Prêtre, René

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The congenital database and the Streif in KitzbühelRené Prêtre*Department of Cardiothoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland* Corresponding author. Department of Cardiothoracic Surgery, Lausanne University Hospital, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.Tel: +41-21-3142695; fax: +41-21-3142278; e-mail: rene.pretre@chuv.ch (R. Prêtre).Keywords: Database • Mortality rate • Tetralogy of Fallot • Arterial switch operation • ReoperationThe Streif in Kitzbühel, Austria, is regarded as the most challen-ging ski downhill race. It starts with the ‘Mausefalle’ (the mouse-trap), a stunning, almost vertical jump—the most dangerous inthe whole championship circuit—that propels skiers withinseconds to a rocket speed and a landing compression of over1000 kg (Fig. 1). Every champion will tell you that you may havealready lost the race with a timorous jump, but you still have notwon it with an intrepid and successful one. Only about 150 ofthe 3312 m would have been accomplished, and the rest of thesteep slope is a succession of fall away turns and leaps, manywith limited visibility and on glaring ice.This month, the Journal publishes two reports from the twolargest congenital databases—the European and the The Societyof Thoracic Surgeons (STS) National ones [1, 2]—and gives theopportunity to recall the main objectives and limitations ofthese registries. In one report, the various methods to enlargethe right ventricular outﬂow tract (RVOT) in Tetralogy of Fallotare evaluated, and in the other, an overview of a large spectrumof congenital procedures with its attendant mortality is given.The primary goal of the database is to improve the quality ofcare and patients’ safety [3]. The congenital database gathers andmonitors the procedures performed in the ﬁeld of congenitalheart defects, and reports their early outcome. This analysis andthe establishment of an average performance set a reliable refer-ence for individual measurement and should positively impacton the quality of care. The 30-day mortality rate is the corner-stone of the outcome. This rate certainly provides important in-formation regarding an operative risk but, like the Streif initialjump, remains incomplete in the assessment of the overallsuccess or beneﬁt of an operation. In many situations, anincreased operative risk is bargained with a better long-termquality of life and survival. Take the arterial switch, the doubleswitch or the Bex-Nikaidoh procedure as examples. None ofthem would compete favourably in a 30-day mortality with theirtechnically easier counterparts such as the Senning procedure, aphysiological correction or a Fontan pathway, respectively. Still,these demanding operations are rightly favoured by expert sur-geons, because of their proven mid-term and their anticipatedlong-term beneﬁts [4, 5]. The same shortcoming arises fromSarris et al.’s report [2]. Using only the early mortality—withoutany reoperation rate—to evaluate the various methods of RVOTopening can only lead to incomplete and dubious conclusionsthat many of us might draw in spite of the repeated warningsfrom the investigators. Congenital cardiac surgeons have learnedsince long back that the less the myocardium is cut into, thebetter the heart will function. The decision regarding theinfundibulum is no longer taken blindly as a ‘rule of school‘ butis actually dictated by local ﬁndings. With an infundibulummethodically left intact, many kids would come back for asecond relief of an excessive obstruction [6, 7].The second drawback of any such registry study is that it doesnot account for the temporospatial characteristic of the truth.The truth in London is already not the one prevailing in Madridor in Paris (not to mention the one in less-developed countries)for many good reasons related to local expertise, facilities andbeliefs and convictions. Likewise, the truth of today will onlypartly be valid in the next decade. Consider simply the fate ofthe chronic pulmonary insufﬁciency in longstanding Fallot patients.Not long ago, our reluctance to reoperate on these patients wasgreat because of a signiﬁcant mortality rate, which was mainlydue to the fact that these procedures were performed too late,on already exhausted hearts [8]. With better criteria to implant avalve in the pulmonary position, the mortality rate of these redoprocedures has dropped dramatically [9]. We are now all con-vinced that a ﬁrst redo