
year. Of these, only three institutions perform more than 400
operations per year (►Fig. 2). A large number of institutions
fall behind 250 or even 100 operations per year. Unfortunately, no information can currently be provided by the DGTHG
about the presence of certified congenital surgeons in the 31
centers for protection of data privacy reasons.
In the United Kingdom, the bar is being raised even more.
Ian Kennedy published an extensive report that included
recommendations not only for congenital cardiac care but
also for the National Health Service (NSH) as a whole in the
United Kingdom.12 These recommendations included new
minimum standards for care. Furthermore, they imply that
congenital heart surgery and interventional cardiac catheterization should be conducted in fewer (larger) units and that
care should be conducted by nurses and doctors trained to
look after these patients in surroundings built for children.
One of the recommendations followed nationwide was the
creation of the Central Cardiac Audit Database. All the results
for units in the United Kingdom are published and available
on the Internet.13 Since 2008, the “Safe and Sustainable”
review has developed standards, in partnership with the
public, NHS staff, and their associations.14 A public consultation involved over 75,000 people and was one of the largest
responses to an NHS public consultation. The quality standards decided upon require that each unit should have a
minimum of four surgeons and that there should be a
proposed critical mass of 500 congenital cardiac procedures
per year with an absolute minimum of 400 per year. Each unit
should be able to provide 24-hour coverage throughout the
year. Mr. William Brawn summarized these reorganization
efforts in the United Kingdom in a special report.15
Coming back to the current German situation, it must be
emphasized that only three institutions “qualify” for the
standards supported by the EACTS, the DGTHG, and the
United Kingdom.
Low-volume institutions may have a problem with training and quality of care. A single, well-trained surgeon could in
fact operate at a high level of quality, performing at least 100
to 150 operations per year. However, other structural requirements such as “around the clock availability” and a highly
trained team of pediatric cardiologists, anesthesiologists,
perfusionists, and nursing staff would be missing. Hence,
the institutions that operate as a “one man show” are
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Fig. 2 Operative numbers for congenital heart disease split among German institutions (reprinted with permission from E. Bruckenberger).8
Obstacles to Training in Surgery for Congenital Heart Disease
dependent on the single surgeon. They are unable to treat
patients in urgent situations, neither in case of complications
on the intensive care unit nor in case of emergency admissions, when this individual is indisposed or not on site.
Furthermore, in complicated congenital cases, the intraprocedural exchange at the table between two experienced
surgeons facilitates decision making and enhances the overall
results considerably. Even worse is the fact that “single
congenital surgeon institutions” are incapable of training
other surgeons. This kind of situation only exasperates the
severe shortage of pediatric cardiac surgeons in Germany.
Taking this into account, only a few high-volume centers can
provide training in congenital heart disease for cardiac surgeons. These few centers have to carry the financial burden of
training too. The German Heart Center Munich, with an
annual case load of approximately 550 cases, for example,
managed to train 6 fully independent congenital surgeons
over the past 12 years.
Why Can Training in Congenital Cardiac
Surgery in Germany No Longer Be
Guaranteed Even at High-Volume Centers?
The German “Weiterbildungsordnung für die Ärzte” (WBO,
regulations for training for MDs) in its current version does
not take training in congenital cardiac surgery into consideration. The requirements of the “WBO für die Ärzte Bayerns vom
24. April 2004” need 120 coronary bypass operations, 10 mitral
valve procedures, and 25 procedures on the aortic valve or aortic
root.16 A surgeon interested in congenital surgery needs to fulfill
this catalog of procedures during a period of at least 6 years.
Operations on congenital patients do not “count” in this WBO,
unlike they did in the previous version from 1993. As we have
highlighted, the undue spread of congenital patients over many
institutions is per se a hindrance to the residents’ adequate
exposure to congenital cases. Only very few institutions could in
theory guarantee this. In our opinion, 185 specified operations
on patients with acquired heart disease may not be an adequate
number for those residents who aim for a later subspecialization
in congenital care. Furthermore, this number cannot be fulfilled
unless the trainees accept a very long training program, because
they find themselves in competition with the other surgeons in
training, who want to remain in adult cardiac surgery exclusively. Fortunately, the DGTHG is working on an amendment of the
current WBO. We suggest that this amendment should entail a
considerable reduction in the amount of those procedures that
are specifically stipulated and an increase in the number of
unspecified operations with CPB (where congenital heart operations could be accommodated).
