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ANZSCTS National Cardiac Surgery Database

Data Definitions Manual

Version 4

An initiative of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS)

In association with the School of Public Health and Preventive Medicine, Monash University

January 2018 ANZSCTS

ANZSCTS Data Definitions Manual Version 4.1.1 2018

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Table of Contents INTRODUCTION ................................................................................................................................................................................................................................................... 19

BACKGROUND ................................................................................................................................................................................................................................................. 19

OBJECTIVE ....................................................................................................................................................................................................................................................... 19

DATA COLLECTION ........................................................................................................................................................................................................................................ 19

DATABASE INCLUSION CRITERIA .............................................................................................................................................................................................................. 20

PROGRAM MANAGEMENT ........................................................................................................................................................................................................................... 20

VERSION HISTORY ............................................................................................................................................................................................................................................. 21

ACKNOWLEDGEMENTS .................................................................................................................................................................................................................................... 21

HOW TO INTERPRET THIS DOCUMENT ....................................................................................................................................................................................................... 22

GLOSSARY ............................................................................................................................................................................................................................................................ 23

SECTION 1: PATIENT DEMOGRAPHICS................................................................................................................................................................................................ 24

HOSPITAL MEDICAL RECORD NUMBER .......................................................................................................................................................................................... 24

PATIENT SURNAME ................................................................................................................................................................................................................................ 24

PATIENT FIRST NAME ........................................................................................................................................................................................................................... 24

PATIENT MIDDLE NAME ........................................................................................................................................................................................................................ 24

DATE OF BIRTH ....................................................................................................................................................................................................................................... 24

SEX .............................................................................................................................................................................................................................................................. 24

ADDRESS .................................................................................................................................................................................................................................................. 24

SUBURB ..................................................................................................................................................................................................................................................... 24

STATE ......................................................................................................................................................................................................................................................... 24

POSTCODE ............................................................................................................................................................................................................................................... 25

PRIMARY PHONE NUMBER .................................................................................................................................................................................................................. 25

SECONDARY PHONE NUMBER ........................................................................................................................................................................................................... 25


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EMAIL ADDRESS ..................................................................................................................................................................................................................................... 25

INSURANCE .............................................................................................................................................................................................................................................. 26

MEDICARE NUMBER .............................................................................................................................................................................................................................. 26

PATIENT DOES NOT HAVE A MEDICARE NUMBER....................................................................................................................................................................... 26

DEPARTMENT OF VETERANS AFFAIRS (DVA) FILE NUMBER ................................................................................................................................................... 26

INDIGENOUS STATUS (1) ..................................................................................................................................................................................................................... 26



ELECTIVE DAY OF SURGERY ADMIT (DOSA) PATIENT ............................................................................................................................................................... 27

ADMISSION DATE ................................................................................................................................................................................................................................... 27

SURGERY DATE ...................................................................................................................................................................................................................................... 27

DISCHARGE DATE .................................................................................................................................................................................................................................. 27

OPERATION NUMBER ............................................................................................................................................................................................................................ 27

VERIFIED COMMENT ............................................................................................................................................................................................................................. 27

SECTION 2: PATIENT RISK FACTORS ................................................................................................................................................................................................... 28

SMOKING HISTORY ................................................................................................................................................................................................................................ 28

CURRENT SMOKER ................................................................................................................................................................................................................................ 28

DIABETES .................................................................................................................................................................................................................................................. 28

DIABETES CONTROL ............................................................................................................................................................................................................................. 28

HYPERCHOLESTEROLAEMIA .............................................................................................................................................................................................................. 28

RENAL – LAST PRE-OP CREATININE LEVEL ................................................................................................................................................................................... 29

RENAL – DIALYSIS .................................................................................................................................................................................................................................. 29

RENAL – TRANSPLANT ......................................................................................................................................................................................................................... 29

PRE-OPERATIVE HAEMOGLOBIN ...................................................................................................................................................................................................... 29


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HYPERTENSION ...................................................................................................................................................................................................................................... 29

CEREBROVASCULAR DISEASE .......................................................................................................................................................................................................... 29

CEREBROVASCULAR DISEASE – TYPE ........................................................................................................................................................................................... 30

CEREBROVASCULAR DISEASE – CEREBROVASCULAR ACCIDENT – WHEN ...................................................................................................................... 30

CEREBROVASCULAR DISEASE – CAROTID TEST RESULT ....................................................................................................................................................... 30

PERIPHERAL VASCULAR DISEASE (PVD) ....................................................................................................................................................................................... 31

RESPIRATORY DISEASE ....................................................................................................................................................................................................................... 31

RESPIRATORY DISEASE – TYPE ........................................................................................................................................................................................................ 31

INFECTIVE ENDOCARDITIS ................................................................................................................................................................................................................. 31

INFECTIVE ENDOCARDITIS – TYPE ................................................................................................................................................................................................... 32

IMMUNOSUPPRESSIVE THERAPY ..................................................................................................................................................................................................... 32

SECTION 3: PRE-OPERATIVE CARDIAC STATUS .............................................................................................................................................................................. 33

PREVIOUS MYOCARDIAL INFARCTION (MI) .................................................................................................................................................................................... 33

MYOCARDIAL INFARCTION – TYPE ................................................................................................................................................................................................... 33

MYOCARDIAL INFARCTION – WHEN ................................................................................................................................................................................................. 35

ANGINA – CCS CLASS CLASSIFICATION ......................................................................................................................................................................................... 35

TREATMENT OF ANGINA – IV GTN .................................................................................................................................................................................................... 35

TREATMENT OF ANGINA – IV HEPARIN ........................................................................................................................................................................................... 36

TREATMENT OF ANGINA – FULL DOSE HEPARINOIDS ............................................................................................................................................................... 36

HISTORY OF CONGESTIVE HEART FAILURE ................................................................................................................................................................................. 36

CHF – CHF AT CURRENT ADMISSION .............................................................................................................................................................................................. 36

NYHA CLASS – DYSPNOEA CLASSIFICATION ................................................................................................................................................................................ 36

CARDIOGENIC SHOCK .......................................................................................................................................................................................................................... 37

RESUSCITATION (within one hour prior to operation) ....................................................................................................................................................................... 37


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ARRHYTHMIA ........................................................................................................................................................................................................................................... 38

ARRHYTHMIA TYPE – ATRIAL ............................................................................................................................................................................................................. 38

ARRHYTHMIA – ATRIAL TYPE ............................................................................................................................................................................................................. 38

ARRHYTHMIA TYPE – HEART BLOCK ............................................................................................................................................................................................... 38

ARRHYTHMIA TYPE – VENTRICULAR ............................................................................................................................................................................................... 39

ARRHYTHMIA TYPE – OTHER ............................................................................................................................................................................................................. 39

PERMANENT PACEMAKER IN SITU ................................................................................................................................................................................................... 39

MEDICATIONS AT TIME OF SURGERY – INOTROPES .................................................................................................................................................................. 39

MEDICATIONS AT TIME OF SURGERY – IV NITRATES (GTN) .................................................................................................................................................... 39

MEDICATIONS AT TIME OF SURGERY – ANTICOAGULATION THERAPY ............................................................................................................................... 39

MEDICATIONS AT TIME OF SURGERY – STEROIDS ..................................................................................................................................................................... 40

ANTIPLATELET THERAPY – ASPIRIN ONLY .................................................................................................................................................................................... 40

ASPIRIN – WHEN ..................................................................................................................................................................................................................................... 40

ANTIPLATELET THERAPY – THIENOPYRIDINE .............................................................................................................................................................................. 40

THIENOPYRIDINE – WHEN ................................................................................................................................................................................................................... 40

ANTIPLATELET THERAPY – TICAGRELOR ...................................................................................................................................................................................... 40

TICAGRELOR – WHEN ........................................................................................................................................................................................................................... 41

ANTIPLATELET THERAPY – TIROFIBAN OR EPTIFIBATIDE ........................................................................................................................................................ 41

TIROFIBAN OR EPTIFIBATIDE – WHEN ............................................................................................................................................................................................. 41

ANTIPLATELET – ABCIXIMAB .............................................................................................................................................................................................................. 41

ABCIXIMAB – WHEN ............................................................................................................................................................................................................................... 41

ANTIPLATELET THERAPY – OTHER .................................................................................................................................................................................................. 41

OTHER ANTIPLATELET THERAPY – WHEN ..................................................................................................................................................................................... 41

SECTION 4: PREVIOUS INTERVENTIONS ............................................................................................................................................................................................ 42


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PREVIOUS CARDIOTHORACIC INTERVENTION (SURGICAL OR PERCUTANEOUS) ........................................................................................................... 42

PREVIOUS CARDIAC SURGERY ......................................................................................................................................................................................................... 42

NUMBER OF PRIOR CARDIAC OPERATIONS REQUIRING CARDIOPULMONARY BYPASS ............................................................................................... 42

NUMBER OF PRIOR CARDIAC OPERATIONS WITHOUT CARDIOPULMONARY BYPASS (BEATING HEART SURGERY) .......................................... 42

TYPES OF PREVIOUS SURGERY – CABG ........................................................................................................................................................................................ 42

TYPES OF PREVIOUS SURGERY – OFF PUMP CABG .................................................................................................................................................................. 42

TYPES OF PREVIOUS SURGERY – VALVE ...................................................................................................................................................................................... 42

TYPES OF PREVIOUS SURGERY – OTHER CARDIAC .................................................................................................................................................................. 42

PREVIOUS PERCUTANEOUS INTERVENTION ................................................................................................................................................................................ 42

PREVIOUS PERCUTANEOUS INTERVENTION – TAVR ................................................................................................................................................................. 43

PREVIOUS PERCUTANEOUS INTERVENTION – PTCA/STENT ................................................................................................................................................... 43

PTCA/STENT – ADMISSION .................................................................................................................................................................................................................. 43

PTCA/STENT – INTERVAL ..................................................................................................................................................................................................................... 43

PREVIOUS PERCUTANEOUS INTERVENTION – NON-SURGICAL BALLOON VALVULOPLASTY ...................................................................................... 43

ASD/PFO DEVICE CLOSURE ................................................................................................................................................................................................................ 43

VSD DEVICE CLOSURE ......................................................................................................................................................................................................................... 43

LEFT ATRIAL APPENDAGE OCCLUSION .......................................................................................................................................................................................... 44

ELECTROPHYSIOLOGY ABLATION .................................................................................................................................................................................................... 44

PERCUTANEOUS MITRAL VALVE REPAIR ....................................................................................................................................................................................... 44

PREVIOUS PERCUTANEOUS INTERVENTION – TMVR ................................................................................................................................................................ 44

SECTION 5: HAEMODYNAMICS ............................................................................................................................................................................................................... 45

HEIGHT ...................................................................................................................................................................................................................................................... 45

CARDIAC CATHETERISATION (ANGIOGRAPHY) ............................................................................................................................................................................ 45

DATE OF CARDIAC CATHETERISATION ........................................................................................................................................................................................... 45


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LVEF METHOD ......................................................................................................................................................................................................................................... 45

LVEF ............................................................................................................................................................................................................................................................ 45

LVEF ESTIMATE....................................................................................................................................................................................................................................... 46

LEFT MAIN CORONARY ARTERY STENOSIS >50% ....................................................................................................................................................................... 46

NUMBER OF DISEASED CORONARY SYSTEMS ............................................................................................................................................................................ 46

SECTION 6: OPERATION STATUS .......................................................................................................................................................................................................... 48

CONSULTANT SURGEON ..................................................................................................................................................................................................................... 48

OPERATING SURGEON (PROCEDURALIST) ................................................................................................................................................................................... 48

STATUS ...................................................................................................................................................................................................................................................... 48

URGENT PROCEDURE – REASON ..................................................................................................................................................................................................... 49

DIRECT TRANSFER FROM CATH LAB/ICU TO THEATRE ............................................................................................................................................................ 49

CORONARY ARTERY BYPASS ............................................................................................................................................................................................................ 50

VALVE SURGERY .................................................................................................................................................................................................................................... 50

OTHER CARDIAC SURGERY ................................................................................................................................................................................................................ 50

LV ANEURYSM ......................................................................................................................................................................................................................................... 50

VSD (ACQUIRED)..................................................................................................................................................................................................................................... 50

ASD ............................................................................................................................................................................................................................................................. 50

TRAUMA ..................................................................................................................................................................................................................................................... 50

LVOT MYECTOMY ................................................................................................................................................................................................................................... 50

LV RUPTURE REPAIR ............................................................................................................................................................................................................................ 51

PERICARDIECTOMY ............................................................................................................................................................................................................................... 51

PULMONARY THROMBO-ENDARTERECTOMY............................................................................................................................................................................... 51

LEFT VENTRICULAR RECONSTRUCTION ........................................................................................................................................................................................ 51

PULMONARY EMBOLECTOMY ............................................................................................................................................................................................................ 51


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CARDIAC TUMOUR ................................................................................................................................................................................................................................. 51

CARDIAC TRANSPLANT ........................................................................................................................................................................................................................ 51

CARDIOPULMONARY TRANSPLANT ................................................................................................................................................................................................. 51

OTHER CONGENITAL ............................................................................................................................................................................................................................. 51

PERMANENT LV EPICARDIAL LEAD .................................................................................................................................................................................................. 52

LEFT ATRIAL APPENDAGE CLOSURE .............................................................................................................................................................................................. 52

ATRIAL ARRHYTHMIA SURGERY ....................................................................................................................................................................................................... 52

ATRIAL ARRHYTHMIA SURGERY – LESION SET ........................................................................................................................................................................... 52

ATRIAL ARRHYTHMIA SURGERY – ENERGY SOURCE ................................................................................................................................................................ 53

OTHER ........................................................................................................................................................................................................................................................ 53

OTHER REASON/PROCEDURE ........................................................................................................................................................................................................... 53

AORTIC PROCEDURE ............................................................................................................................................................................................................................ 53

AORTIC PATHOLOGY/AETIOLOGY .................................................................................................................................................................................................... 53

AORTIC DISSECTION – WHEN ............................................................................................................................................................................................................ 54

AORTIC PROCEDURE TYPE – DIRECT AORTOPLASTY............................................................................................................................................................... 54

AORTOPLASTY TYPE – ENDARTERECTOMY ................................................................................................................................................................................. 54

AORTOPLASTY TYPE – PATCH REPAIR ........................................................................................................................................................................................... 54

AORTIC PROCEDURE TYPE – REPLACEMENT .............................................................................................................................................................................. 54

AORTIC REPLACEMENT LOCATION – ASCENDING ...................................................................................................................................................................... 55

AORTIC REPLACEMENT LOCATION – ARCH .................................................................................................................................................................................. 55

AORTIC REPLACEMENT LOCATION – DESCENDING ................................................................................................................................................................... 55

AORTIC REPLACEMENT LOCATION – THOR/ABD ......................................................................................................................................................................... 55

OTHER NON-CARDIAC PROCEDURE ................................................................................................................................................................................................ 55

CAROTID ENDARTERECTOMY............................................................................................................................................................................................................ 55


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LUNG RESECTION .................................................................................................................................................................................................................................. 55

OTHER VASCULAR SURGERY ............................................................................................................................................................................................................ 55

OTHER THORACIC SURGERY ............................................................................................................................................................................................................. 55

OTHER ........................................................................................................................................................................................................................................................ 55

OTHER REASON ...................................................................................................................................................................................................................................... 56

SECTION 7: MINIMALLY INVASIVE ......................................................................................................................................................................................................... 57

MINIMALLY INVASIVE OPEN TECHNIQUE ATTEMPTED .............................................................................................................................................................. 57

ROBOTICALLY ASSISTED ..................................................................................................................................................................................................................... 57

SECTION 8: CPB AND SUPPORT ............................................................................................................................................................................................................ 58

CARDIOPULMONARY BYPASS USED................................................................................................................................................................................................ 58

CARDIOPLEGIA ........................................................................................................................................................................................................................................ 58

TYPE OF CARDIOPLEGIA ..................................................................................................................................................................................................................... 58

CUMULATIVE CROSS CLAMP TIME ................................................................................................................................................................................................... 58

CUMULATIVE CARDIOPULMONARY BYPASS TIME (PERFUSION TIME) ................................................................................................................................. 58

INTRA-OPERATIVE HAEMOGLOBIN ................................................................................................................................................................................................... 58

INTRA-AORTIC BALLOON PUMP ......................................................................................................................................................................................................... 58

INTRA-AORTIC BALLOON PUMP – WHEN ........................................................................................................................................................................................ 58

INTRA-AORTIC BALLOON PUMP – INDICATION ............................................................................................................................................................................. 59

OTHER MECHANICAL SUPPORT – ECMO ........................................................................................................................................................................................ 59