on a tired ventricle is more perilous thana second or third redo on a well functioning one. The boomingof percutaneously implantable valves will also drastically reducethe need for reoperation [10]. When, on top of that, one consid-ers that, as a rule, a ventricle tolerates a volume load better thana pressure load [11], it is difﬁcult to advocate a preference for aresidual signiﬁcant stenosis over a calibrated transannular patchwith some degree of regurgitation. Limiting the evaluation to themortality rates of the various methods of the correction ofTetralogy of Fallot, the information given by the database, is likegiving the ranking of the skiers after the initial jump of the Streif.Some may appear to be to be in a better position at that time,but the ultimate winners will be those able to negotiate the sub-sequent turns and leaps with the straightest line and least im-pairment. The divergence between the surgical and the ultimateoutcome is certainly less pronounced in an adult databasebecause the critical ‘surgical jump’ happens much later in therace, closer to the ﬁnal strides of life.The second report, which presents the results in congenitalcardiac surgery on both sides of the Atlantic, is perplexing [1].Courteously, no formal comparison is made, but everyone isprone to make it (we have not acquired a scientiﬁc mind to not© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.EDITORIALEuropean Journal of Cardio-Thoracic Surgery 42 (2012) 763–765 EDITORIALdoi:10.1093/ejcts/ezs471use it), and will then be confronted with intriguing facts. The ﬁrstone will be the difference in the caseload distribution within cat-egories. In continents where the same incidence of diseases isexpected—and in the absence of an asymmetric distribution ofacquired disease, like rheumatic valve disease could produce—this difference is difﬁcult to understand. Even more puzzling willbe the analysis of the mortality rates, which are higher (at timesalmost doubled) in all categories of procedures in the Europeandatabase compared with the STS one. This difference, probablyreaching statistical signiﬁcance, results in a worrisome excess ofdeaths in the European cohort. This embarrassing surplus willsurely torment any surgeon on this side of the Atlantic with theunrelenting question: is the quality of our work, of my work, somuch behind? Some reports from individual European units arein accordance with the STS predictions and will comfort ussomehow [12, 13]. Certainly, the states in the USA and Canadahave a more homogenous distribution of high-quality surgicalexpertise and facilities in congenital heart disease than thevarious countries in Europe. Disparities between the eastern andwestern blocks probably still exist, but they have been consider-ably attenuated over the past years and cannot account for themagnitude of the reported differences in mortality. In a laconicsentence of the article, it is stipulated that no less than 30% ofthe so-called European data stems from other continents. If thisturns out to be true, then the relevance of the adjectiveEuropean should eventually be questioned. However, this is onlythe slightest problem. For us, the database sets the standardsagainst which we monitor our results. It helps us identify theareas of suboptimal performance needing prompt action toremain within, or regain, accepted limits. By setting the averagestandard at an inferior level, borderline units will not timelyundertake these actions, and more children may suffer from un-satisfactory management. We still have in mind the so-calledBristol affair. The implicated unit had the surgical results manyhad 10–15 years earlier, but, in 1998, it was already prohibitivelyhigh and led to an unprecedented press scandal [14]. Developingcountries are progressing fast, but many units have still notreached the standards we were working with a decade ago [15].In an ideal world, the distribution of performances would beconcentrated around a median line with a limited dispersion (anarrow bell-shaped curve for statisticians). The STS distributionlooks like the ranking of the ﬁrst group (the downhill specialists)of the Streif competitors, while the European one resembles theﬁnal ranking, the one that also includes the slalom specialistsand the amateur skiers.It is not our intention to contest the usefulness of the data-base in congenital cardiac surgery. We need it. Simply, its objec-tives should not be overplayed. The database is an instrumentfor everyone to measure