ABC | Volume 114, Nº4, April 2020

Original Article Analysis of >100,000 Cardiovascular Surgeries Performed at the Heart Institute and a New Era of Outcomes Omar A.V. Mejia, 1 Luiz Augusto Ferreira Lisboa, 1 Luiz Fernando Caneo, 1 Elisandra Trevisan Arita, 1 Carlos Manuel de Almeida Brandão, 1 Ricardo Ribeiro Dias, 1 Roberto Costa, 1 Marcelo Biscegli Jatene, 1 Pablo Maria Alberto Pomerantzeff, 1 Luís Alberto Oliveira Dallan, 1 Fabio Biscegli Jatene 1 Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas Instituto do Coração, São Paulo, SP – Brazil Mailing Address: Omar A.V. Mejia • Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Av. Doutor Enéas de Carvalho Aguiar, 44. Postal Code 05403-900, São Paulo, SP – Brazil E-mail: omar.mejia@incor.usp.br Manuscript received October 24, 2019, Manuscript revised October 24, 2019, accepted November 26, 2019 DOI: https://doi.org/10.36660/abc.20190736 Abstract Background: The current challenge of cardiovascular surgery (CVS) is to improve the outcomes in increasingly severe patients. In this respect, continuous quality improvement (CQI) programs have had an impact on outcomes. Objective: To assess the evolution of the incidence and mortality due to CVS, as well as the current outcomes of the Hospital das Clínicas Heart Institute of the University of São Paulo Medical School (InCor-HCFMUSP). Methods: An outcome analysis of CVSs performed at the InCor, between January 1984 and June 2019. We observed the surgical volume and mortality rates in 5 time periods: 1st (1984-1989), 2nd (1990-1999), 3rd (2000-2007), 4th (2008-2015) and 5th (2016-2019). The CQI program was implemented between 2015 and 2016. The analysis included the total number of surgeries and the evolution of the most frequent procedures. Results: A total of 105,599 CCVs were performed, with an annual mean of 2,964 procedures and mortality of 5,63%. When comparing the 4th and the 5th periods, the average global volume of surgeries was increased from 2,943 to 3,139 (p = 0.368), bypass graft (CABG), from 638 to 597 (p = 0.214), heart valve surgery, from 372 to 465 (p = 0.201), and congenital heart disease surgery, from 530 to 615 (p = 0.125). The average global mortality went from 7.8% to 5% (p < 0.0001); in CABG surgery, from 5.8% to 3.1% (p < 0.0001); in heart valve surgery, from 14% to 7.5% (p < 0.0001) and in congenital heart disease surgery, from 12.1% to 9.6% (p < 0.0001). Conclusion: In spite of a recent trend towards increased surgical volume, there was a significant decrease in operative mortality in the groups studied. After the implementation of the CQI program, the mortality rates were closer to international standards. (Arq Bras Cardiol. 2020; 114(4):603-612) Keywords: Cardiovascular Surgical Procedures/trends; Quality Improvement; Patient Safety; Hospital Mortality; Database. Introduction Cardiovascular surgery has undergone transformations throughout its history, especially after the consolidation of large databases. 1 These data helped reduce surgical mortality by implementing data-oriented improvements. 2 At that time, this was the reality of only a few centers in the world. In 1984, the Hospital das Clínicas Heart Institute of the University of São Paulo Medical School (InCor‑HCFMUSP) database was structured wih the purpose of defining and improving cardiovascular surgery outcomes. Thus, the InCor, one of the largest Cardiology centers in Brazil, took its first step into the virtuous cycle of outcome continuous improvement. In this respect, a national analysis of cardiovascular surgery outcomes already showed a mortality of 8%, 3 virtually twice as much than that in the best centers worldwide, although the data were obtained from an administrative database. There was a wide range of justifications, such as healthcare access difficulties, lack of adherence to protocols and socioeconomic conditions. In fact, it was quite difficult to identify the health service weaknesses, given the lack of clinical data available. In InCor, limitations in variable definitions, regarding both data completeness and consistency, as well as the lack of reference parameters to follow the results caused the development of a data-driven culture over time, which was strengthened after the implementation and validation of the EuroSCORE I and the modified Parsonnet’s score. 4 Afterwards, the InCor created the InsCor, becoming one of the few centers in the world to have its own risk model for prediction, planning and optimization of outcomes. 5 Over time, the InCor took the lead by establishing a partnership with the São Paulo State Department of Health, in order to build the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR). 6 Next, the InCor established the Patient Safety and Quality Surgical Unit, which gave rise to the CQI Program, consolidated in 2016, whose initial mission was to reduce mortality rates in cardiovascular surgery. 603