OTHER MECHANICAL SUPPORT – ECMO WHEN .......................................................................................................................................................................... 59

OTHER MECHANICAL SUPPORT – ECMO INDICATION ............................................................................................................................................................... 60

OTHER MECHANICAL SUPPORT – VAD ........................................................................................................................................................................................... 60

OTHER MECHANICAL SUPPORT – VAD WHEN .............................................................................................................................................................................. 60

OTHER MECHANICAL SUPPORT – VAD INDICATION ................................................................................................................................................................... 61


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INTRA-OPERATIVE TOE ........................................................................................................................................................................................................................ 61

INTRA-OPERATIVE ANTIFIBRINOLYTIC USE .................................................................................................................................................................................. 61

INTRA-OPERATIVE ANTIFIBRINOLYTIC USE – TYPE .................................................................................................................................................................... 62

SECTION 9: CORONARY ARTERY BYPASS GRAFT .......................................................................................................................................................................... 63

INTRA-OPERATIVE DECISION TO GRAFT CORONARY ARTERY .............................................................................................................................................. 63

ITA USED ................................................................................................................................................................................................................................................... 63

ITA USED – LITA (LEFT) ......................................................................................................................................................................................................................... 63

ITA USED – LITA (LEFT) SKELETONISED ......................................................................................................................................................................................... 63

ITA USED – RITA (RIGHT) ..................................................................................................................................................................................................................... 63

ITA USED – RITA (RIGHT) SKELETONISED ...................................................................................................................................................................................... 63

NUMBER OF RADIAL ARTERY CONDUITS HARVESTED ............................................................................................................................................................. 63

NUMBER OF DISTAL ARTERIAL GRAFTS (DISTAL ANASTOMOSES WITH ARTERIAL CONDUITS) ................................................................................. 63

NUMBER OF ITA DISTAL ANASTOMOSES ....................................................................................................................................................................................... 63

NUMBER OF RADIAL DISTAL ANASTOMOSES ............................................................................................................................................................................... 64

NUMBER OF VEIN DISTAL ANASTOMOSES .................................................................................................................................................................................... 64

NUMBER OF GEPA DISTAL ANASTOMOSES .................................................................................................................................................................................. 64

T-GRAFT OR Y-GRAFT ........................................................................................................................................................................................................................... 64

NUMBER OF DISTAL ANASTOMOSES ............................................................................................................................................................................................... 64

SECTION 10: VALVE SURGERY .............................................................................................................................................................................................................. 65

AORTIC VALVE PROCEDURE .............................................................................................................................................................................................................. 65

AORTIC VALVE PROSTHESIS – IMPLANT SERIAL NUMBER ...................................................................................................................................................... 66

AORTIC VALVE PROSTHESIS – IMPLANT LOT NUMBER ............................................................................................................................................................. 66

AORTIC VALVE PROSTHESIS – IMPLANT SIZE .............................................................................................................................................................................. 66

AORTIC VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER ............................................................................................................... 67


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AORTIC VALVE PROSTHESIS – EXPLANT SIZE ............................................................................................................................................................................. 67

AORTIC STENOSIS ................................................................................................................................................................................................................................. 67

AORTIC REGURGITATION/INSUFFICIENCY .................................................................................................................................................................................... 67

AORTIC VALVE PATHOLOGY/AETIOLOGY ...................................................................................................................................................................................... 67

MITRAL VALVE PROCEDURE .............................................................................................................................................................................................................. 69

MITRAL VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER ................................................................................................................. 70

MITRAL VALVE PROSTHESIS – IMPLANT SERIAL NUMBER ....................................................................................................................................................... 70

MITRAL VALVE PROSTHESIS – IMPLANT LOT NUMBER ............................................................................................................................................................. 70

MITRAL VALVE PROSTHESIS – IMPLANT SIZE .............................................................................................................................................................................. 70

MITRAL VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER ................................................................................................................ 70

MITRAL VALVE PROSTHESIS – EXPLANT SERIAL NUMBER ...................................................................................................................................................... 70

MITRAL VALVE PROSTHESIS – EXPLANT SIZE .............................................................................................................................................................................. 70

MITRAL STENOSIS .................................................................................................................................................................................................................................. 71

MITRAL REGURGITATION/INSUFFICIENCY ..................................................................................................................................................................................... 71

MITRAL VALVE PATHOLOGY/ AETIOLOGY ...................................................................................................................................................................................... 71

TRICUSPID VALVE PROCEDURE........................................................................................................................................................................................................ 72

TRICUSPID VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER .......................................................................................................... 73

TRICUSPID VALVE PROSTHESIS – IMPLANT SERIAL NUMBER ................................................................................................................................................ 73

TRICUSPID VALVE PROSTHESIS – IMPLANT LOT NUMBER ...................................................................................................................................................... 74

TRICUSPID VALVE PROSTHESIS – IMPLANT SIZE ........................................................................................................................................................................ 74

TRICUSPID VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER ......................................................................................................... 74

TRICUSPID VALVE PROSTHESIS – EXPLANT SERIAL NUMBER ............................................................................................................................................... 74

TRICUSPID VALVE PROSTHESIS – EXPLANT SIZE ....................................................................................................................................................................... 74

TRICUSPID STENOSIS ........................................................................................................................................................................................................................... 74


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TRICUSPID REGURGITATION/INSUFFICIENCY .............................................................................................................................................................................. 74

TRICUSPID VALVE PATHOLOGY/AETIOLOGY ................................................................................................................................................................................ 74

PULMONARY VALVE PROCEDURE .................................................................................................................................................................................................... 76

PULMONARY VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER ...................................................................................................... 76

PULMONARY VALVE PROSTHESIS – IMPLANT SERIAL NUMBER ............................................................................................................................................ 76

PULMONARY VALVE PROSTHESIS – IMPLANT LOT NUMBER ................................................................................................................................................... 76

PULMONARY VALVE PROSTHESIS – IMPLANT SIZE .................................................................................................................................................................... 77

PULMONARY VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER ..................................................................................................... 77

PULMONARY VALVE PROSTHESIS – EXPLANT SERIAL NUMBER ........................................................................................................................................... 77

PULMONARY VALVE PROSTHESIS – EXPLANT SIZE ................................................................................................................................................................... 77

PULMONARY STENOSIS ....................................................................................................................................................................................................................... 77

PULMONARY REGURGITATION/INSUFFICIENCY .......................................................................................................................................................................... 77

PULMONARY VALVE PATHOLOGY/AETIOLOGY ............................................................................................................................................................................ 77

SECTION 10.1: TAVR MODULE ................................................................................................................................................................................................................ 79

PREVIOUS AVR ........................................................................................................................................................................................................................................ 79

PREVIOUS PROSTHESIS ...................................................................................................................................................................................................................... 79

EVALUATION TO PERFORM TAVR ..................................................................................................................................................................................................... 79

CANADIAN CLINICAL FRAILTY SCALE .............................................................................................................................................................................................. 79

PORCELAIN AORTA ................................................................................................................................................................................................................................ 80

PROCEDURAL ACCESS ........................................................................................................................................................................................................................ 81

SUCCESSFUL DEPLOYMENT .............................................................................................................................................................................................................. 81

SURGICAL AVR ........................................................................................................................................................................................................................................ 81

ANAESTHESIA .......................................................................................................................................................................................................................................... 81

VASCULAR CLOSURE TECHNIQUE ................................................................................................................................................................................................... 81


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PROCEDURE INITIATION DATE/TIME ................................................................................................................................................................................................ 82

PROCEDURE COMPLETION DATE/TIME .......................................................................................................................................................................................... 82

PROCEDURE ABORTION DATE/TIME ................................................................................................................................................................................................ 82

NUMBER OF DAYS POST OPERATION ............................................................................................................................................................................................. 82

AORTIC VALVE PEAK GRADIENT ....................................................................................................................................................................................................... 82

AORTIC VALVE MEAN GRADIENT ...................................................................................................................................................................................................... 82

AORTIC VALVE AREA ............................................................................................................................................................................................................................. 82

AORTIC VALVE REGURGITATION ...................................................................................................................................................................................................... 82

SECTION 10.2: TMVR MODULE ............................................................................................................................................................................................................... 83

PREVIOUS MVR ....................................................................................................................................................................................................................................... 83

PREVIOUS PROSTHESIS ...................................................................................................................................................................................................................... 83

EVALUATION TO PERFORM TMVR .................................................................................................................................................................................................... 83

CANADIAN CLINICAL FRAILTY SCALE .............................................................................................................................................................................................. 84

PROCEDURAL ACCESS ........................................................................................................................................................................................................................ 85

SUCCESSFUL DEPLOYMENT .............................................................................................................................................................................................................. 85

SURGICAL MVR ....................................................................................................................................................................................................................................... 85

ANAESTHESIA .......................................................................................................................................................................................................................................... 85

VASCULAR CLOSURE TECHNIQUE ................................................................................................................................................................................................... 85

PROCEDURE INITIATION DATE/TIME ................................................................................................................................................................................................ 86

PROCEDURE COMPLETION DATE/TIME .......................................................................................................................................................................................... 86

PROCEDURE ABORTION DATE/TIME ................................................................................................................................................................................................ 86

NUMBER OF DAYS POST OPERATION ............................................................................................................................................................................................. 86

MITRAL VALVE PEAK GRADIENT ....................................................................................................................................................................................................... 86

MITRAL VALVE MEAN GRADIENT ....................................................................................................................................................................................................... 86


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MITRAL VALVE AREA ............................................................................................................................................................................................................................. 86

MITRAL VALVE REGURGITATION ....................................................................................................................................................................................................... 86

SECTION 11: BLOOD PRODUCT USE .................................................................................................................................................................................................... 87

BLOOD BANK PRODUCTS – RBC ....................................................................................................................................................................................................... 87

BLOOD BANK PRODUCTS – RBC Units ............................................................................................................................................................................................. 87

BLOOD BANK PRODUCTS – NON RBC ............................................................................................................................................................................................. 87

BLOOD BANK PRODUCTS – PLATELETS ......................................................................................................................................................................................... 87

BLOOD BANK PRODUCTS – NOVO 7 ................................................................................................................................................................................................. 87

BLOOD BANK PRODUCTS – CRYOPRECIPITATE .......................................................................................................................................................................... 87

BLOOD BANK PRODUCTS – FRESH FROZEN PLASMA ............................................................................................................................................................... 87

Indicate the number of Fresh Frozen Plasma (FFP) units used. ....................................................................................................................................................... 87

SECTION 12: POST-OPERATIVE DATA ................................................................................................................................................................................................. 88

ICU ADMISSION – DATE/TIME ............................................................................................................................................................................................................. 88

EXTUBATION – DATE/TIME .................................................................................................................................................................................................................. 88

ICU DISCHARGE – DATE/TIME ............................................................................................................................................................................................................ 88

READMITTED TO ICU ............................................................................................................................................................................................................................. 88

RE-INTUBATION....................................................................................................................................................................................................................................... 88

RE-INTUBATION – DATE/TIME ............................................................................................................................................................................................................. 88

RE-EXTUBATION – DATE/TIME ........................................................................................................................................................................................................... 88

ICC LOSS (FIRST 4 HOURS POST SURGERY) ................................................................................................................................................................................ 88

RETURN TO THEATRE ........................................................................................................................................................................................................................... 89

RETURN TO THEATRE – VALVE DYSFUNCTION ........................................................................................................................................................................... 89

RETURN TO THEATRE – BLEEDING/TAMPONADE ........................................................................................................................................................................ 89

RETURN TO THEATRE – GRAFT OCCLUSION ................................................................................................................................................................................ 89


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RETURN TO THEATRE – DEEP STERNAL WOUND INFECTION ................................................................................................................................................. 89

RETURN TO THEATRE – DEEP THORACOTOMY WOUND INFECTION ................................................................................................................................... 89

RETURN TO THEATRE – INSERTION OF PACEMAKER/AICD ..................................................................................................................................................... 89

RETURN TO THEATRE – OTHER CARDIAC ..................................................................................................................................................................................... 89

RETURN TO THEATRE – OTHER NON-CARDIAC ........................................................................................................................................................................... 89

NEW RENAL INSUFFICIENCY .............................................................................................................................................................................................................. 90

HAEMOFILTRATION ................................................................................................................................................................................................................................ 90

HIGHEST POST-OP CREATININE LEVEL .......................................................................................................................................................................................... 90

PERI-/POST- OPERATIVE MI ................................................................................................................................................................................................................ 90

PERI-/POST- OPERATIVE CARDIOGENIC SHOCK ......................................................................................................................................................................... 91

POST-OPERATIVE HAEMOGLOBIN .................................................................................................................................................................................................... 91

CARDIAC INOTROPE USE – FOR LONGER THAN 4 HOURS POST-OPERATIVELY .............................................................................................................. 91

CARDIAC INOTROPE USE – FOR LOW CARDIAC OUTPUT SYNDROME ................................................................................................................................. 91

CARDIAC VASOPRESSOR USE – FOR LOW SVR SYNDROME .................................................................................................................................................. 91

NEW CARDIAC ARRHYTHMIA .............................................................................................................................................................................................................. 91

NEW HEART BLOCK (REQUIRING PPM) ........................................................................................................................................................................................... 92

NEW OTHER BRADYARRHYTHMIA (REQUIRING PPM) ................................................................................................................................................................ 92

CARDIAC ARREST .................................................................................................................................................................................................................................. 92

NEW ATRIAL ARRHYTHMIA (REQUIRING TREATMENT) ATRIAL FIBRILLATION OR FLUTTER ......................................................................................... 92

NEW VENTRICULAR TACHYCARDIA ................................................................................................................................................................................................. 92

STROKE PERMANENT ........................................................................................................................................................................................................................... 92

STROKE TRANSIENT ............................................................................................................................................................................................................................. 92

NEW CONTINUOUS COMA ≥ 24 HOURS ......................................................................................................................................................................................... 92

PROLONGED VENTILATION > 24 HOURS ........................................................................................................................................................................................ 93


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PULMONARY EMBOLISM ...................................................................................................................................................................................................................... 93

PNEUMONIA ............................................................................................................................................................................................................................................. 93

DEEP STERNAL WOUND INFECTION ................................................................................................................................................................................................ 93

SUPERFICIAL ACCESS-WOUND INFECTION .................................................................................................................................................................................. 93

DONOR SITE DEEP WOUND INFECTION .......................................................................................................................................................................................... 93

DEEP ACCESS-WOUND INFECTION OF PARASTERNAL SITE (NOT OF STERNOTOMY) ................................................................................................... 94

SEPTICAEMIA ........................................................................................................................................................................................................................................... 94

AORTIC DISSECTION ............................................................................................................................................................................................................................. 94

ACUTE LIMB ISCHAEMIA ....................................................................................................................................................................................................................... 94

ANTICOAGULANT COMPLICATIONS.................................................................................................................................................................................................. 95

GASTROINTESTINAL TRACT (GIT) COMPLICATIONS ................................................................................................................................................................... 95

MULTI-SYSTEM FAILURE ...................................................................................................................................................................................................................... 95

SECTION 13: MORTALITY/READMISSION ............................................................................................................................................................................................ 96

DISCHARGE .............................................................................................................................................................................................................................................. 96

MORTALITY POST-DISCHARGE .......................................................................................................................................................................................................... 96

MORTALITY – DATE ................................................................................................................................................................................................................................ 96

MORTALITY – LOCATION ...................................................................................................................................................................................................................... 97

MORTALITY – PRIMARY CAUSE ......................................................................................................................................................................................................... 97

MORTALITY – SUBSEQUENT CAUSE ................................................................................................................................................................................................ 97

COGNISANT PATIENT WITHDRAWS FROM TREATMENT ........................................................................................................................................................... 98

READMISSION ≤ 30 DAY FROM SURGERY .................................................................................................................................................................................... 98

READMISSION REASON – ANTICOAGULANT COMPLICATION .................................................................................................................................................. 98

READMISSION REASON – ARRHYTHMIA ......................................................................................................................................................................................... 98

READMIT REASON – CONGESTIVE HEART FAILURE (CHF) ....................................................................................................................................................... 98


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READMIT REASON – VALVE DYSFUNCTION .................................................................................................................................................................................. 99

READMIT REASON – PERICARDIAL EFFUSION ............................................................................................................................................................................. 99

READMIT REASON – CARDIAC TAMPONADE ................................................................................................................................................................................. 99

READMIT REASON – PLEURAL EFFUSION ...................................................................................................................................................................................... 99

READMISSION REASON – OTHER COMPLICATION RELATED TO CARDIAC SURGERY .................................................................................................... 99

READMIT REASON – DEEP STERNAL INFECTION ........................................................................................................................................................................ 99

READMIT REASON – INCISIONAL COMPLICATION ....................................................................................................................................................................... 99

READMIT REASON – PNEUMONIA OR OTHER RESPIRATORY COMPLICATION ................................................................................................................ 100

READMIT REASON – MYOCARDIAL INFARCTION (MI) ............................................................................................................................................................... 100

READMIT REASON – RECURRENT ANGINA .................................................................................................................................................................................. 100

READMIT REASON – READMISSION UNRELATED TO CARDIAC SURGERY ........................................................................................................................ 100

AUTOMATED DATA (not collected on data collection form) ............................................................................................................................................................... 101

Patient ID .................................................................................................................................................................................................................................................. 101

Admission ID ............................................................................................................................................................................................................................................ 101

Operation ID ............................................................................................................................................................................................................................................. 101

Age ............................................................................................................................................................................................................................................................ 101

BMI ............................................................................................................................................................................................................................................................ 101

BSA ............................................................................................................................................................................................................................................................ 101

Estimated Glomerular Filtration Rate ................................................................................................................................................................................................... 102

Angina - Type ........................................................................................................................................................................................................................................... 102

Number of Distal Anastomoses ............................................................................................................................................................................................................. 102

Prolonged Intubation ............................................................................................................................................................................................................................... 102

Hours intubated (initial post-operative ventilation only) ..................................................................................................................................................................... 103

Hours in ICU (initial stay only) ............................................................................................................................................................................................................... 103


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Mortality within 30 Days of Surgery ...................................................................................................................................................................................................... 103

Aortic Valve Prosthesis – Implant Type ............................................................................................................................................................................................... 103

Aortic Valve Prosthesis – Explant Type ............................................................................................................................................................................................... 104

Mitral Valve Prosthesis – Implant Type................................................................................................................................................................................................ 104

Mitral Valve Prosthesis – Explant Type ............................................................................................................................................................................................... 104

Tricuspid Valve Prosthesis – Implant Type ......................................................................................................................................................................................... 105

Tricuspid Valve Prosthesis – Explant Type ......................................................................................................................................................................................... 105

Pulmonary Valve Prosthesis – Implant Type ...................................................................................................................................................................................... 105

Pulmonary Valve Prosthesis – Explant Type ...................................................................................................................................................................................... 106


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INTRODUCTION Cardiac Surgery is a highly technical and specialised area of medicine, which is constantly evolving in terms of techniques, knowledge base and patient mix.