his/her own performance and compareit with colleagues or institutions working under similar condi-tions. It is not an instrument to denounce the poor performanceof one team or one surgeon, and likewise, it is also not an instru-ment for praise or advertisement (all too often, we have seen incongresses surgeons proudly showing their own circle radiatingin the pole position). Finally, it should be used extremely cau-tiously as an instrument for the evaluation of therapies andrecommendations, because it reﬂects no more than the rankingafter the ﬁrst Streif jump in an often long, tortuous and eventful‘congenital cardiac life’. If, however—through the process of com-parison and appropriate reaction—the database was able to prevent,even if only once, another ‘Bristol affair’, then its justiﬁcation andobjectives would have been more than fully accomplished.Conﬂict of interest: none declared.REFERENCES[1] Jacobs JP, Jacobs ML, Maruszewski B, Lacour–Gayet FG, Tchervenkov CI,Tobota Z et al. Initial application in the EACTS and STS Congenital HeartSurgery Databases of an empirically derived methodology of complexityadjustment to evaluate surgical case mix and results. Eur J CardiothoracSurg 2012;42:775–80.[2] Sarris GE, Comas JV, Tobota Z, Maruszewski B. Results of reparativesurgery for tetralogy of Fallot: data from the European Association forCardio-Thoracic Surgery Congenital Database. Eur J Cardiothorac Surg2012;42:766–74.[3] Lacour-Gayet F, Clarke D, Jacobs J, Gaynor W, Hamilton L, Jacobs Met al. The Aristotle score for congenital heart surgery. Semin ThoracCardiovasc Surg Pediatr Card Surg Annu 2004;7:185–91.[4] Hraska V, Mattes A, Haun C, Blaschczok HC, Photiadis J, Murin P et al.Functional outcome of anatomic correction of corrected transposition ofthe great arteries. Eur J Cardiothorac Surg 2011;40:1227–34.[5] Vouhe PR. Editorial comment corrected transposition of the great arter-ies: is ‘anatomic’ repair the optimal option? Eur J Cardiothorac Surg2011;40:1235.[6] Alexiou C, Chen Q, Galogavrou M, Gnanapragasam J, Salmon AP,Keeton BR et al. Repair of Tetralogy of Fallot in infancy with a trans-ventricular or a transatrial approach. Eur J Cardiothorac Surg 2002;22:174–83.[7] Bove T, Francois K, Van De Kerckhove K, Panzer J, De Groote K, De WolfD et al. Assessment of a right-ventricular infundibulum-sparing approachin transatrial-transpulmonary repair of Tetralogy of Fallot. Eur JCardiothorac Surg 2012;41:126–33.[8] Dos L, Dadashev A, Tanous D, Ferreira-Gonzalez IJ, Haberer K, Siu SCet al. Pulmonary valve replacement in repaired Tetralogy of Fallot: deter-minants of early postoperative adverse outcomes. J Thorac CardiovascSurg 2009;138:553–9.[9] Buechel ER, Dave HH, Kellenberger CJ, Dodge-Khatami A, Pretre R,Berger F et al. Remodelling of the right ventricle after early pulmonaryvalve replacement in children with repaired Tetralogy of Fallot: assess-ment by cardiovascular magnetic resonance. Eur Heart J 2005;26:2721–7.[10] Eicken A, Ewert P, Hager A, Peters B, Fratz S, Kuehne T et al.Percutaneous pulmonary valve implantation: two-centre experience withmore than 100 patients. Eur Heart J 2011;32:1260–5.Figure 1: Didier Cuche in the Streif heading for his fourth victory in themythic race. The Swiss champion won it one more time in 2012 and beat thefamous record set by the legendary Franz Klammer. Note the ﬁnish line farbelow (Courtesy of Didier Cuche).R. Prêtre / European Journal of Cardio-Thoracic Surgery764[11] Turina J, Milincic J, Seifert B, Turina M. Valve replacement in chronicaortic regurgitation. True predictors of survival after extended follow-up.Circulation 1998;98 (Suppl. 19):II100–6; discussion II6–7.[12] Arenz C, Asfour B, Hraska V, Photiadis J, Haun C, Schindler Eet al. Congenital heart surgery: surgical performance according tothe Aristotle complexity score. Eur J Cardiothorac Surg 2011;39:e33–7.[13] Bojan M, Gerelli S, Gioanni S, Pouard P, Vouhe P. The AristotleComprehensive Complexity score predicts mortality and morbidity aftercongenital heart surgery. Ann Thorac Surg 2011;91:1214–21.[14] Treasure T. Lessons from the Bristol case. More openness–on risks andon individual surgeons’ performance. BMJ 1998;316:1685–6.[15] Saxena A. Congenital cardiac surgery in the less privileged regions of theworld. Expert Rev Cardiovasc Ther 2009;7:1621–9.EDITORIALR. Prêtre / European Journal of Cardio-Thoracic Surgery 765

The congenital database and the Streif in Kitzbühel

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