Such an amendment may not be exclusively demanded for
the specific needs of congenital cardiac surgery. In contrast to
the past, congenital cardiac surgery is nowadays no longer the
only subspecialization in the field of cardiac surgery. Recent
developments have shown that also in “adult/acquired lesion”
cardiac surgery, the technical challenges of complex procedures are met in many centers by subspecialization within
their respective teams. Complex revascularization strategies,
valve reconstruction, extracardiac assist, intrathoracic vascular
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Lange et al.
repair, interventional catheter-based procedures, and surgery
for rhythm disorders also require a specific case load for the
individual surgeon. Even in high-volume centers, the amount
of cases indispensable for high-quality care can only be provided if a limited group of surgeons is selected to perform these
procedures. Therefore, the former claim for a broad basic
training before subspecialization may not be realistic today.
The trainee should be put in a position where he/she can reach
specific competence early in their surgical life.
A young colleague at the German Heart Center Munich
who is in her 6th year of training may serve as an example of
this dilemma. She has performed more than 200 congenital
operations including complex procedures such as correction
for tetralogy of Fallot (n ¼ 10) and Norwood operations
(n ¼ 3). However, she has performed only 45 operations on
adult patients presenting with acquired heart disease and
thus the Bavarian Ärztekammer has so far not accepted her
application for the board examination. This means that it
might take her at least another 2 to 3 years to fulfill the catalog
for operations on adult patients presenting with acquired
heart disease. After this, she would in theory have to wait a
further 1.5 years to be entitled to apply for the DGTHG’s
Certificate for Congenital Cardiac Surgery. Overall, 11 to
12 years would then have passed before she would have a
chance to become a certified congenital heart surgeon in
Germany, although she already meets many qualifications
even today.
Potential Solutions to the Problem
First solution for “What are the obstacles to training in congenital cardiac surgery in Germany?”
There are too many low-volume centers in Germany
putting the cardiac surgeon into the role of a “soloist.” In
this situation, adequate training cannot be provided in the
majority of the centers in Germany.
Following the UK efforts, we suggest to review the number
of centers that perform congenital cardiac surgery in
Germany. If the total number of congenital operations was
spread across 16 institutions, then a total of 350 cases would
be performed in each institution. If the British threshold
number of 500 operations was considered, only 12 institutions would be necessary for the whole of Germany.
In France, for example, 3,600 operations are performed in 10
centers by 23 surgeons. Five of these centers perform more than
400 operations per year, one center performs over 700, and one
center performs more than 800 procedures per year. Hence, a
reasonable number of centers are active in France, whereas a
more even distribution of the caseload per center has not been
achieved yet. Taking an even distribution of 500 cases per center
as a baseline, France would need only seven centers for the
whole country. In the United Kingdom, the total number of
procedures is the same as in France and seven is exactly the
number of centers that is intended for the United Kingdom. In
the United States, 27,000 operations are performed in 107
centers. Again, taking an even distribution of 500 operations
per center as the ultimate goal, the United States could close half
of their centers and leave only 55 institutions operating.
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4 Sinzobahamvya N, Kopp T, Photiadis J, et al. Surgical management
5
6
7
8
9
10
11
12
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Second solution for “Why can training in congenital cardiac
surgery in Germany no longer be guaranteed even at highvolume centers?”
As stated above, a considerable reduction of the specifically required operations in the “WBO” will be paramount for
the future. There should be a stronger consideration for the
specific requirements for congenital heart surgeons to make
their training shorter and less cumbersome.
The DGTHG’s Certificate for Congenital Cardiac Surgery
should be tailored to realistic needs in the field of congenital surgery. In our opinion, the current criteria are not
sufficient. The German certificate,17 endorsed by the
DGTHG, demands only 20 operations in patients younger
than 1 year, 40 in patients older than 1 year, and 20 in
adolescents. As mentioned above, the statements of the
EACTS and DGTHG agreed that a fully trained congenital
cardiac surgeon ought to perform a minimum of three
surgical procedures a week. In line with this, the amended
Certificate should require not only more procedures in each
age category but also an adequate case load per year.
Recertification must guarantee the consistence of experience. An adjustment of both the WBO and the Certificate
would be in line with the justified claim made in the
recommendations of the DGTHG.
Lange et al.