Integral to this advancement is the requirement to ensure the attainment and maintenance of best practice, at an individual, unit, state and national level. The

Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) views routine systematic collection of data related to each surgical procedure

and the monitoring of that data as a cornerstone of best practice. Knowledge of performance, identification of outstanding performance and active

dissemination of techniques leading to that performance, are designed to maintain and improve the standard of cardiac surgery in Australia.

BACKGROUND

The ANZSCTS Database records details of all adult cardiac surgical procedures performed in participating units. Currently, twenty three out of twenty four public

hospital units are members of the Program in addition to seventeen private hospital services.

OBJECTIVE

The aims of this Program are to standardise surgical and clinical data collection and to report on performance standards at the individual, unit, state and national

level. This Program provides the following:

A common dataset with identical definitions of all data points.

Collation of reliable data for research, risk assessment, and outcome prediction.

Evaluation of individual, unit, hospital, state and national performance.

Improvement of the quality of patient care through an effective peer review mechanism.

At the Institutional level, provision of a core data set for in-house mortality and morbidity review.

Availability of appropriate information for external research purposes.

DATA COLLECTION

Standard data is collected on the paper form shown in this booklet. Data is entered and transmitted via a secure online web-based system or via an

accredited data export system. Data management, analysis, and database development are provided by Centre of Cardiovascular Research and Education in

Therapeutics (CCRE-T), in the School of Public Health and Preventive Medicine, Monash University.


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DATABASE INCLUSION CRITERIA ANZSCTS require data on the following:

All patients undergoing:

(i) cardiac surgery

(ii) other thoracic surgery using cardiopulmonary bypass, or

(iii) pericardiectomy for constrictive pericarditis, where performed on or off Cardiopulmonary Bypass

One form must be completed per surgical operation that fits the above criteria. If multiple operations are performed in the one admission, a new form must be completed

for each operation.

PROGRAM MANAGEMENT

The Program is supervised by a Steering Committee that meets at least four times per year to review the direction and progress of the Program. Its members

in 2018 are:

Mr Gil Shardey Mr Andrew Newcomb Dr Christopher Cole Prof Paul Bannon Mr Deepak Mehrotra Prof Julian Smith Mr Hugh Wolfenden Mr Jurgen Passage Mr Greg Rice A/ Prof Andrew Cochrane Dr Robert Costa Dr Sumit Yadav Mr Ashutosh Hardikar A/Prof Rob Baker Prof Chris Reid Prof Danny Liew Dr Lavinia Tran Ms Angela Brennan

ANZSCTS (Cabrini Health), Chair ANZSCTS (St Vincent’s Hospital) ANZSCTS (Princess Alexandra Hospital) ANZSCTS (Royal Prince Alfred) ANZSCTS (Mount Hospital) ANZSCTS (Monash Medical Centre) ANZSCTS (Prince of Wales Hospital) ANZSCTS (Sir Charles Gairdner Hospital) ANZSCTS (Flinders Medical Centre) ANZSCTS (Monash Medical Centre) ANZSCTS (Westmead Hospital) ANZSCTS (Townsville Hospital) ANZSCTS (Royal Hobart Hospital) Perfusion (Flinders Medical Centre) Head, CCRE-T, Monash University Head, CCRE-T, Monash University Program Manager, CCRE-T, Monash University Senior Research Fellow, CCRE-T, Monash University


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Ms Eileen Thompson Victorian Cardiac Clinical Network, Safer Care Victoria, Department of Health and Human Services (Victoria) Mr Tom Hunter Data Manager representative (St Vincent’s Hospital (NSW)) Dr Rochelle Wynne Data Manager representative (Royal Melbourne Hospital)

Complete and accurate data collection and strict adherence to the data definitions in this booklet are essential and integral to the success of the Program. The

Steering Committee appreciates that significant effort and attention to detail will be required from each cardiac surgery unit to successfully perform these

tasks.

The key contact person for the data collection and analysis process is Dr Lavinia Tran, Program Manager, School of Public Health and Preventive Medicine,

Monash University. Dr Tran can be contacted on +61 3 9903 0229. However, in the first instance, all enquiries should be directed to [email protected].

VERSION HISTORY Version number Release Date

1.0 2001

2.0 August 2005

3.0 August 2008

4.0 July 2016

4.1 February 2017

4.1.1 January 2018

ACKNOWLEDGEMENTS The following people contributed to Version 4.1.1 of the ANZSCTS Data Definitions: Mr Gil Shardey, Mr Andrew Newcomb, A/Prof Rob Baker, Prof Chris Reid, Dr Lavinia

Tran, Ms Angela Brennan, Ms Heather Baxter, Ms Dhenisha Dahya, Mrs Nicole Marrow and Ms Christina Ayres.

mailto:[email protected]

snoah

Highlight


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HOW TO INTERPRET THIS DOCUMENT A sample of the format of the definitions in this document is shown in Table 1 below. Table 2 explains what the various column headers mean.

Table 1.

Table 2.

Item # An individual variable number (Item #) is allocated to each variable in the dataset and corresponds to the question number on the case report form (CRF).

Field Name The field name is the ‘code name’ for the variable. When data is imported or exported it is done so under the field name.

Variable Name and Description Includes the data definition, specific instructions and guiding notes to ensure data accuracy.

Data Details Demonstrates the format in which the data should be entered: Selection list Free Text Numeric


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Date

Rules Level 1 – There is a mandatory requirement to answer this variable e.g. Indigenous Status (1) Level 2 – The requirement to answer this variable is conditional on another variable e.g. an answer for Indigenous Status (2) is only required if Indigenous Status (1) is answered yes. Level 3 –The requirement to answer this variable is conditional on another conditional variable. Optional – The requirement to answer this variable is optional i.e. if the information is available enter it otherwise it can be left blank.

GLOSSARY

Index Admission –the current admission i.e. the admission in which the operation (for which you are completing a form) was performed.

Index Operation –the current operation i.e. the operation for which you are completing the form.


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SECTION 1: PATIENT DEMOGRAPHICS

Item # Field Name Variable Name and Description Data Details Rules

1.0 UR HOSPITAL MEDICAL RECORD NUMBER Record the unique medical record number of the patient at the hospital where the index operation was performed.

Free Text Alphanumeric

Level 1

2.0 LNAME PATIENT SURNAME Record the last name (surname) of the patient including hyphens (-), apostrophes (‘) and spaces. Note: Do not add spaces before and after the surname.

Free Text Alpha

Level 1

3.0 FNAME PATIENT FIRST NAME Record the first name (Christian name/given name) of the patient including hyphens (-), apostrophes (’) and spaces. Note: Do not add spaces before and after the first name.

Free Text Alpha

Level 1

4.0 MNAME PATIENT MIDDLE NAME Record the middle name of the patient, including hyphens (-), apostrophes (’) and spaces. Note: Do not add spaces before and after the middle name.

Free Text Alpha

Optional

5.0 DOB DATE OF BIRTH Record the date of birth of the patient.

Date DD/MM/YYYY

Level 1 Must be before system date

6.0 SEX SEX Record the sex of the patient.

Selection List 1=Male 2=Female

Level 1

7.0 ADDRESS ADDRESS Record the street number, name and type of the patient’s residence. Note: This definition includes non-Australian temporary residents, visitors and travellers who have residence in any Australian accommodation (e.g. hostel, hotel/motel, dormitory, resort, residential home, etc.) and likely to return upon discharge.


Level 1

8.0 SUBURB SUBURB Record the suburb of the patient’s residence. Note: This definition includes non-Australian temporary residents, visitors and travellers who have residence in any Australian accommodation (e.g. hostel, hotel/motel, dormitory, resort, residential home, etc.) and likely to return upon discharge.


Level 1

9.0 STATE STATE Selection List Level 1



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Indicate the state of the patient’s residence. Note: This definition includes non-Australian temporary residents, visitors and travellers who have residence in any Australian accommodation (e.g. hostel, hotel/motel, dormitory, resort, residential home, etc.) and likely to return upon discharge.

Code State

1 VIC

2 NSW

3 QLD

4 SA

5 NT

6 ACT

7 WA

8 TAS

Alphanumeric Web-Users Select from list

10.0 PCODE POSTCODE Record the postcode of the patient’s residence. Note: This definition includes non-Australian temporary residents, visitors and travellers who have residence in any Australian accommodation (e.g. hostel, hotel/motel, dormitory, resort, residential home, etc.) and likely to return upon discharge.

Numeric NNNN

Level 1

11.0 PHONE1 PRIMARY PHONE NUMBER Record the contact phone number of the patient.

Numeric NNNNNNNNNN

Level 1

12.0 PHONE2 SECONDARY PHONE NUMBER Record the secondary contact phone number of the patient.

Numeric NNNNNNNNNN

Optional

13.0 EMAIL EMAIL ADDRESS Record the email address of the patient.


Optional



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14.0 INSUR INSURANCE Indicate the patient’s insurance status. Select the most accurate option from the list below:

Code Insurance Status Insurance Description

1 Private Patient has Private Health Insurance.

2 DVA Patient is funded by the Department of Veteran Affairs.

3 Medicare Patient is funded by Medicare.

4 Self-Insured Patient is self-funded (private patient without Private Health Insurance).

5 Overseas Patient is an overseas visitor.

6 Other Patient is funded by a payment class other than those listed above (e.g. TAC, Australian Military, Seamen, Work cover).

Selection List 1=Private 2=DVA 3=Medicare 4=Self insured 5=Overseas 6=Other

Level 1

15.0 MEDC MEDICARE NUMBER Record the full Medicare number of the patient (if the patient is registered with Medicare). Note: The full Medicare number is comprised of the family number AND the individual reference number).

Numeric NNNN-NNNNN-NN (11)

Level 1

15.1 NOMEDC PATIENT DOES NOT HAVE A MEDICARE NUMBER Does the patient have a registered Medicare number? Note: Examples of patients that are not registered with Medicare include; overseas patients and most DVA patients.

Selection List 0=Registered 1=Not Registered

Level 2 Must not be null if MEDC=null

16.0 DVAF DEPARTMENT OF VETERANS AFFAIRS (DVA) FILE NUMBER If the patient is admitted as a DVA patient, record their full DVA number.

Free Text Alphanumeric NNNNNNNNN

Level 2 Must not be null if INSUR=2

17.0 RACE1 INDIGENOUS STATUS (1) Is the patient Aboriginal and/or Torres Strait Islander?

Selection List 1=Yes 0=No

Level 1

17.1 RACE2 INDIGENOUS STATUS (2) Does the patient’s racial group include Aboriginal?


Level 2 Must not be null if RACE1=1

17.2 RACE3 INDIGENOUS STATUS (3) Does the patient’s racial group include Torres Strait Islander?

Selection List 1=Yes

Level 2



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0=No Must not be null if RACE1=1

18.0 DOSA ELECTIVE DAY OF SURGERY ADMIT (DOSA) PATIENT Was the patient admitted electively to the acute hospital in which the surgery was to be performed on the same day as the procedure? Note: Patients admitted to a Medihotel on the night prior to surgery still qualify as DOSA.


Level 1 If DOSA=1, DOP must equal or be 1 day after DOA and STAT =1

19.0 DOA ADMISSION DATE On what date was the patient admitted/transferred to the hospital where the surgery was performed?

Date DD/MM/YYYY

Level 1 Must be before date of data entry

20.0 DOP SURGERY DATE On what date was the first surgical incision made for the index cardiac operation?

Date DD/MM/YYYY

Level 1 Must be before date of data entry and on/after admission date

21.0 DOD DISCHARGE DATE On what date was the patient discharged from inpatient status at the hospital where the procedure was performed?

Date DD/MM/YYYY

Level 1 Must be on/before date of data entry and on/after admission date

22.0 PROCNO OPERATION NUMBER Record the sequential number of cardiac operation(s) performed on this patient on the day of the index operation. Note: Where a patient has two (or more) cardiac operations on the same day that warrants the completion of a new form, code ‘1’ on the first CRF and ‘2’ on the second CRF.

Selection List 1=1st 2=2nd 3=3rd 4=4th 5=5th 6=6th -1= Unobtainable

Level 1

23.0

Verified Comment

VERIFIED COMMENT Comments of verification on surgery.


Optional


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SECTION 2: PATIENT RISK FACTORS Item # Field Name Variable Name and Description Data Details Rules

24.0 SMO_H SMOKING HISTORY Does the patient have a history confirming any form of tobacco use in the past? Note: Tobacco products include (but are not limited to) cigarettes, cigars, pipes, and chewing tobacco.

Selection List 1=Yes 0=No -1=Unknown

Level 1

24.1 SMO_C CURRENT SMOKER Has the patient used tobacco products within one month of the index operation? Note: Tobacco products include (but are not limited to) cigarettes, cigars, pipes, and chewing tobacco.


Level 2 Must not be null if SMO_H=1

25.0 DB DIABETES Does the patient have a history of diabetes (regardless of the duration of disease or need for anti-diabetic agents)?


Level 1

25.1 DB_CON DIABETES CONTROL Indicate the most aggressive diabetes control therapy at the time of surgery from the options below. Note: Aggressiveness of treatment is ranked in the following order: insulin > oral > diet

Code Control Method Control Method Description

1 None Patient is not on any treatment for diabetes.

2 Diet Diabetes is managed by diet only.

3 Oral Diabetes is managed by oral agent treatment.

4 Insulin Diabetes is managed with insulin treatment (includes any combination of the above with insulin).

Selection List 1=None 2=Diet 3=Oral 4=Insulin

Level 2 Must not be null if DB=1

26.0 HCHOL HYPERCHOLESTEROLAEMIA Does the patient have a history of hypercholesterolaemia diagnosed and/or treated by a physician, and/or Cholesterol > 5.0mmol/L, HDL <1.0mmol/L or Triglycerides >2.0mmol/L? Note: Examples of treatments include but are not limited to: (Definition continues overleaf)

Brand Name Generic Name

Lipitor, Caduet Atorvastatin

Lescol, Lescol XL, Vastin Fluvastatin


Level 1


SECTION 3: PRE-OPERATIVE CARDIAC STATUS

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Pravachol, Cholstat, Lipostat

Pravastatin

Crestor Rosuvastatin

Zocor, Lipex, Vytorin, Simvar

Simvastatin

27.0 PRECR RENAL – LAST PRE-OP CREATININE LEVEL Record the patient’s last serum creatinine recorded prior to the index operation. 20µmol/L to 2000µmol/L

Numeric 20µmol/L to 2000µmol/L

Level 1

28.0 DIAL RENAL – DIALYSIS Is the patient on pre-operative dialysis? Note: Renal dialysis includes Haemodialysis (HD), Peritoneal Dialysis (PD) and Acute Renal Replacement Therapy (ARRT) which includes Haemofiltration and Haemodiafiltration.


