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The Survey Committee of Japanese Association for Coronary Artery Surgery (JACAS)
Coronary artery surgery results
In 2016
Coronary artery bypass grafting (CABG), 2016 Total cases : 12,729 Isolated CABG : 8,492 (67%)(previous year:70%)
Concomitant CABG : 4,237 (33%)(previous year:30%) Isolated CABG Initial elective : 7,142 Except initial elective :1,350
Off-pump : 4,424 Off-pump : 695 On-pump : 2,718 On-pump : 655 (Off-pump rate : 62%) (Off-pump rate : 51%) (previous year : 63%) (previous year : 51%)
Changes of off-pump CABG rate(Initial elective CABG)
62%
0
10
20
30
40
50
60
70
80
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
%
year
Initial elective CABG :7,142(100%) On-pump (arrest) :1,706(23.9%) On-pump (beating) :1,012(14.2%) Off-pump (total) :4,424(61.9%) Off-pump (complete) :4,322 On-pump (conversion) : 102 Off-pump complete rate :97.7%
Off to on-pump conversion rate :2.3% (previous year:1.8%)
Mortality of isolated CABG :1.66% (previous year:1.72%) Mortality of initial elective CABG:1.09% (previous year:0.83%) On-pump (arrest) :1.29% On-pump (beating) :1.28% Off-pump (total) :0.97% Off-pump (complete):0.86% (previous year:0.54%) On-pump (conversion):5.88% (previous year:4.40%)
Changes of mortality (Isolated and initial elective CABG)
1.66%
1.09%
0
0.5
1
1.5
2
2.5
3
3.5
4
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
mo
rtal
ity
(%)
year
Isolated CABG
Initial elective CABG
Changes of mortality for procedures(Initial elective CABG)
0
1
2
3
4
5
6
7
8
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
mo
rtal
ity
(%)
year
Off-pump(complete)
On-pump(beating)
On-pump(arrest)
Off to on-pump(conversion)
Mortality according to number of diseased vessels (Initial elective CABG:7,142, mortality:1.09%)
mortality
(%)
1.0
0 25 50 75 100 (%)
1VD
(0%)
2VD
(0.65%)
3VD
(1.20%)
LMT
(0%)
LMT+2VD
(0.78%)
LMT+1VD
(0.62%)
LMT+3VD
(1.56%)
2.0
Mortality according to number of diseased vessels (Except initial elective CABG:1,350, mortality:4.67%)
mortality
(%)
10
5
0 25 50 75 100 (%)
1VD
(7.50%)
2VD
(4.49%) 3VD
(4.17%)
LMT
(5.00%)
LMT+1VD
(0.00%)
LMT+2VD
(5.20%)
LMT+3VD
(5.08%)
mortality
(%)
10
5
0 25 50 75 100 (%)
Off-pump (total)
2.59%
On-pump
(beating)
7.46% On-pump
(arrest)
6.14%
Mortality according to surgical procedures (Except initial elective CABG:1.350, mortality:4.67%)
Graft number according to procedures(Initial elective CABG)
Total
On-pump
(arrest)
On-pump
(beating)
Off to on
(conversion)
Off-pump (complete)
0 25 50 75 100%
average No. (previous year)
3.05
(2.99)
3.17
(3.17)
3.10
(3.01)
3.25
(3.08)
2.99
(2.74)
1 2 3 4≦
4≦
4≦
4≦
4≦
3
3
3
3
2
2
2
2 1
1
1
1
graft number
1
2
3
4≦
0 25 50 75 100%
Off-pump
Off to on-pump (conversion) On-pump (beating)
On-pump
(arrest)
Off-pump
Off-pump
Off-pump
On-pump
(arrest)
On-pump
(arrest)
On-pump
(arrest)
57.2%
Procedure according to graft number(Initial elective CABG)
graft number
On-pump (arrest) vs. off-pump (Initial elective CABG)
0 25 50 75 100%
On-pump (arrest)
On-pump (arrest)
On-pump (arrest)
Off-pump
Off-pump
Off-pump
68%
68%
88%
91%
78%
76%
bypass+
bypass −
RCA
LAD
LCX
Off-pump vs. off to on-pump conversion (Initial elective CABG)
0 25 50 75 100%
RCA(+) 3,003
LAD(+) 4,497
LCX(+) 3,367
RCA(−) 1,421
LAD(−) 93
LCX(−) 1,057
Off-pump
Off to on-pump conversion
2.3%
2.0%
2.5%
2.1%
10.7%
1.6%
Off-pump
Off-pump
Off-pump
Off-pump
Off-pump
Bypass No. conversion
rate
Age distribution according to gender (Initial elective CABG)
2000 1000 1000 0 0
313
780
2094
2212
709
60
123
420
677
330
49≧
60−69
50−59
70−79
≧80
(Age) Male:79.1% Female:20.9%
3000
(case) (case)
Changes of elderly cases(Initial elective CABG)
50.9%
13.5%
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2014 2015 2016
%
year
70 y.o. ≦
80 y.o. ≦
Changes of mortality according age(Initial elective CABG)
0
0.5
1
1.5
2
2.5
3
3.5
2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2014 2015 2016
mo
rtal
ity
(%)
year
49 y.o. ≧
50-59 y.o.
