ABC | Volume 114, Nº4, April 2020

Original Article Mejia et al. Quality, the new era of cardiovascular surgery Arq Bras Cardiol. 2020; 114(4):603-612 Figure 5 – Year-by-year graph of the volume and mortality of the most complex and most frequently performed procedures in cardiovascular surgery since 2008. Mortality rate observed per surgery type Mortality Rate Observed (%) Aorta – Dissection Congenital Coronary Coronary + Valve Valve – Aortic Valve – Aortic and Mitral Valve – Mitral 40 30 20 10 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019-1S annual surgical volume has only increased, with the largest increase occurring in the 3rd period. The annual death rate was progressively increasing until the 4th period. The significant growth in surgical volume between the 2nd and 3rd periods (35%) caused the increase in mortality rate to be insignificant (0.1%). Nevertheless, the major decrease in surgical volume in the 4th period (22.7%) caused the mortality rate to increase significantly (2.9%). Although surgical volume growth between the 4th and 5th periods (6.7%) was not significant, the mortality rate reduced significantly (2.8%). Anyway, since its origins until the current period of the InCor, there has been a significant increase in surgical volume (47.9%), with a decrease in mortality rates (0.8%). The significant decrease in the global surgical volume in period 4 was directly related with the significant decrease in surgical volume in all subgroups, excepted for the arrhythmia subgroup. This was more evident in the CABG group, most probably due to the boom in percutaneous procedures, such as coronary angioplasty. 17 Moreover, new evidence changed the practice of cardiovascular disease treatment, with the advances in drug therapy 18 and accurate indication for surgical intervention. 19 Here, we highlight the role of Science in balancing and adjusting the scenario for the benefit of better patient outcomes. The decreased volume of CABG was significant between the 3rd and 4th periods (42.3%). However, we can say that it stopped to decline, since between the 4th and 5th periods, there was a decrease of only 6.4% (p = 0.21). We can see that, even though the highest CABG volume occurred in the 3rd period, the mortality rate has also increased (0.5%). Although this was not significant, it shows an increase in the number of deaths in this period. As described before, the incorporation of risk scores into our practice only took place by the beginning of the 4th period, which may explain to some extent the outcomes observed. As a result, the reduction of 42.3% in CABG volume in the 4th period undoubtedly impacted the mortality rate, which reached 5.78% (p = 0.01). What is evident is that, even though the volume reduction was not significant, in the 5th period, the mortality rate reduced 2.6% (p = 0.0001). By examining Figure 2, we note that the mortality rate in CABG surgeries reached 1% in 2019, a historic achievement, which is very close to the results of the best centers in the world. 20 The volume of Valve Surgeries, which had been progressively increasing, suffered a significant reduction in the 4th period (37.6%), with a significant increase in mortality (5.5%). However, in the 5th period, the surgical volume increased 24.9% (p = 0.20), and there was a decrease of 6.5% in the 609