Level 1

29.0 TRANS RENAL – TRANSPLANT Has the patient undergone a prior renal transplant?


Level 1

30.0 HG PRE-OPERATIVE HAEMOGLOBIN Record the patient’s last haemoglobin recorded prior to surgery. 40g/L to 200g/L

Numeric 40g/L to 200g/L

Level 1

31.0 HYT HYPERTENSION Does the patient have a diagnosis of hypertension, documented by any one or more of the following?

a. Documented history of hypertension diagnosed and treated with medication, diet, and/or exercise.

b. Blood pressure > 140 systolic or >90 diastolic on at least two occasions. c. Current use of antihypertensive medication.


Level 1

32.0 CBVD CEREBROVASCULAR DISEASE Does the patient have a history of cerebrovascular disease (CBVD), documented by any of the following?

a. Unresponsive coma >24 hours at any time prior to the index admission. b. Cerebrovascular accident (CVA) with symptoms remaining > 72 hours after onset. c. Reversible ischaemic neurologic deficit (RIND) with recovery within 72 hours. d. Transient ischaemic attack (TIA) with recovery within 24 hours.


Level 1



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e. Non-invasive carotid test with 50% diameter stenosis (equivalent to 75% cross-sectional area stenosis).

32.1 CBVD_T CEREBROVASCULAR DISEASE – TYPE Indicate the most severe type of cerebrovascular disease (CVD) the patient has from the list below. Note: Severity of CVD is ranked in the following order: Coma > CVA > RIND/TIA > Carotid

Code CVD Type CVD Type Description

1 Unresponsive coma > 24 hours at any time prior to the index admission

Patient experienced complete cerebral unresponsiveness with no evidence of appropriate psychological or physiological responses to stimulation.

2 CVA Patient has a history of stroke characterised by loss of neurological function with residual symptoms > 72 hours after onset.

3 RIND/TIA RIND – Patient has experienced loss of neurological function with symptoms remaining > 24 hours after onset but with complete return of function within 72 hours OR TIA – Patient has experienced loss of neurological function that was abrupt in onset but with complete return of function within 24 hours.

4 Carotid test Non-invasive/invasive carotid test demonstrating 50% or greater diameter stenosis (equivalent to 75% cross-sectional area stenosis).

Selection List 1=Coma 2=CVA 3=RIND/TIA 4=Carotid test

Level 2 Must not be null if CBVD=1

32.2 CVA_W CEREBROVASCULAR DISEASE – CEREBROVASCULAR ACCIDENT – WHEN If the patient suffered a cerebrovascular accident (CVA), was it recent or remote? Events occurring within two weeks of the surgical procedure are considered recent; all other events are considered remote. Note: Recent (≤ 2 weeks) Remote (> 2 weeks)

Selection List 1=Recent 2=Remote

Level 2 Must not be null if CBVD_T=2

33.0 CART CEREBROVASCULAR DISEASE – CAROTID TEST RESULT Does the result of a non-invasive/invasive carotid test indicate 50% or greater diameter stenosis (equivalent to 75% cross-sectional area stenosis)?


Level 1



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34.0 PVD PERIPHERAL VASCULAR DISEASE (PVD) Does the patient have a history of PVD characterised by aneurysmal, chronic, or acute occlusion/narrowing of the arterial lumen of the aorta or extremities? Examples include:

a. Claudication either with exertion or rest. b. Amputation for arterial insufficiency. c. Vascular reconstruction, bypass surgery, or percutaneous intervention to the extremities. d. Documented aortic aneurysm. e. Documented renal artery stenosis. f. Positive non-invasive testing documented (e.g. ankle brachial index < 0.8).


Level 1

35.0 LD RESPIRATORY DISEASE Does the patient have a chronic respiratory/lung disease which is characterised by any of following?

Disease Type Disease Description

Mild Patient is on chronic inhaled or oral bronchodilator therapy.

Moderate Patient is on chronic oral steroid therapy directed at lung disease.

Severe p02 on room air < 60 or pC02 on room air > 50 or mechanical ventilation for chronic lung disease.


Level 1

35.1 LD_T RESPIRATORY DISEASE – TYPE Indicate the severity of the chronic lung/respiratory disease from the list below.

Code Respiratory Disease Type Respiratory Disease Type Description

2 Mild Patient is on chronic inhaled or oral bronchodilator therapy.

3 Moderate Patient is on chronic oral steroid therapy directed at lung disease.

4 Severe Room air p02 < 60 or room air pC02 > 50 or mechanical ventilation for chronic lung disease.

Selection List 2=Mild 3=Moderate 4=Severe

Level 2 Must not be null if LD=1

36.0 IE INFECTIVE ENDOCARDITIS Selection List Level 1



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Did the patient present with valvular disease of infectious aetiology with: a. Past or present positive blood culture, OR b. Post-operative histology or microbiological confirmation?

1=Yes 0=No

36.1 IE_T INFECTIVE ENDOCARDITIS – TYPE Indicate if endocarditis is active or treated.

Code Endocarditis Type Endocarditis Type Description

1 Active The patient is currently on antibiotic therapy for endocarditis.

2 Treated No antibiotic medication (other than prophylactic medication) is being given at the time of surgery.

Selection List 1=Active 2=Treated

Level 2 Must not be null if IE=1

37.0 IMSRX IMMUNOSUPPRESSIVE THERAPY Was the patient on any form of immunosuppressive therapy within 30 days of the current surgery, or is the patient on any steroids for chronic long term use? This includes, but is not limited to systemic steroid therapy equivalent to ≥5mg prednisolone within 30 days, anti-rejection medication and chemotherapy. Note: Drug classes that are considered to be immunosuppressive include:

Corticosteroids (only if taken systemically)

Cytotoxic drugs

Antimetabolites (cyclosporine)

Monoclonal antibodies


Level 1


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38.0 MI PREVIOUS MYOCARDIAL INFARCTION (MI) Has the patient been hospitalised at any time for a Myocardial Infarction (MI) either documented in the medical record or during the current admission?


Level 1

38.1 MI_T MYOCARDIAL INFARCTION – TYPE NON ST- ELEVATION MYOCARDIAL INFARCTION (NSTEMI) AT LEAST ONE of the following biomarkers for detecting myocardial necrosis MUST be present (refer to Note regarding Reference Control Limits):

1. Troponin T or I: Maximal concentration of troponin T or I > the MI diagnostic limit on at least one occasion within the first 24 hours from the index clinical event;

2. CK-MB:

Maximal value of CK-MB > 2 x the upper limit of normal (ULN) on one occasion during the first hours after the index clinical event; OR

Maximal value of CK-MB (preferable CK-MB mass) > ULN on two successive samples. 3. Total CK: Only where Troponin or CK-MB assays are unavailable, total CK > 2 x the ULN (or the

B fraction of CK) may be employed.

Note: The preferred assays to use as biomarkers for myocardial necrosis are Troponin, CK-MB or total CK (in that order).

AND ONE of the following:

1. ST segment depression or T wave abnormalities in the ECG; OR 2. In the presence or absence of chest discomfort. Ischemic symptoms may include:

Unexplained nausea and vomiting; or

Persistent shortness of breath secondary to left ventricular failure; or

Unexplained weakness, dizziness, light- headedness, or syncope. ST- ELEVATION MYOCARDIAL INFARCTION (STEMI)

Selection List 1=NSTEMI 2=STEMI -1=Unknown

Level 2 Must not be null if MI=1



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AT LEAST ONE of the following biochemical indicators for detecting myocardial necrosis MUST be present (see below for a definition of Reference Control Limits):

1. Troponin T or I: Maximal concentration of troponin T or I > the MI diagnostic limit on at least one occasion within the first 24 hours from the index clinical event;

2. CK-MB:

Maximal value of CK-MB > 2 x the upper limit of normal (ULN) on one occasion during the first hours after the index clinical event; OR

Maximal value of CK-MB, (preferable CK-MB mass) > ULN on two successive samples. 3. Total CK: Only where Troponin or CK-MB assays are unavailable, total CK > 2 x the ULN (or the

B fraction of CK) may be employed.

Note: The preferred assays to use as biomarkers for myocardial necrosis are Troponin, CK-MB or total CK (in that order).

AND ONE of the following ECG changes:

1. ST-segment elevation: New or presumed new ST segment elevation at the J point in two or more contiguous leads with the cut-off points >=0.2 mV in leads V1, V2, or V3, or ≥0.1 mV in other leads;

2. Development of any Q wave in leads V1 through V3, or the development of a Q-wave ≥ 30 ms (0.03s) in leads I, II, aVL, aVF, V4, V5, or V6. (Q wave changes must be present in any two contiguous leads, and be ≥ 1mm in depth.)

Defining Reference Control Values (MI Diagnostic Limit and Upper Limit of Normal): Reference values must be determined in each laboratory by studies using specific assays with appropriate quality control, as reported in peer-reviewed journals. Acceptable imprecision (coefficient of variation) at the 99th percentile for each assay should be defined as < or = to 10%. Each individual laboratory should confirm the range of reference values in their specific setting



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38.2 MI_W MYOCARDIAL INFARCTION – WHEN Indicate the time period between onset of the last documented myocardial infarction and surgery.

Code Time point

1 ≤6hrs

2 >6hrs but <24hrs

3 1 to 7 days

4 >7 to 21 days

5 >21 days

Selection List 1=≤6hrs 2=>6hrs but <24hrs 3=1-7 days 4=>7-21 days 5=>21days

Level 2 Must not be null if MI=1

39.0 CCS ANGINA – CCS CLASS CLASSIFICATION Indicate the patient’s highest Canadian Cardiovascular Society (CCS) classification leading to the current episode of hospitalisation and/or intervention. CCS classification is as follows:

Code CCS class description

0 No angina symptoms.

1 Ordinary physical activity, such as walking or climbing the stairs does not cause angina. Angina may occur with strenuous, rapid or prolonged exertion at work or recreation.

2 There is slight limitation of ordinary activity. Angina may occur with moderate activity such as walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold, in the wind, or under emotional stress, or walking more than two blocks on the level, and climbing more than one flight of stairs at a normal pace under normal conditions.

3 There is marked limitation of ordinary physical activity. Angina may occur after walking one or two blocks on the level or climbing one flight of stairs under normal conditions at a normal pace.

4 There is inability to carry on any physical activity without discomfort; angina may be present at rest.

Selection List 0-4 (according to adjacent table).

Level 1

39.1 ANGRXG TREATMENT OF ANGINA – IV GTN Did the patient receive IV GTN to treat angina on the day of surgery?


Level 2 Must not be null if CCS > 0



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39.2 ANGRXH TREATMENT OF ANGINA – IV HEPARIN Did the patient receive IV Heparin to treat angina ≤12 hours prior to surgery?



39.3 ANGRXC TREATMENT OF ANGINA – FULL DOSE HEPARINOIDS Did the patient receive full dose Heparinoids to treat angina ≤24 hours prior to surgery? Examples of treatment include subcutaneous Clexane (Enoxaparin) at ≥1mg/kg bi-daily. Treatment also includes use of other low molecular weight heparinoids (LMWH) at an equivalent dose. Examples of LMWH include but are not limited to the list below:


Fragmin Dalteparin

Clexane Enoxaparin



40.0 CHF HISTORY OF CONGESTIVE HEART FAILURE Does the patient have a history of congestive heart failure (CHF) diagnosed by a physician and evidenced by TWO of the following?

a. Paroxysmal nocturnal dyspnoea (PND) or orthopnoea. b. Shortness of breath on exertion (SOBOE) due to heart failure i.e. not as an angina equivalent. c. Chest x-ray (CXR) showing pulmonary congestion. d. Patient received treatment for CHF by use of ACE inhibition, diuretics, Carvedilol (Coreg).


Level 1

40.1 CHF_C CHF – CHF AT CURRENT ADMISSION During the current admission, was the patient diagnosed with CHF or was the management of CHF changed due to deterioration in CHF?


Level 2 Must not be null if CHF=1

41.0 NYHA NYHA CLASS – DYSPNOEA CLASSIFICATION Indicate the patient’s highest level of dyspnoea as classified by the New York Heart Association (NYHA) leading to the current episode of hospitalisation and/or procedure. Note: Dyspnoea in a patient who has only coronary artery disease (CAD) should be considered an angina equivalent and therefore indicated by CCS class. The NYHA class should be marked 1 in such patients.

Code NYHA class description

Selection List (1-4 as per adjacent table).

Level 1



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1 Patient with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations or dyspnoea.

2 Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitations or dyspnoea.

3 Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity results in fatigue, palpitations, or dyspnoea.

4 Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest. If any physical activity is undertaken, discomfort is increased.

42.0 SHOCK CARDIOGENIC SHOCK Was the patient in cardiogenic shock at the time of procedure? Only code yes if all of the following criteria apply:

a. Sustained (>30 minutes) episode of systolic blood pressure <90mmHg or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g. Intra-aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices to maintain BP >90mmHg); AND

b. Evidence of elevated filling pressures (e.g. elevated PAWP or pulmonary oedema on examination or chest radiograph); AND

c. Evidence of end organ hypoperfusion (e.g. urine output <30mL/hour; or cold/diaphoretic extremities; or altered mental status, etc.)


Level 1

43.0 RESUS RESUSCITATION (within one hour prior to operation) Did the patient require either of the following within one hour of the start of the operative procedure?

a. cardiopulmonary resuscitation OR b. initiation of treatment for cardiogenic shock.


Level 1



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44.0 ARRT ARRHYTHMIA Was there a clinically documented pre-operative arrhythmia present? Includes any one of the following:

a. Atrial fibrillation/flutter requiring treatment. b. Heart block. c. Sustained ventricular tachycardia or ventricular fibrillation requiring cardioversion and/or IV

medication*. d. Other arrhythmia (e.g. sick sinus syndrome).

*Note: IV medications for treatment of ventricular tachycardia/fibrillation include but are not limited to:


Cordarone Amiodarone

Xylocaine Lignocaine

Flecatab, Tambacor Flecainide

Cardol, Solavert Sotalol


Level 1

44.1 ARRT_A ARRHYTHMIA TYPE – ATRIAL Was the clinically documented arrhythmia an atrial fibrillation or flutter requiring treatment?


Level 2 Must not be null if ARRT=1

44.1.1 ARRT_AT ARRHYTHMIA – ATRIAL TYPE Indicate the type of atrial fibrillation/flutter from the list below:

Code Atrial Arrhythmia Type Atrial Arrhythmia Type Description

1 Paroxysmal AF terminates spontaneously.

3 Permanent No periods of sinus rhythm.

Selection List 1=Paroxysmal 3=Permanent -1=Unknown

Level 3 Must not be null if ARRT_A=1

44.2 ARRT_H ARRHYTHMIA TYPE – HEART BLOCK Was the clinically documented arrhythmia a complete heart block (AV dissociation)?





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44.3 ARRT_V ARRHYTHMIA TYPE – VENTRICULAR Was the clinically documented arrhythmia sustained or recurrent ventricular tachycardia or ventricular fibrillation requiring cardioversion and/or IV medication?



44.4 ARRT_O ARRHYTHMIA TYPE – OTHER Was the clinically documented arrhythmia an ‘other’ arrhythmia, i.e. not one documented in variables 44.1-44.3? Note: Examples of ‘other’ arrhythmia include but are not limited to; sick sinus syndrome, Wenckebach, 2:1 heart block.



45.0 PACE PERMANENT PACEMAKER IN SITU Indicate whether a previous permanent pacemaker was placed any time prior to this surgical procedure. This includes ICD, CRT and other implantables. It does not include lead placement only.


Level 1

46.0 MEDIN MEDICATIONS AT TIME OF SURGERY – INOTROPES Did the patient receive inotropes on the day of surgery for haemodynamic support (excludes renal dose Dopamine)?