60-69 y.o.
70-79 y.o.
80 y.o. ≦
Graft selection (Total graft number of isolated CABG:22,938)
GEA
(3.2%)
RA
(3.8%)
LITA
(35.3%)
RITA
(15.6%)
SVG
(42.1%)
Changes of graft selection
0
5
10
15
20
25
30
35
40
45
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
%
year
LITA
RITA
GEA
RA
SVG
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Off-pump (complete) On-pump(arrest) On-pump(beating) Off to on-pump (coversion)
%
Stroke rate according to procedures(Isolated CABG)
Stroke cases:108
Stroke rate:108/8492(isolated CABG)=1.27%
1.10% 1.05%
1.96%
3.96%
p:0.0072
p:0.0332
p:0.0071
Results of emergency CABG after PCI complications
Emergency CABG; operation after PCI complications (coronary
occlusion and/or bleeding), within 24 hours
Cases:78
Rate:78/8492(isolated CABG);0.92%
Death cases:8
Mortality:10.2%
Results
cases death cases mortality(%)
CABG① 21 1 4.76
CABG② 27 3 11.11
CABG③ 16 3 18.75
CABG④ 6 0 0
Other procedures 8 1 12.5
Changes in results of ventricular septal perforation
Total No.:174, death:37 (mortality:21.2%)
0
10
20
30
40
50
60
mo
rtal
ity
(%)
year
Results of ventricular septal perforation (1)
alive
0 50 100 150
Total cases
Bypass(+)
Bypass(−)
death
37
174(mortality;21.2%)
72 13
102 24
137
78
(mortality;18.0%)
(mortality;23.5%)
(case)
200
59
Results of ventricular septal perforation (2)
0 50 100 150
Patch closure
alive
death
(mortality;22.0%)
18
19
(mortality;22.2%)
(mortality;21.0%)
(case)
Infarction exclusion
50
76
39 11
93 (mortality;18.4%)
Anterior infarction(mortality;19.5%)
Post-inferior infarction(mortality;26.8%)
52 14
Others 7 (mortality;14.2%)
14
15
Others 4 (mortality;75%)
4
1 3
6 1
Patch closure
Infarction exclusion
4
0
10
20
30
40
50
60
70
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
mo
rtal
ity
(%)
Anterior VSP
Post-inferior VSP
Changes in results of ventricular septal perforation
according to region
year
Changes in results of papillary muscle rupture
Total No.:32, death:4 (mortality:12.5%)
0
5
10
15
20
25
30
35
40
45
50
mo
rtal
ity
(%)
year
0 10 20 30
Total cases
Bypass(+)
Bypass(−)
alive
death
32 (mortality:12.5%)
12
20 17
(mortality;8.33%)
(mortality;15.0%)
(case)
4 28
11
3
1
Results of papillary muscle rupture
Total No.:144, death:38 (mortality:26.4%)
0
20
40
60
80
100
120
mo
rtal
ity
(%)
year
Changes in results of LV free wall rupture
0 50 100 150
Total cases
Bypass(+)
Bypass(−)
alive
death
144 (mortality;26.4%)
(mortality;54.2%)
(mortality;9.5%)
(case)
38 106
Blowout type 60 (mortality;50.0%) 30 30
12 (mortality;33.3%) 8
48 26 22
Oozing type
Bypass(+)
Bypass(−)
84 8 76
22 (mortality;9.1%)
6 56 62 (mortality;9.7%)
20
4
2
Results of LV free wall rupture
0
10
20
30
40
50
60
70
80
2009 2010 2011 2012 2013 2014 2015 2016
mo
rtal
ity
(%)
Blowout type
Oozing type
Changes in results of LV free wall rupture
according to rupture type
year
Changes in results of left ventricular aneurysm (LVA)
Total No.:164, death:8 (mortality:4.87%)
0
2
4
6
8
10
12
14
16
18
mo
rtal
ity
(%)
year
0 100 200 300
Total cases
Bypass(+)
Bypass(−)
alive
death
8 (mortality;4.87%)
114
156
109 (mortality;4.38%)
(mortality;5.88%)
(case)
51 48
164
Results of left ventriculoplasty and/or aneurysmectomy
5
3
0 100 200
Total cases
death
312 (mortality;3.84%)
(case)
12 300
Total
Bypass(+)
Bypass(+)
Bypass(−)
Bypass(−)
Total
226(mortality;1.76%) 4 222
200(mortality;2.00%) 271
26(mortality;0%)
26
86(mortlity;9.30%)
78
59(mortality;11.86%)
8
52
27(mortality;3.70%)
26
alive
Mitral valve
plasty
Mitral valve
replacement
50 150 250
7
300
196 4
1
Results of MVR or MVP for ischemic MR
0 50 100 150
Total cases
death
67 (mortality;5.97%)
(case)
4
Total
Bypass(+)
Bypass(+)
Bypass(−)
Bypass(−)
Total
55(mortality;5.45%) 52
38(mortality;7.89%) 35
17(mortality;0%)
8(mortality;0%)
8
12(mortality;8.33%)
4(mortality;25.0%)
alive
Left ventriculoptasty
+ Mitral valve plasty
17
11
63
3
1
3
3
1
Results of ischemic MR+LVA or ischemic cardiomyopathy
Left ventriculoptasty
+ Mitral valve
replacement
Conclusions (1)
1. The mortality of isolated CABG was 1.66%, that of initial
elective CABG was 1.09%, indicating almost same excellent
results than those of previous year.