Level 1

47.0 MEDNI MEDICATIONS AT TIME OF SURGERY – IV NITRATES (GTN) Did the patient receive IV nitrates on the day of surgery?


Level 1

48.0 MEDAC MEDICATIONS AT TIME OF SURGERY – ANTICOAGULATION THERAPY Did the patient receive warfarin/heparin/ low molecular weight heparinoid/thrombin inhibitors, and/or factor Xa inhibitors ≤ 24 hours prior to surgery? Examples include (but are not limited to) the those listed in the table below:


HEPARIN –UNFRACTIONATED

Heparin

HEPARIN LOW MOLECULAR WEIGHT – (Injectable)

Fragmin Dalteparin

Lovenox Enoxaparin

Tinzaparin Innohep

PARENTERAL THROMBIN INHIBITORS

Angiomax Bivalirudin


Level 1



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Argatroban Argatroban

Anxtra Fondaparinux

Iprivask Desirudin

Refludan Lepirudin

ORAL THROMBIN INHIBITORS

Pradaxa Dabigatran

Coumadin, Marevan Warfarin

FACTOR Xa INHIBITORS

Xarelto Rivaroxaban

Arixtra Fondaparinux

Eliquis Apixaban

49.0 MEDST MEDICATIONS AT TIME OF SURGERY – STEROIDS Did the patient receive systemic steroids within 24 hours of surgery?


Level 1

50.0 MED_ASP ANTIPLATELET THERAPY – ASPIRIN ONLY Did the patient take aspirin within seven days prior to surgery?


Level 1

50.1 MED_ASP_W

ASPIRIN – WHEN Enter number of days since the time the last documented aspirin was taken. Note: Enter ‘0’ if this was within 24 hours of surgery.

Numeric 0 to 7 days

Level 2 Must not be null if MED_ASP=1

51.0 MED_CLOP ANTIPLATELET THERAPY – THIENOPYRIDINE Did the patient take thienopyridine within seven days prior to surgery? Thienopyridine agents include Clopidogrel, Prasugrel or Ticlopidine.


Level 1

51.1 MED_CLOP_W

THIENOPYRIDINE – WHEN Enter number of days since the last documented Thienopyridine therapy was taken. Note: Enter ‘0’ if this was within 24 hours of surgery.

Numeric 0 to 7 days

Level 2 Must not be null if MED_CLOP=1

52.0 MED_TICA ANTIPLATELET THERAPY – TICAGRELOR Did the patient take Ticagrelor within seven days prior to surgery?


Level 1



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52.1 MED_TICA_W

TICAGRELOR – WHEN Enter number of days since the last documented Ticagrelor therapy was taken. Note: Enter ‘0’ if this was within 24 hours of surgery.

Numeric 0 to 7 days

Level 2 Must not be null if MED_TICA=1

53.0 MED_AGG ANTIPLATELET THERAPY – TIROFIBAN OR EPTIFIBATIDE Did the patient take Tirofiban or Eptifibatide (short-acting glycoprotein IIb/IIIa inhibitor) within seven days prior to surgery?


Level 1

53.1 MED_AGG_W

TIROFIBAN OR EPTIFIBATIDE – WHEN Enter number of days since the last documented Tirofiban or Eptifibatide taken. Note: Enter ‘0’ if this was within 24 hours of surgery.

Numeric 0 to 7 days

Level 2 Must not be null if MED_AGG=1

54.0 MED_ABCI ANTIPLATELET – ABCIXIMAB Did the patient receive abciximab (long acting glycoprotein IIb/IIIa inhibitor) within seven days prior to surgery?


Level 1

54.1 MED_ABCI_W

ABCIXIMAB – WHEN Enter number of days since the last documented abciximab was received? Note: Enter ‘0’ if this was within 24 hours of surgery.

Numeric 0 to 7 days

Level 2 Must not be null if MED_ABCI=1

55.0 MED_OTH ANTIPLATELET THERAPY – OTHER Did the patient receive any other antiplatelet therapy (apart from those listed in variables 50.0-54.0) within seven days prior to surgery?


Level 1

55.1 MED_OTH_W

OTHER ANTIPLATELET THERAPY – WHEN Enter number of days since the last documented ‘other’ antiplatelet therapy was received? Note: Enter ‘0’ if this was within 24 hours of surgery.

Numeric 0 to 7 days

Level 2 Must not be null if MED_OTH=1


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SECTION 4: PREVIOUS INTERVENTIONS


56.0 POP PREVIOUS CARDIOTHORACIC INTERVENTION (SURGICAL OR PERCUTANEOUS) Does the patient have any history of previous cardiothoracic intervention (surgical or percutaneous) prior to the index operation (including prior procedures performed in the current admission)? Note: Code ‘yes’ for all forms of percutaneous angioplasty and transcatheter cardiac interventions INCLUDING prior interventions in the same admission episode e.g. the patient had a prior PTCA/stent at another hospital before transfer to current hospital for surgery.


Level 1

56.1 PCS PREVIOUS CARDIAC SURGERY Has the patient had any previous cardiac surgery prior to the index operation? This includes prior procedures performed during the index admission.


Level 2 Must not be null if POP=1

56.1.1 PBYP NUMBER OF PRIOR CARDIAC OPERATIONS REQUIRING CARDIOPULMONARY BYPASS Record the number of cardiac surgical operations performed on this patient utilising cardiopulmonary bypass prior to the index operation.

Numeric 0-9

Level 3 Must not be null if PCS=1

56.1.2 PBH NUMBER OF PRIOR CARDIAC OPERATIONS WITHOUT CARDIOPULMONARY BYPASS (BEATING HEART SURGERY) Record the number of cardiac surgical operations performed on this patient without cardiopulmonary bypass prior to the index operation.

Numeric 0-9


56.1.3 PCAB TYPES OF PREVIOUS SURGERY – CABG Has the patient undergone a previous coronary artery bypass surgery through any approach prior to the index operation (including those performed in the current admission)?



56.1.3.1 POPCAB TYPES OF PREVIOUS SURGERY – OFF PUMP CABG Was the previous coronary artery bypass graft surgery performed without the use of cardiopulmonary bypass through any approach?


Level 4 Must not be null if PCAB=1

56.1.4 PVAL TYPES OF PREVIOUS SURGERY – VALVE Has the patient undergone previous surgical replacement and/or repair of a cardiac valve through any approach, prior to index operation (including those performed in the current admission)?



56.1.5 PCOP TYPES OF PREVIOUS SURGERY – OTHER CARDIAC Has the patient undergone any other previous cardiac surgery, including operations on the ascending aorta and/or aortic arch including pericardiectomy?



56.2 PPCI PREVIOUS PERCUTANEOUS INTERVENTION Selection List 1=Yes

Level 2



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Has the patient undergone any prior percutaneous intervention, prior to or including the current admission?

0=No Must not be null if POP=1

56.2.1 PTAVR PREVIOUS PERCUTANEOUS INTERVENTION – TAVR Was a transcatheter aortic valve replacement (TAVR) procedure performed at any time prior to the index operation (including those performed in the current admission)?


Level 3 Must not be null if PPCI=1

56.2.2 PTCA PREVIOUS PERCUTANEOUS INTERVENTION – PTCA/STENT Was a transluminal coronary angioplasty/coronary atherectomy and/or coronary stent procedure performed at any time prior to the index operation (including prior procedures performed in the current admission)?



56.2.2.1 PTCA_ADM

PTCA/STENT – ADMISSION Was a PTCA/stent procedure performed prior to the current admission (remote) or during the current admission (this admission)? Note: Include patients that were directly transferred from the hospital where the percutaneous intervention procedure was performed to the current hospital where index operation will be performed as this admission.

Selection List 1=This Admission 0=Remote

Level 4 Must not be null if PTCA=1

56.2.2.1.1 PTCA_H PTCA/STENT – INTERVAL Record the time interval between PTCA/atherectomy/stent and the current surgical procedure. The time interval should be recorded as the number of hours that have lapsed since previous PTCA/ atherectomy /stent and the current surgical procedure. Note: Includes patients that were directly transferred from the hospital where the percutaneous intervention procedure was performed to the current hospital where index operation will be performed.

Numeric NNN

Level 5 Must not be null if PTCA_ADM=1

56.2.3 PBALL PREVIOUS PERCUTANEOUS INTERVENTION – NON-SURGICAL BALLOON VALVULOPLASTY Has the patient undergone a non-surgical balloon valvuloplasty at any time prior to the index operation (including those done in the current admission)?



56.2.4 PPCI_ASD ASD/PFO DEVICE CLOSURE Has the patient undergone a percutaneous procedure for closure of an atrial septal defect or patent foramen ovale prior to the index operation (including those in the current admission)?



56.2.5 PPCI_VSD VSD DEVICE CLOSURE Selection List 1=Yes

Level 3



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Has the patient undergone a percutaneous procedure for closure of a ventricular septal defect prior to the index operation (including those in the current admission)?

0=No Must not be null if PPCI=1

56.2.6 LAAO LEFT ATRIAL APPENDAGE OCCLUSION Has the patient undergone occlusion of the atrial appendage prior to the index operation (including those in the current admission) by either of the following techniques: Intracardiac –e.g. Watchman or Amplatzer OR Extracardiac –e.g. Thoracoscopic insertion of clips.



56.2.7 SVT ELECTROPHYSIOLOGY ABLATION Has the patient undergone a percutaneous ablation procedure for any form of supraventricular tachycardia (SVT) or ventricular tachycardia prior to the index operation (including those done in the current admission)?



56.2.8 PMVR PERCUTANEOUS MITRAL VALVE REPAIR Has the patient undergone percutaneous mitral valve repair (e.g. Mitraclip) prior to the index operation (including those done in the current admission)?



56.2.9 PTMVR PREVIOUS PERCUTANEOUS INTERVENTION – TMVR Was a transcatheter mitral valve replacement (TMVR) procedure performed at any time prior to the index operation (including those performed in the current admission)?




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SECTION 5: HAEMODYNAMICS


57.0 HTM HEIGHT Record the patient’s height in centimetres. Note: Patient should have bare feet or stockinged feet when height is measured. Range 100-250cm

Numeric NNN 100-250cm

Level 1

58.0 WKG WEIGHT Record the patient’s weight in kilograms. Note: Patient should be wearing light clothes and have bare or stockinged feet when weight is measured. Range 35-200kg

Numeric NNN 35-200kg

Level 1

59.0 CATH CARDIAC CATHETERISATION (ANGIOGRAPHY) Has the patient had cardiac catheterisation (angiography)?


Level 1

59.1 CATH_W DATE OF CARDIAC CATHETERISATION Record the date of the most recent cardiac catheterisation. Enter 09/09/9999 for unknown date.

Date DD/MM/YYYYY

Level 2 Must not be null if CATH=1 Must be before or on DOP

60.0 EF_T LVEF METHOD Did the patent have their left ventricular ejection fraction (LVEF) measured? Indicate the method was used.

Code Measurement Method Measurement Method Description

1 No Not measured

2 Angiogram Angiographic LV gram, obtained during cardiac catheterisation

3 Radionuclide Nuclear

4 Echocardiogram Echocardiogram: TTE or TOE

5 MRI Magnetic resonance imaging

Selection List 1=No 2=Angiogram 3=Radionuclide 4=Echo 5=MRI -1=Unknown

Level 1

60.1 EF LVEF Numeric Level 2



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Record the percentage of blood emptied from the left ventricle at the end of the contraction. Use the most recent determination prior to intervention. If exact percentage is unknown, enter -1 and indicate EF estimate.

NN 5-90% -1=Unknown

Must not be null if EF_T>1 Must not be null if EF_EST is null Must enter value between 5-90%

60.2 EF_EST LVEF ESTIMATE If nuclear scan, echocardiogram, or left ventriculogram did not yield a digital EF%, review the study and provide an estimate. Indicate the most accurate estimate from the table below:

Code EF Estimate EF Estimate Description

1 Normal LVEF > 60%

2 Mild impairment LVEF 46-60%

3 Moderate LVEF 30-45%

4 Severe LVEF <30%

Selection List 1=Normal 2=Mild 3=Moderate 4=Severe

Level 2 Must not be null if EF_T>1 Must not be null if EF=-1

61.0 LMD LEFT MAIN CORONARY ARTERY STENOSIS >50% Does the patient have any stenosis that involves any part of the left main? Left main coronary stenosis is present when there is >50% compromise of vessel diameter in any angiographic view.


Level 1

62.0 DISVES NUMBER OF DISEASED CORONARY SYSTEMS Indicate the number of (the three) major coronary systems (LAD system, Circumflex system, Right Coronary system) with >50% narrowing in any angiographic view. The number of diseased systems should be the number of systems requiring surgical approach at that operation.

Code Number of diseased coronary systems

0 None

1 One

2 Two

3 Three

Note:

Selection List 0=None 1=One 2=Two 3=Three

Level 1



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Left Main Disease (>50%) is counted as TWO systems (LAD and Circumflex). Left main and RCA would count as THREE in total and dominant circumflex would count as TWO systems.

LMCAD associated with dominant Circumflex counts as THREE systems. If a system has been grafted previously and the graft has no haemodynamically significant stenosis, then that system is NOT counted as diseased. If a previous graft requires replacement, then that system IS counted as diseased. ALWAYS ANSWER THIS QUESTION. IF THERE ARE NO DISEASED CORONARY ARTERY SYSTEMS THEN INDICATE 0.


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SECTION 6: OPERATION STATUS


63.0 SURG CONSULTANT SURGEON Record the individual ANZSCTS database surgeon code of the surgeon responsible for the index operation.

Numeric NNNN

Level 1

64.0 PROC OPERATING SURGEON (PROCEDURALIST) Indicate the status of the surgeon who performed the majority of the ‘specific’ part of the operation. ‘Specific’ means the actual coronary artery graft, valve, or other cardiac procedure. Indicate status from the table below:

Code Operating surgeon status

1 Consultant

2 Senior registrar (FRACS)

3 Trainee or accredited registrar

4 Overseas fellow

5 Oversight –foreign graduate under oversight supervision

Selection List 1=Consultant 2=Senior Registrar 3=Trainee 4=Overseas Fellow 5=Oversight

Level 1

65.0 STAT STATUS Indicate the clinical status of the patient prior to entering the operating room from the table below:

Code Status Status Description

1 Elective The procedure could be deferred without risk of compromised cardiac outcome.

2 Urgent Not routine – clinical reason for operating in this admission: a. Within 72 hours of angiography if index operation was

performed in the same admission as angiography (here ‘same admission’ includes situations where angiography was performed in another hospital prior to direct transfer to current hospital where index operation is to be performed). OR

Selection List 1=Elective 2=Urgent 3=Emergency 4=Salvage

Level 1



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b. Within 72 hours of an unplanned admission (in patients who had a previous angiogram and was scheduled for surgery but was admitted acutely). OR

c. Procedure required during same hospitalisation in a clinically compromised patient in order to minimise chance of further clinical deterioration.

3 Emergency Unscheduled surgery required in the next available theatre on the same day (as admission) due to refractory angina or haemodynamic compromise.

4 Salvage The patient underwent CPR en route to, or in the operating room, prior to surgical incision.

65.1 UOR URGENT PROCEDURE – REASON Indicate why the patient’s clinical status was ‘urgent’:

Code Urgent Reason

1 Acute Myocardial Infarction (AMI) stabilised and not requiring emergency

operation.

2 Pre-op Intra-Aortic Balloon Pump (IABP).

3 Threatening coronary anatomy with acute symptoms.

4 Unstable angina requiring IV therapy.

5 Severe acute valve dysfunction either native or prosthetic.

Selection List 1=AMI 2=Pre-op IABP 3=Coronary anatomy 4=Unstable angina 5=Severe acute valve dysfunction

Level 2 Optional

66.0 DTCATH DIRECT TRANSFER FROM CATH LAB/ICU TO THEATRE Did the patient require direct transfer to theatre for ongoing management as a result of a cardiac catheter lab event? This includes transfers directly from the cardiac catheter lab, or via ICU or general ward. Note: This includes patients who have been temporarily transferred to a ward, usually CCU or ICU, for stabilisation or whilst the OR is being prepared. Typical situations include (but are not limited to); ischaemia, rest angina despite maximal treatment, pulmonary oedema requiring intubation, or shock.


Level 1 Must not be 1 if STAT<3



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67.0 CCAB CORONARY ARTERY BYPASS Is the index operation a Coronary Artery Bypass Graft (CABG)?


Level 1

68.0 CVLV VALVE SURGERY Is the index operation a Valve Procedure?


Level 1

69.0 COTH OTHER CARDIAC SURGERY Is the index operation for a cardiac procedure that is not a CABG or Valve?


Level 1

69.1 LVA LV ANEURYSM Is the index operation for repair of a Left Ventricular Aneurysm (LVA)? Note: E.g. Keel, Jatene, or Dor.


Level 2 Must not be null if COTH=1

69.2 VSD VSD (ACQUIRED) Is the index operation for the correction of an acquired (usually ischaemic) ventricular septal defect?



69.3 ASD ASD Is the index operation for the correction of an Atrial Septal Defect (excludes closure of incidental PFO)?



69.4 TRAUMA TRAUMA Is the index operation for the repair of cardiac trauma?



69.5 HOCM LVOT MYECTOMY Is the index operation for any of the following? Hypertrophic obstructive cardiomyopathy OR Left ventricular muscular dynamic LVOT obstruction OR Tunnel stenosis in the left ventricular outflow tract. This procedure involves excision of left ventricular endocardial muscle from the left ventricular outflow tract.





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69.6 LVRR LV RUPTURE REPAIR Is the index operation for the repair of an ischaemic rupture of the free wall of the left ventricle? Note: This does not include traumatic LV rupture repair.



69.7 PCAR PERICARDIECTOMY Is the index operation a pericardiectomy?



69.8 PTE PULMONARY THROMBO-ENDARTERECTOMY Is the index operation for chronic pulmonary thromboembolic disease? Note: Procedure involves cardiopulmonary bypass, and usually hypothermic circulatory arrest and incisions are made in the right and left (or both) pulmonary arteries and an endarterectomy performed out of the distal branches.



69.9 LVRECON LEFT VENTRICULAR RECONSTRUCTION Is the index operation to reshape the left ventricle by lateral excision (Batista)? Note: Do not include resection and repair of chronic left ventricular aneurysm, by whatever technique.



69.10 PULEMB PULMONARY EMBOLECTOMY Is the index operation for pulmonary embolectomy?



69.11 TUMOUR CARDIAC TUMOUR Is the index operation for removal of cardiac tumour(s)? Note: This excludes the removal of tumour from valve tissue (fibroelastoma).



69.12 CT CARDIAC TRANSPLANT Is the index operation for cardiac transplant?



69.13 CPT CARDIOPULMONARY TRANSPLANT Is the index operation for transplant of the heart and lungs?



69.14 OTHCON OTHER CONGENITAL Is the index operation for a congenital complication not otherwise specified?





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69.15 PLVEL PERMANENT LV EPICARDIAL LEAD Does the index operation include the insertion of a permanent LV Epicardial Lead?



69.16 LAA LEFT ATRIAL APPENDAGE CLOSURE Is the index operation specifically for closure of the left atrial appendage? Note: By any approach. This does not include “en passant” closure in association with another procedure i.e. CABG or valve.



69.17 AAS ATRIAL ARRHYTHMIA SURGERY Is the index operation for paroxysmal, persistent or permanent atrial tachyarrhythmia?



69.17.1 LESION1 ATRIAL ARRHYTHMIA SURGERY – LESION SET Indicate the predominant lesion set from the following:

Code Lesion Set Lesion Set Description

1 Cox-Maze III Complete Maze III lesions as described by James Cox.

2 Radial Radiating lesions from the SA node as described by Nitta or Westmead group (star).

3 Mini-Maze Circumferential pulmonary veins isolation and line of conduction block in both right and atrial isthmus and left atrial isthmus (including coronary sinus).

4 Left atrial reduction

Circumferential pulmonary veins isolation with excision or exclusion of cuff of atrial tissue to reduce left atrial dimensions. Note: this does not include mere removal of the left atrial appendage.

5 Pulmonary vein isolation

Circumferential pulmonary vein isolation only.

6 Left atrial only

Left atrial component of Cox-Maze II.

7 Right atrial only

Right atrial component of Cox-Maze III.

8 Other When lesion set does not meet above definitions.

Selection List 1=Cox-Maze III 2=Radial 3=Mini-Maze 4=Left atrial reduction 5=Pulmonary vein isolation 6=Left atrial only 7=Right atrial only 8=Other 9=Cox-Maze IV

Level 3 Must not be null if AAS=1



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9 Cox-Maze IV A procedure designed to treat atrial fibrillation. It is performed on CPB, creating the same ablation lines as a Cox III, but through limited left and right atriotomies.

69.17.2 ES1 ATRIAL ARRHYTHMIA SURGERY – ENERGY SOURCE Indicate the predominant technique use for creating the lines of conduction block from the following:

Code Technique

1 Cut & Sew

2 Unipolar radiofrequency

3 Bipolar radiofrequency

4 Cryoablation

5 Microwave

6 Laser

7 Ultrasound

8 Other

Selection List 1=Cut & Sew 2=Unipolar RF 3=Bipolar RF 4=Cryoablation 5=Microwave 6=Laser 7=Ultrasound 8=Other

Level 3 Must not be null if AAS=1

69.18 OTHER OTHER Is the index operation for a cardiac operation not otherwise specified?



69.18.1 OTHER_REA OTHER REASON/PROCEDURE If ‘yes’ to other (69.18), record the specific reason/procedure that was performed.


Level 3 Must not be null if OTHER=1

70.0 AO AORTIC PROCEDURE Is the index operation for an Aortic Procedure?


Level 1

70.1 AOP AORTIC PATHOLOGY/AETIOLOGY Indicate the aortic aetiology necessitating current procedure. Choose one of the following:

Selection List 1=Aortic aneurysm

Level 2 Must not be null if AO=1



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Code Aetiology

1 Aortic aneurysm

2 Aortic dissection

3 Traumatic transection (occurring within the last 2 weeks)

4 Calcification

5 Other

2=Aortic dissection 3=Traumatic transection 4=Calcification 5=Other

70.1.1 AODS_A AORTIC DISSECTION – WHEN What was the timing (acuity) of the aortic dissection? Choose one of the following:

Code Time Point

1 Acute (≤2 weeks)

2 Non-Acute (> 2 weeks)

Selection List 1=≤2 weeks 2=>2 weeks

Level 3 Must not be null if AOP=2

70.2 AO_TR AORTIC PROCEDURE TYPE – DIRECT AORTOPLASTY Is the aortic procedure a Direct Aortoplasty? Note: Defined as a resection of a segment of aorta with direct suture closure or suture plication of a segment of aorta to reduce diameter.



70.2.1 AO_TRE AORTOPLASTY TYPE – ENDARTERECTOMY Has an extensive Endarterectomy been performed? Note: Extensive is defined by more than one quarter of the circumference of the aorta, and more than 2 cm wide.


Level 3 Must not be null if AO_TR=1

70.2.2 AO_TRP AORTOPLASTY TYPE – PATCH REPAIR Has the aorta been repaired with a patch after resection or to enlarge it? Note: Does NOT include patch placed to the aortic root to facilitate closure after aortic valve replacement.


Level 3 Must not be null if AO_TR=1

70.3 AOTREP AORTIC PROCEDURE TYPE – REPLACEMENT Is the aortic procedure classified as a replacement? Note: Replacement is defined as circumferential replacement of the aorta, performed for aortic pathology. It does not include incidental replacement of a short segment of the ascending aorta as part of an aortic root replacement.





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70.3.1 AOTREP_A AORTIC REPLACEMENT LOCATION – ASCENDING Does the aortic replacement involve the ascending aorta?


Level 3 Must not be null if AOTREP=1

70.3.2 AOTREP_H AORTIC REPLACEMENT LOCATION – ARCH Does the aortic replacement involve the aortic arch?



70.3.3 AOTREP_D AORTIC REPLACEMENT LOCATION – DESCENDING Does the aortic replacement involve the descending aorta?



70.3.4 AOTREP_T AORTIC REPLACEMENT LOCATION – THOR/ABD Does the aortic replacement involve the thoraco-abdominal aorta?



71.0 NCOTH OTHER NON-CARDIAC PROCEDURE Does the index operation include a non-cardiac procedure?


Level 1

71.1 CEND CAROTID ENDARTERECTOMY Does the index operation include surgical removal of stenotic atheromatous plaque(s) from the carotid artery?


Level 2 Must not be null if NCOTH=1

71.2 ROLU LUNG RESECTION Does the index operation include surgical removal of damaged or diseased portion(s) of the lung?



71.3 VOTH OTHER VASCULAR SURGERY Does the index operation include procedures correcting peripheral vascular stenosis or occlusion? Note: A peripheral vascular procedure may include procedures such as femoral artery repair, iliac artery repair etc.



71.4 TOTH OTHER THORACIC SURGERY Does the index operation include procedure involving the thorax/pleura?



71.5 OTH OTHER Does the index operation include any other concomitant surgery not specified in the non-cardiac procedures listed in 71.1-71.4?





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71.5.1 OTH_REA

OTHER REASON If the index operation is classified as any type of concomitant surgery no listed above, record the specific procedure performed.


Level 3 Must not be null if OTH=1


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SECTION 7: MINIMALLY INVASIVE


72.0 MIN MINIMALLY INVASIVE OPEN TECHNIQUE ATTEMPTED Was a non-standard (sternotomy or thoracotomy) incision used for the cardiac procedure (on- or off-pump)?


Level 1

73.0 ROBOT ROBOTICALLY ASSISTED Was the procedure performed with the assistance of a robot (e.g. Da Vinci, AESOP)?


Level 1


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SECTION 8: CPB AND SUPPORT


74.0 CPB CARDIOPULMONARY BYPASS USED Did the index operation use cardiopulmonary bypass (i.e. was the operation performed on-pump)?


Level 1

74.1 CPLEG CARDIOPLEGIA Was cardioplegia used in the index operation?


Level 2 Must not be null if CPB=1

74.2 CPLEG_T TYPE OF CARDIOPLEGIA What type of cardioplegia was used?

Code Type of cardioplegia

1 Hyperkalaemic

2 Bretschneider HTK (Custodial)

3 Del Nido solution

Selection List 1=Hyperkalaemic 2=Bretschneider HTK (Custodial) 3= Del Nido solution

Level 3 Must not be null if CPLEG=1

74.3 CCT CUMULATIVE CROSS CLAMP TIME Where the index operation was performed on-pump, indicate the total number of minutes the aorta was completely cross-clamped and the heart was ischaemic during bypass.

Numeric NNN 0-600 minutes

Level 2 Must not be null if CPB=1 Must be less than or equal to PERF

74.4 PERF CUMULATIVE CARDIOPULMONARY BYPASS TIME (PERFUSION TIME) Where the index operation was performed on-pump, indicate the total number of minutes the patient was on cardiopulmonary bypass.

Numeric NNN 1-999 minutes

Level 2 Must not be null if CPB=1

74.5 MINHT INTRA-OPERATIVE HAEMOGLOBIN What was the lowest haemoglobin recorded whilst the patient was on cardiopulmonary bypass?

Numeric 40-200g/L NN-NNN

Level 2 Optional

75.0 IABP INTRA-AORTIC BALLOON PUMP Did the patient have an Intra-Aortic Balloon Pump (IABP) inserted at any point during the current admission? Note: This includes pre, intra & post-operatively.


Level 1

75.1 IABP_W INTRA-AORTIC BALLOON PUMP – WHEN Where an IABP was inserted, indicate time of earliest insertion from the list below: Select ONE of the following:

Selection List 1=Pre-operative 2=Intra-operative

Level 2 Must not be null if IABP=1



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Code Time Point

1 Pre-operative –before the patient enters the operating theatre

2 Intra-operative –whilst the patient is in the operating theatre

3 Post-operative –after the patient leaves the operating theatre

3=Post-operative

75.2 IABP_I INTRA-AORTIC BALLOON PUMP – INDICATION What was the PRIMARY reason for insertion of the IABP? Select ONE of the following:

Code Reason for IABP

1 Haemodynamic instability (hypotension/shock)

2 PTCA/PCI Support

3 Unstable Angina

4 CPB wean: Cardiopulmonary bypass (CPB) weaning failure (select this option if IABP was inserted to facilitate weaning from CPB even though the problem is haemodynamic instability).

5 Prophylactic

Selection List 1=Haemodynamic 2=PTCA 3=Angina 4=CPB wean 5=Prophylactic

Level 2 Must not be null if IABP=1

76.0 ECMO OTHER MECHANICAL SUPPORT – ECMO Was the patient placed on Extra-Corporeal Membrane Oxygenation (ECMO) at any time during the current admission? Note: ECMO includes peripheral or central Veno-Arterial or Veno-venous.


Level 1

76.1 ECMO_W OTHER MECHANICAL SUPPORT – ECMO WHEN Indicate the earliest use of ECMO in the current admission. Select ONE of the following:

Code Time Point

1 Pre-operative

2 Intra-operative

3 Post-operative

Selection List 1=Pre-operative 2=Intra-operative 3=Post-operative

Level 2 Must not be null if ECMO=1



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76.2 ECMO_I OTHER MECHANICAL SUPPORT – ECMO INDICATION Indicate the PRIMARY reason for use of ECMO. Select ONE of the following:

Code Time Point

1 Cardiac failure

2 Respiratory failure

3 Hypothermia

4 Rescue/Salvage

Selection List 1=Cardiac failure 2=Respiratory failure 3=Hypothermia 4=Rescue/Salvage

Level 2 Must not be null if ECMO=1

77.0 VAD OTHER MECHANICAL SUPPORT – VAD Did the patient have a ventricular assist device (VAD) implanted at any point during the current admission? Note: VAD should be inserted for a true VAD indication, either temporary or otherwise.


Level 1

77.1 VAD_W OTHER MECHANICAL SUPPORT – VAD WHEN Indicate the earliest insertion of VAD during the current admission. Select ONE of the following:

Code Time Point

1 Pre-operative

2 Intra-operative

3 Post-operative

Selection List 1=Pre-operative 2=Intra-operative 3=Post-operative

Level 2 Must not be null if VAD=1



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77.2 VAD_I OTHER MECHANICAL SUPPORT – VAD INDICATION Indicate the PRIMARY reason for inserting a VAD. Select ONE of the following:

Code Reason Reason Definition

1 Bridge to Transplantation

Includes patients who are supported with a VAD until a heart transplant is possible.

2 Bridge to Recovery

Includes patients who are expected to have ventricular recovery (i.e. myocarditis, postcardiotomy syndromes, viral cardiomyopathies, AMI with revascularisation, and post-transplant reperfusion injury).

3 Destination Includes patients where a heart transplant is not an option. The VAD is placed for permanent life sustaining support.

4 Postcardiotomy Ventricular Failure

Includes postcardiotomy patients who receive a VAD because of failure to separate from the heart-lung machine. Postcardiotomy refers to those patients with the inability to wean from cardiopulmonary bypass secondary to left, right or biventricular failure.

5 Device Malfunction

Includes patients who are currently VAD supported and are experiencing device failure.

6 End of Life Mechanical device pump has reached functional life expectancy and requires replacement.

Selection List 1=Bridge to Transplantation 2=Bridge to Recovery 3=Destination 4=Post Cardiotomy Ventricular Failure 5=Device Malfunction 6=End of Life

Level 2 Must not be null if VAD=1

78.0 IOTOE INTRA-OPERATIVE TOE Was trans-oesophageal echocardiography performed during the index operation?


Level 1

79.0 ANTIFIB INTRA-OPERATIVE ANTIFIBRINOLYTIC USE Was an antifibrinolytic agent used intra-operatively during the index operation? Note: Antifibrinolytic agents include aminocaproic acid and tranexamic acid.

Selection List 1=Yes 0=No 9=ATACAS -1=Unknown

Level 1



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79.1 ANTIFIB_T INTRA-OPERATIVE ANTIFIBRINOLYTIC USE – TYPE Was Trasylol, Tranexamic Acid or Aminocaproic Acid or other used peri-operatively during the index operation? Select ONE option from the following:

Code Time Point

1 Trasylol

2 Tranexamic Acid

3 Other

4 Aminocaproic Acid

Selection List 1=Trasylol 2=Tranexamic Acid 3= Other 4=Aminocaproic Acid

Level 2 Must not be null if ANTIFIB=1


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SECTION 9: CORONARY ARTERY BYPASS GRAFT


80.0 IDGCA INTRA-OPERATIVE DECISION TO GRAFT CORONARY ARTERY Was a decision made during the intra-operative stage to graft the coronary artery/arteries (i.e. CCAB not proposed before operation commenced)?


Level 2 Must not be null if CCAB=1

81.0 ITA ITA USED Was an internal thoracic artery used for coronary artery bypass?



81.1 LITA ITA USED – LITA (LEFT) Was the left internal thoracic artery used for coronary artery bypass?


Level 3 Must not be null if ITA=1

81.1.1 LITA_SK ITA USED – LITA (LEFT) SKELETONISED Was the left internal thoracic artery skeletonised?


Level 4 Must not be null if LITA=1

81.2 RITA ITA USED – RITA (RIGHT) Was the right internal thoracic artery used for coronary artery bypass graft?


Level 3 Must not be null if ITA=1

81.2.1 RITA_SK ITA USED – RITA (RIGHT) SKELETONISED Was the right internal thoracic artery skeletonised?


Level 4 Must not be null if RITA=1

82.0 RAC NUMBER OF RADIAL ARTERY CONDUITS HARVESTED Indicate the total number of radial artery/arteries conduits used.

Numeric 0-2 N


83.0 DAN_AC NUMBER OF DISTAL ARTERIAL GRAFTS (DISTAL ANASTOMOSES WITH ARTERIAL CONDUITS) Indicate the total number of distal anastomoses with arterial conduits, whether IMA, GEPA, radial artery etc.