2. Of initial elective CABGs, 62% cases underwent off-pump
procedure, showing still high rate. The mortality of off-pump
was 0.86%, which was slightly higher than that of previous
year, indicating still good results.
3. Off to on-pump conversion rate was 2.3%, and the mortality
of those cases was 5.88%, resulting getting worse.
4. The more bypass number, the lower the off-pump rate.
However, of all 4 and/more bypass procedures, 57.2% cases
were done by off-pump CABG.
5. CABG cases is getting older year by year, more than 70
years old patients rate was 50.9%, more than 80 was 13.5%,
showing high rate.
Conclusions (2)
6. Arterial grafts were used in 57.9%n of all grafts, while vein
grafts were used in 42.1%. The frequency of vein graft
usage increased in recent years.
7. The complication rate of central nerve system stroke of all
isolated CABG was 1.27%. This rate of off-pump CABG
showed significantly lower than those of on-pump (beating)
and off to on-pump conversion procedures, resulting
OPCAG can avoid this complication.
8. After PCI complications, emergency operation underwent in
0.92% of all isolated CABG within 24 hours. The mortality of
those cases was 10.2%, showing still high rate.
9. The results of complications for acute and old myocardial
infarction improved than those of previous year. However,
the mortality of post-inferior VSP and blowout type free wall
rupture, were high rate, indicating worse prognosis.
Special survey of intra-operative graft flow measurement for CABG
The Survey Committee of Japanese Association for Coronary Artery Surgery (JACAS)
Question 1 ;Do you know that an intra-operative graft flow measurement fee can
charge as payment for medical services ?
Question 2 ;Do you charge this fee, actually ?
Yes(90.2%)
No(9.8%)
Yes(78.6%)
No(21.4%)
Question 3 ;What kind of equipment do you use for intra-operative graft flow
measurement ?
0
50
100
150
200
250
TTFM TTFM+Echo Echo others
215
26
6 6
Question 4 ;What kind of parameters do you measure for intra-operative graft
flow measurement ?
0
50
100
150
200
250
mean flow PI DF flow waveform
others
236
196
108
202
3
Question 5 ;What kind of parameters do you emphasize for intra-operative
graft flow measurement ?
0
20
40
60
80
100
120
140
160
180
200
mean flow PI DF flow waveform
others
174
140
10
81
3
Question 6 :Do you use any diagnostic image equipment except graft flow
measurement ?
Yes(16.5%)
No(83.5%)
Question 7 :What kind of diagnostic image equipment do you use ?
0
5
10
15
20
25
30
SPY PDE Echo Others
11
26
10
6
Question 8 :How many grafts did you revise to perform CABG due to
abnormal graft flow measurement, in last year ?
Answer; 347
Question 9 :How many grafts did you perform CABG, in last year ?
Answer; 29,008
Revision rate;1.2%
Question 10 :What were the reasons for revision to perform CABG ?
0
20
40
60
80
100
120
Technical error Graft dissection Coronary arterydissection
Bleeding and/orhematoma
Unknouw Others
108
36
14 13
23 15
Question 11(1) :Do you have any standard to revise to perform CABG ?
83
33
23
14
7
0
10
20
30
40
50
60
70
80
90
Graft flow measuement(flow, PI, DF)
Flow wave form Anastomosis shape Diagnostic imaging Doppler flow meter
Question 11(2) :Do you have any standard to revise to perform to CABG ?
(detail of graft flow measurement standard)
0
1
2
3
4
5
6
7
8
9
10
0 < 10 <15 < 20
0
2
4
6
8
10
12
> 4 > 5 > 10
mean flow PI
DF < 60% : 2
(ml/min)