Numeric 0-9 N


84.0 DANITA NUMBER OF ITA DISTAL ANASTOMOSES Indicate the total number of distal anastomoses done using internal thoracic artery grafts.

Numeric 0-6 N



SECTION 9: CORONARY ARTERY BYPASS GRAFT

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85.0 RDAN NUMBER OF RADIAL DISTAL ANASTOMOSES Indicate the total number of anastomoses done using the radial artery.

Numeric 0-6 N


86.0 DANV NUMBER OF VEIN DISTAL ANASTOMOSES Indicate the total number of distal anastomoses with venous conduits.

Numeric 0-9 N


87.0 DANGEP NUMBER OF GEPA DISTAL ANASTOMOSES Indicate the total number of Gastro-Epiploic Artery (GEPA) distal anastomoses.

Numeric 0-6 N


88.0 ATY T-GRAFT OR Y-GRAFT Was any form of T or Y grafts used between segments of conduit during the index operation?



89.0 DAN NUMBER OF DISTAL ANASTOMOSES Indicate the total number of distal anastomoses

Numeric NN Auto-populated



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SECTION 10: VALVE SURGERY


90.0 AOPROC AORTIC VALVE PROCEDURE Was the index operation performed on the aortic valve, and if so, specify the procedure type from the list below:

Code Valve Procedure

1 No

3 Replacement

6 Root reconstruction with valved conduit This includes The "Bentall" and "Cabrol" techniques. That is, any procedure in which the aortic valve and sinuses are replaced en bloc and the coronary buttons are attached to the conduit.

7 Root reconstruction with valve sparing This includes the "David" and "Yacoub" techniques. That is when the native aortic valve is left in situ and THREE aortic sinuses are excised and the coronary button are attached to the conduit.

8 Re-suspension of the aortic valve This includes a specific procedure to resuspend the aortic commissures. It does not include "resuspension" performed merely by suturing a conduit at the sino-tubular junction.

9 Resection of sub-aortic stenosis

10 Valvotomy with annuloplasty ring

11 Valvotomy without annuloplasty ring

12 Repair of paravalvular leak

15 Ross procedure

16 Inspection only

17 Decalcification of valve only

18 Subcommissural annuloplasty

20 Thrombus removal

21 Root enlargement (Manougian type excludes Nicks)

22 Transcatheter Aortic Valve Replacement (TAVR)

Selection List 1=No 3=Replacement 6=Root reconstruction with valved conduit 7=Root reconstruction with valve sparing 8=Re-suspension aortic valve 9=Resection sub-aortic stenosis 10=Valvotomy with annuloplasty ring 11=Valvotomy without annuloplasty ring 12=Repair paravalvular leak 15=Ross procedure 16=Inspection only 17=Decalcification of valve only 18=Subcommissural annuloplasty 20=Thrombus removal 21=Root enlargement 22=TAVR 23= Aortic Valvuloplasty with

Level 2 Must not be null if CVLV=1



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23 Aortic Valvuloplasty with subcommissural annuloplasty This refers to a procedure to modify one or more aortic cusps, such as shortening or lengthening the free edge, or cusp-body enlargement, with subcommissural annuloplasty

24 Aortic Valvuloplasty without subcommissural annuloplasty This refers to a procedure to modify one or more aortic cusps, such as shortening or lengthening the free edge, or cusp-body enlargement, without subcommissural annuloplasty

26 Removal of tumour valve tissue (e.g. Fibroelastoma)

subcommissural annuloplasty 24= Aortic Valvuloplasty without subcommissural annuloplasty 26=Tumour tissue removal

90.1 AOIM AORTIC VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number from the ANZSCTS database prosthesis list.

Numeric Use prosthesis list

Level 3 Must not be null if AOPROC=3, 6, 10, 15, 22 or 23

90.2 AOIM_SR AORTIC VALVE PROSTHESIS – IMPLANT SERIAL NUMBER Enter the serial number of implanted prosthesis.



90.3 AOIM_LN AORTIC VALVE PROSTHESIS – IMPLANT LOT NUMBER Enter the lot number of implanted prosthesis.


Optional

90.4 AOIM_S AORTIC VALVE PROSTHESIS – IMPLANT SIZE Enter the size of the aortic prosthesis implant.

Numeric NN 5-50mm




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90.5 AOEX AORTIC VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number for the explanted valve using the ANZSCTS database prosthesis list.


Level 3

90.6 AOEX_SR AORTIC VALVE PROSTHESIS – EXPLANT SERIAL NUMBER Enter the serial number of explanted prosthesis.


Level 3

90.7 AOEX_S AORTIC VALVE PROSTHESIS – EXPLANT SIZE Enter the size of the aortic prosthesis explant.

Numeric NN 5-50mm

Level 3

90.8 AOSTEN AORTIC STENOSIS Was a clinically significant aortic stenosis present?



90.9 AOREG AORTIC REGURGITATION/INSUFFICIENCY If aortic regurgitation was present, indicate the severity of aortic valve regurgitation from the list below:

Code Stenosis Severity

0 None

1 Trivial

2 Mild

3 Moderate

4 Severe

Selection List 0=None 1=Trivial 2=Mild 3=Moderate 4=Severe


90.10 AOPATH AORTIC VALVE PATHOLOGY/AETIOLOGY If aortic pathology was present, indicate the predominant aetiology/pathology from the list below:

Code Valve Pathology Aetiology/Pathology Description

1 Rheumatic Valve is tricuspid, typically symmetrical and has rolled edges, shortened, fibrosed leaflets. There may be commissural fusion.

2 Congenital Spectrum of appearances: from asymmetrical, with varying degree of fusion of (typically L-R commissure) and normally disposed coronary orifices, through to classical bicuspid

Selection List 1=Rheumatic 2=Congenital 4=Idiopathic Calcific 5=Myxomatous degeneration 6=Failed prior repair 7=Prosthetic valve failure 8=Peri-prosthetic leak

Level 3

Must not be

null if

AOPROC>1 or

AOSTEN=1 or

AOREG>0



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valve and opposing coronary orifices. May or may not be calcified.

4 Idiopathic Calcific Senile dystrophic calcification, not having the characteristics of 1 or 2 above.

5 Myxomatous degeneration Elongated, thickened leaflets, one or more may be prolapsing. More securely determined if associated with typical myxomatous mitral valve disease. Most securely determined if confirmed by histology.

6 Failed prior repair Self-evident (failure not due to infection).

7 Prosthetic valve failure Structural failure of a tissue or mechanical valve.

8 Peri-prosthetic leak Self-evident (failure not due to infection).

9 Prosthetic valve thrombosis Leaflet, poppet or disc restriction due to (non-infective) thrombus. Includes sub-valvular pannus formation.

10 Active infection Characterised by clinical and pathologic features of unhealed endocarditis with patients still receiving antibiotic therapy.

11 Previous infection Previously diagnosed endocarditis that has been treated and is quiescent.

12 Marfan’s Variety of myxomatous aortic valve disease in a patient with clinical features of Marfan’s syndrome.

13 Annuloaortic ectasia Aortic regurgitation due to dilation of the aortic annulus and sino-tubular junction (possibly also the ascending aorta) with essentially normal leaflets.

14 Other degenerative disease Generally a myxomatous valve but associated with a systemic syndrome other than Marfan’s (Sjogren, Lupus, Ehlers-Danlos, etc.)

15 Dissection Regurgitation in a previously normal valve due to dissection disrupting the commissural attachments.

16 Tumour Typical macroscopic characteristics of tumour, preferably with histological confirmation.

17 Trauma Due to mechanical trauma.

9=Prosthetic valve thrombosis 10=Active infection 11=Previous infection 12=Marfan’s 13=Annuloaortic ectasia 14=Other degenerative disease 15= Dissection 16=Tumour 17=Trauma 18=Iatrogenic 22=Failed TAVR 99=Other



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18 Iatrogenic Due to iatrogenic trauma (e.g. when operating for HOCM or resection of sub-valvular stenosis, or operating on the mitral valve).

22 Failed TAVR

99 Other

Note: Where there is a congenital pathology/aetiology such as a bicuspid aortic valve in combination with either a myxomatous degeneration or calcific pathology, indicate ‘congenital’.

91.0 MIPROC MITRAL VALVE PROCEDURE Was the index operation performed on the mitral valve, and if so, specify the procedure type from the list below:


1 No

2 Annuloplasty only

3 Replacement

4 Repair or reconstruction with annuloplasty

5 Repair or reconstruction without annuloplasty

10 Commissurotomy with annuloplasty ring

11 Commissurotomy without annuloplasty ring


16 Inspection only

17 Decalcification of valve only

20 Thrombus removal

25 Alfieri Suture


27 Insertion of Mitraclip device

28 Transcatheter mitral valve replacement (TMVR)

Selection List 1=No 2=Annuloplasty only 3=Replacement 4=Repair or reconstruction with annuloplasty 5=Repair or reconstruction without annuloplasty 10=Commissurotomy with annuloplasty ring 11=Commissurotomy without annuloplasty ring 12=Repair paravalvular leak 16=Inspection only 17=Decalcification of valve only 20=Thrombus removal 25=Alfieri Suture




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26=Tumour tissue removal 27=Insertion of Mitraclip device 28=TMVR

91.1 MIIM MITRAL VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number from the ANZSCTS database prosthesis list.


Level 3 Must not be null if MIPROC=2,3,4, 10, 27 or 28

91.2 MIIM_SR MITRAL VALVE PROSTHESIS – IMPLANT SERIAL NUMBER Enter the serial number of implanted prosthesis.



91.3 MIIM_LN MITRAL VALVE PROSTHESIS – IMPLANT LOT NUMBER Enter the lot number of implanted prosthesis.


Optional

91.4 MIIM_S MITRAL VALVE PROSTHESIS – IMPLANT SIZE Enter the size of the mitral prosthesis implant.

Numeric NN 5-50mm


91.5 MIEX MITRAL VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number for the explanted valve using the ANZSCTS database prosthesis list.


Level 3

91.6 MIEX_SR MITRAL VALVE PROSTHESIS – EXPLANT SERIAL NUMBER Enter the serial number of explanted prosthesis.


Level 3

91.7 MIEX_S MITRAL VALVE PROSTHESIS – EXPLANT SIZE Enter the size of the mitral prosthesis explant.

Numeric NN 5-50mm

Level 3



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91.8 MISTEN MITRAL STENOSIS Was a clinically significant mitral stenosis present?



91.9 MIREG MITRAL REGURGITATION/INSUFFICIENCY If mitral regurgitation was present, indicate the severity of mitral valve regurgitation from the list below:


0 None

1 Trivial

2 Mild

3 Moderate

4 Severe



91.10 MIPATH MITRAL VALVE PATHOLOGY/ AETIOLOGY If mitral pathology was present, indicate the predominant aetiology/pathology from the list below:

Code Valve Pathology Pathology Description

1 Rheumatic Commissural fusion, shortened, thickened leaflets, subvalvular fusion.

2 Congenital Eccentrically fused, leaflets without characteristics of chronic rheumatic disease.

3 Ischaemic Regurgitation due to ischaemia (not just associated with IHD). Evidence of papillary muscle and subjacent mural infarction (acute or chronic). MR associated with IHD and dilated LV, with intact papillary muscles (e.g. anterior infarction) should NOT be considered ischaemic.

4 Idiopathic Calcific Due to calcification ONLY, with no commissural fusion, the non-calcified portions of the leaflets are normal, there is no chordal pathology, but calcium may extend into the annulus and the sub-annular myocardium.

5 Myxomatous degeneration Elongated, thickened leaflets, one or more may be prolapsing. Most securely determined if confirmed by histology.

Selection List 1=Rheumatic 2=Congenital 3= Ischaemic 4=Idiopathic Calcific 5=Myxomatous degeneration 6=Failed prior repair 7=Prosthetic valve failure 8=Peri-prosthetic leak 9=Prosthetic valve thrombosis 10=Active infection 11=Previous infection 12=Marfan’s 14=Other degenerative disease 16=Tumour 17=Trauma

Level 3 Must not be null if MIPROC>1 or MISTEN=1 or MIREG>0



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12 Marfan’s Variety of myxomatous mitral valve disease in a patient with clinical features of Marfan’s syndrome.

14 Other degenerative disease Generally a myxomatous valve but associated with a systemic syndrome other than Marfan’s (Sjogren, Lupus, Ehlers-Danlos etc.).



18 Iatrogenic Due to iatrogenic trauma including Mitraclip procedure.

19 Functional mitral valve Normal leaflet anatomy with mitral regurgitation due to annular dilatation.

23 Failed TMVR

99 Other

18=Iatrogenic 19=Functional mitral valve 23=Failed TMVR 99=Other

92.0 TRPROC TRICUSPID VALVE PROCEDURE Was the index operation performed on the tricuspid valve, and if so, specify the procedure type from the list below:


1 No

Selection List 1=No 2=Annuloplasty only 3=Replacement




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2 Annuloplasty only

3 Replacement

4 Repair or reconstruction with annuloplasty

5 Repair or reconstruction without annuloplasty

10 Commissurotomy with annuloplasty ring

11 Commissurotomy without annuloplasty ring


13 Valvectomy (no replacement)

16 Inspection only

20 Thrombus removal


4=Repair or reconstruction with annuloplasty 5=Repair or reconstruction without annuloplasty 10=Commissurotomy with annuloplasty ring 11=Commissurotomy without annuloplasty ring 12=Repair of paravalvular leak 13=Valvectomy (no replacement) 16=Inspection only 20=Thrombus removal 26=Tumour tissue removal

92.1 TRIM TRICUSPID VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number from the ANZSCTS database prosthesis list.


Level 3 Must not be null if TRPROC=2, 3, 4 or 10

92.2 TRIM_SR TRICUSPID VALVE PROSTHESIS – IMPLANT SERIAL NUMBER Enter the serial number of implanted prosthesis.





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92.3 TRIM_LN TRICUSPID VALVE PROSTHESIS – IMPLANT LOT NUMBER Enter the lot number of implanted prosthesis.


Optional

92.4 TRIM_S TRICUSPID VALVE PROSTHESIS – IMPLANT SIZE Enter the size of the tricuspid prosthesis implant.

Numeric NN 5-50mm


92.5 TREX TRICUSPID VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number for the explanted valve using the ANZSCTS database prosthesis list.


Level 3

92.6 TREX_SR TRICUSPID VALVE PROSTHESIS – EXPLANT SERIAL NUMBER Enter the serial number of explanted prosthesis.


Level 3

92.7 TREX_S TRICUSPID VALVE PROSTHESIS – EXPLANT SIZE Enter the size of the tricuspid prosthesis explant.

Numeric NN 5-50mm

Level 3

92.8 TRSTEN TRICUSPID STENOSIS Was tricuspid stenosis present to clinically warrant valve intervention?



92.9 TRREG TRICUSPID REGURGITATION/INSUFFICIENCY If tricuspid regurgitation was present, indicate the severity of tricuspid valve regurgitation from the list below:


0 None

1 Trivial

2 Mild

3 Moderate

4 Severe



92.10 TRPATH TRICUSPID VALVE PATHOLOGY/AETIOLOGY If tricuspid pathology was present, indicate the predominant aetiology/pathology from the list below:

Code Valve Procedure Procedure Description

Selection List 1=Rheumatic 2=Congenital

Level 3 Must not be null TRPROC>1



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1 Rheumatic Commissural fusion, shortened, thickened leaflets, subvalvular fusion.

2 Congenital Eccentrically fused, leaflets without characteristics of chronic rheumatic disease.

5 Myxomatous degeneration Elongated, thickened leaflets, one or more may be prolapsing. More securely determined if associated with typical myxomatous tricuspid valve disease. Most securely determined if confirmed by histology.







12 Marfan’s Variety of myxomatous tricuspid valve disease in a patient with clinical features of Marfan’s syndrome.

14 Other degenerative disease Generally a myxomatous valve but associated with a systemic syndrome other than Marfan’s (Sjogren, Lupus, Ehlers-Danlos etc.).

16 Tumour Typical macroscopic characteristics of tumour, preferably with histological confirmation


18 Iatrogenic Due to iatrogenic trauma.

20 Functional tricuspid valve Normal leaflet anatomy with tricuspid regurgitation due to annular dilatation.

21 Carcinoid syndrome Tricuspid regurgitation in patient with demonstrated

carcinoid syndrome.

5=Myxomatous degeneration 6=Failed prior repair 7=Prosthetic valve failure 8=Peri-prosthetic leak 9=Prosthetic valve thrombosis 10=Active infection 11=Previous infection 12=Marfan’s 14=Other degenerative disease 16=Tumour 17=Trauma 18=Iatrogenic 20=Functional tricuspid valve 21= Carcinoid syndrome 99=Other

or TRSTEN=1 or TRREG>0



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99 Other

93.0 PUPROC PULMONARY VALVE PROCEDURE Was the index operation performed on the pulmonary valve, and if so, specify the procedure type from the list below:


1 No

3 Replacement

10 Valvotomy with annuloplasty ring

11 Valvotomy without annuloplasty ring


16 Inspection only


29 Replacement of pulmonary root as part of a Ross procedure

Selection List 1=No 3=Replacement 10= Valvotomy with annuloplasty ring 11= Valvotomy without annuloplasty ring 12=Repair paravalvular leak 16=Inspection only 26=Tumour tissue removal 29= Replacement of pulmonary root as part of a Ross procedure


93.1 PUIM PULMONARY VALVE PROSTHESIS – IMPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number from the ANZSCTS database prosthesis list.


Level 3 Must not be null if PUPROC=3 or 29

93.2 PUIM_SR PULMONARY VALVE PROSTHESIS – IMPLANT SERIAL NUMBER Enter the serial number of implanted prosthesis.



93.3 PUIM_LN PULMONARY VALVE PROSTHESIS – IMPLANT LOT NUMBER Enter the lot number of implanted prosthesis.


Optional



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93.4 PUIM_S PULMONARY VALVE PROSTHESIS – IMPLANT SIZE Enter the size of the pulmonary prosthesis implant.

Numeric NN 5-50mm


93.5 PUEX PULMONARY VALVE PROSTHESIS – EXPLANT MANUFACTURER’S MODEL NUMBER Enter the manufacturer’s model number for the explanted valve using the ANZSCTS database prosthesis list.


Level 3

93.6 PUEX_SR PULMONARY VALVE PROSTHESIS – EXPLANT SERIAL NUMBER Enter the serial number of explanted prosthesis.


Level 3

93.7 PUEX_S PULMONARY VALVE PROSTHESIS – EXPLANT SIZE Enter the size of the pulmonary prosthesis explant.

Numeric NN 5-50mm

Level 3

93.8 PUSTEN PULMONARY STENOSIS Was a clinically significant pulmonary stenosis present?



93.9 PUREG PULMONARY REGURGITATION/INSUFFICIENCY If pulmonary regurgitation was present, indicate the severity of aortic valve regurgitation from the list below:

Code Time Point

0 None

1 Trivial

2 Mild

3 Moderate

4 Severe



93.10 PUPATH PULMONARY VALVE PATHOLOGY/AETIOLOGY If pulmonary pathology was present, indicate the predominant aetiology/pathology from the list below:

Code Valve Pathology Pathology Description

Selection List 1=Rheumatic 2=Congenital 5=Myxomatous degeneration 6=Failed prior repair

Level 3 Must not be null if PUPROC>1 or PUSTEN=1 or PUREG>0



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1 Rheumatic Valve is tricuspid, typically symmetrical and has rolled edges, shortened, fibrosed leaflets. There may be commissural fusion.

2 Congenital Spectrum of appearances: from asymmetrical, with varying degree of fusion of (typically L-R commissure) and normally disposed coronary orifices, through to classical bicuspid valve and opposing coronary orifices. May or may not be calcified.

5 Myxomatous degeneration Elongated, thickened leaflets, one or more may be prolapsing. More securely determined if associated with typical myxomatous mitral valve disease. Most securely determined if confirmed by histology.







14 Other degenerative disease Generally a myxomatous valve but associated with a systemic syndrome other than Marfan’s (Sjogren, Lupus, Ehlers-Danlos, etc.)



18 Iatrogenic Due to iatrogenic trauma (e.g. when operating for HOCM or resection of sub-valvular stenosis, or operating on the pulmonary valve).

99 Other

7=Prosthetic valve failure 8=Peri-prosthetic leak 9=Prosthetic valve thrombosis 10=Active infection 11=Previous infection 14=Other degenerative disease 16=Tumour 17=Trauma 18=Iatrogenic 99=Other


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SECTION 10.1: TAVR MODULE SECTION 1: PREVIOUS SURGERY

SECTION 2: DECISION TO IMPLANT


1.0 PAOVR PREVIOUS AVR Has the patient had a previous aortic valve replacement prior to the index operation? This includes prior procedures performed during the index admission.


Level 4 Must not be null if PVAL=1

2.0 AOPP PREVIOUS PROSTHESIS Indicate the previous prosthesis type.

Code Prosthesis Type

1 Stented xenograft

2 Non-stented xenograft

3 Allograft

4 Transcatheter Aortic Valve Replacement (TAVR)

Selection List 1=Stented xenograft 2=Non-stented xenograft 3=Allograft 4=TAVR

Level 5 Must not be null if PAOVR=1


3.0 AOEV EVALUATION TO PERFORM TAVR Indicate the individual (or group) who undertook the evaluation to perform TAVR.

Code Individual (or Group) to Evaluate

1 TAVR proceduralist. This should ONLY be selected if the TAVR proceduralist was involved in the decision to insert the TAV.

2 Consultation with surgeon. This should ONLY be selected if decision to insert the TAV was made by consultation between the TAV proceduralist and a cardiac surgeon.

3 Heart team. This should ONLY be selected if a full heart team was involved in the decision to insert the TAV.

4 Consultation with cardiologist. This should ONLY be selected if decision to insert the TAV was made by consultation between the TAV proceduralist and a cardiologist.

Selection List 1=TAVR proceduralist 2=Consultation with surgeon 3=Heart team 4=Consultation with cardiologist

Level 1

4.0 AOFR CANADIAN CLINICAL FRAILTY SCALE Indicate frailty of the patient according to the Canadian Frailty Scale.

Code Canadian Clinical Frailty Scale description

Selection List 1=Very fit 2=Well 3=Managing well

Level 1


SECTION 10.1: TAVR MODULE

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1 Very fit – people who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.

2 Well – people who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.

3 Managing well – people whose medical problems are well controlled, but are not regularly active beyond routine walking.

4 Vulnerable – while not dependent on others for daily help, often symptoms limit activities. A common complaint is being ‘slowed up’, and/or being tired during the day.

5 Mildly frail – these people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.

6 Moderately frail – people need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.

7 Severely frail – completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~6 months).

8 Very severely frail – completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.

9 Terminally ill – approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.

4=Vulnerable 5= Mildly frail 6=Moderately frail 7=Severely frail 8=Very severely frail 9=Terminally ill

5.0 AOPLN PORCELAIN AORTA Has the patient had a porcelain aorta as documented by findings on a chest x-ray, CT scan, fluoroscopy at the time of cardiac catheterisation or noted during previous cardiothoracic surgery?


Level 1



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SECTION 3: PROCEDURE

SECTION 4: ADDITIONAL PROCEDURAL INFORMATION


6.0 AOACC PROCEDURAL ACCESS Indicate the access site for the TAVR procedure.

Code Procedural Access Site

1 Transapical

2 Transfemoral

3 Transaortic

4 Transsubclavian

5 Transcarotid

Selection List 1=Transapical 2=Transfemoral 3=Transaortic 4=Transsubclavian 5=Transcarotid

Level 1

7.0 AODEP SUCCESSFUL DEPLOYMENT Was the device deployment successful?


Level 1

8.0 AOSAVR SURGICAL AVR Was conversion to open heart surgical access required? Note: Open heart surgical access is the creation of an incision to open the chest and provide direct access to the heart.


Level 2 Must not be null if AODEP=0


9.0 AOANA ANAESTHESIA Indicate the type of anaesthetic that was delivered to the patient prior to the procedure. Local includes regional local and general sedation, whether or not an anaesthetist is present.

Code Anaesthetic Type

1 General

2 Local

Selection List 1=General 2=Local

Level 1

10.0 AOVAS VASCULAR CLOSURE TECHNIQUE Indicate the vascular closure technique used.

Code Vascular Closure Technique

1 Open

2 Percutaneous

Selection List 1=Open 2=Percutaneous

Level 1



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SECTION 5: DISCHARGE ECHOCARDIOGRAPHIC VALVE EVALUATION

11.0 AOPIN PROCEDURE INITIATION DATE/TIME Indicate the date and time that access to the aortic valve was initiated.

Date and Time DD/MM/YYYY HH:MM

Level 1

11.1 AOPCO PROCEDURE COMPLETION DATE/TIME If device deployment was successful, indicate the date and time that the procedure was completed.



11.2 AOPAB PROCEDURE ABORTION DATE/TIME If device deployment was unsuccessful, indicate the date and time that the procedure was aborted.




12.0 AODPO NUMBER OF DAYS POST OPERATION The number of days, from the date of procedure, that the echocardiographic evaluation most proximate to the date of discharge was performed.

Numeric NN 0-30 days

Level 1

13.0 AOPEK AORTIC VALVE PEAK GRADIENT Indicate the aortic valve peak gradient in mmHg obtained from echocardiogram.

Numeric NNN 5-100mmHg

Level 1

14.0 AOMN AORTIC VALVE MEAN GRADIENT Indicate the aortic valve mean gradient in mmHg obtained from echocardiogram.

Numeric NNN 0-100mmHg

Level 1

15.0 AOVA AORTIC VALVE AREA Indicate the smallest aortic valve area (in cm2) obtained from echocardiogram.

Numeric N.N 0.5-5.0 cm2

Level 1

16.0 AODR AORTIC VALVE REGURGITATION Indicate the highest level of aortic regurgitation found on the echocardiogram.


Level 1


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SECTION 10.2: TMVR MODULE SECTION 1: PREVIOUS SURGERY

SECTION 2: DECISION TO IMPLANT


1.0 PMIVR PREVIOUS MVR Has the patient had a previous mitral valve replacement prior to the index operation? This includes prior procedures performed during the index admission.


Level 4 Must not be null if PVAL=1

2.0 MIPP PREVIOUS PROSTHESIS Indicate the previous prosthesis type.

Code Prosthesis Type

1 Stented xenograft

2 Non-stented xenograft

3 Transcatheter Mitral Valve Replacement (TMVR)

Selection List 1=Stented xenograft 2=Non-stented xenograft 3=TMVR

Level 5 Must not be null if PMIVR=1


3.0 MIEV EVALUATION TO PERFORM TMVR Indicate the individual (or group) who undertook the evaluation to perform TMVR.

Code Individual (or Group) to Evaluate

1 TMVR proceduralist. This should ONLY be selected if the TMVR proceduralist was involved in the decision to insert the TMV.

2 Consultation with surgeon. This should ONLY be selected if decision to insert the TMV was made by consultation between the TMV proceduralist and a cardiac surgeon.

3 Heart team. This should ONLY be selected if a full heart team was involved in the decision to insert the TMV.

4 Consultation with cardiologist. This should ONLY be selected if decision to insert the TMV was made by consultation between the TMV proceduralist and a cardiologist.

Selection List 1=TMVR proceduralist 2=Consultation with surgeon 3=Heart team 4=Consultation with cardiologist

Level 1


SECTION 10.2: TMVR MODULE

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4.0 MIFR CANADIAN CLINICAL FRAILTY SCALE Indicate frailty of the patient according to the Canadian Frailty Scale.

Code Canadian Clinical Frailty Scale description

1 Very fit – people who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.

2 Well – people who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.

3 Managing well – people whose medical problems are well controlled, but are not regularly active beyond routine walking.

4 Vulnerable – while not dependent on others for daily help, often symptoms limit activities. A common complaint is being ‘slowed up’, and/or being tired during the day.

5 Mildly frail – these people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.

6 Moderately frail – people need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.

7 Severely frail – completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~6 months).

8 Very severely frail – completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.

9 Terminally ill – approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.

Selection List 1=Very fit 2=Well 3=Managing well 4=Vulnerable 5= Mildly frail 6=Moderately frail 7=Severely frail 8=Very severely frail 9=Terminally ill

Level 1



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SECTION 3: PROCEDURE

SECTION 4: ADDITIONAL PROCEDURAL INFORMATION


5.0 MIACC PROCEDURAL ACCESS Indicate the access site for the TMVR procedure.

Code Procedural Access Site

1 Transapical

2 Transatrial septal

Selection List 1=Transapical 2=Transatrial septal

Level 1

6.0 MIDEP SUCCESSFUL DEPLOYMENT Was the device deployment successful?


Level 1

7.0 MISAVR SURGICAL MVR Was conversion to open heart surgical access required? Note: Open heart surgical access is the creation of an incision to open the chest and provide direct access to the heart.


Level 2 Must not be null if MIDEP=0


8.0 MIANA ANAESTHESIA Indicate the type of anaesthetic that was delivered to the patient prior to the procedure. Local includes regional local and general sedation, whether or not an anaesthetist is present.

Code Anaesthetic Type

1 General

2 Local

Selection List 1=General 2=Local

Level 1

9.0 MIVAS VASCULAR CLOSURE TECHNIQUE Indicate the vascular closure technique used.

Code Vascular Closure Technique

1 Open

2 Percutaneous

Selection List 1=Open 2=Percutaneous

Level 1



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SECTION 5: DISCHARGE ECHOCARDIOGRAPHIC VALVE EVALUATION

10.0 MIPIN PROCEDURE INITIATION DATE/TIME Indicate the date and time that access to the mitral valve was initiated.


Level 1

10.1 MIPCO PROCEDURE COMPLETION DATE/TIME If device deployment was successful, indicate the date and time that the procedure was completed.



10.2 MIPAB PROCEDURE ABORTION DATE/TIME If device deployment was unsuccessful, indicate the date and time that the procedure was aborted.




11.0 MIDPO NUMBER OF DAYS POST OPERATION The number of days, from the date of procedure, that the echocardiographic evaluation most proximate to the date of discharge was performed.

Numeric NN 0-30 days

Level 1

12.0 MIPEK MITRAL VALVE PEAK GRADIENT Indicate the mitral valve peak gradient in mmHg obtained from echocardiogram.

Numeric NN 0-50mmHg

Level 1

13.0 MIMN MITRAL VALVE MEAN GRADIENT Indicate the mitral valve mean gradient in mmHg obtained from echocardiogram.

Numeric NN 0-30mmHg

Level 1

14.0 MIVA MITRAL VALVE AREA Indicate the smallest mitral valve area (in cm2) obtained from echocardiogram.

Numeric N.N 0.5-5.0 cm2

Level 1

15.0 MIDR MITRAL VALVE REGURGITATION Indicate the highest level of mitral regurgitation found on the echocardiogram.


Level 1


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SECTION 11: BLOOD PRODUCT USE ALL VARIABLES IN THIS SECTION REFER TO CUMULATIVE (INTRA-OPERATIVE + POST-OPERATIVE) BLOOD PRODUCT USE


94.0 RBC BLOOD BANK PRODUCTS – RBC Were allogeneic red blood cells (RBC) transfused during the intra-operative or post-operative period? Do NOT include:

a. Pre-donated blood b. Cell saver blood c. Pump residual blood d. Chest tube recirculated blood


Level 1

94.1 RBCUnit BLOOD BANK PRODUCTS – RBC Units Enter the total number of RBC units transfused.

Numeric NN

Level 2 Must not be null if RBC=1

95.0 NRBC BLOOD BANK PRODUCTS – NON RBC During the index admission, were blood products other than RBC (e.g. FFP and Platelets) transfused? Note: Excludes Albumin


Level 1

95.1 PlateUnit BLOOD BANK PRODUCTS – PLATELETS Indicate the number of platelet units transfused. Note: Indicate units and not pooled bags

Numeric NN

Level 2 Must not be null if NRBC=1

95.2 NovoUnit BLOOD BANK PRODUCTS – NOVO 7 Indicate milligrams of Novo 7 used. Note: Novo7 comes in 1, 2, 4, and 8 mg vials. Dose administered is between 50-90mcg per kg. E.g. 50mcgx70kg person = 3500mcg=3.5mg.

Numeric NN.N mg


95.3 CryoUnit BLOOD BANK PRODUCTS – CRYOPRECIPITATE Indicate the number of Cryoprecipitate units used.

Numeric NN


95.4 FFPUnit BLOOD BANK PRODUCTS – FRESH FROZEN PLASMA Indicate the number of Fresh Frozen Plasma (FFP) units used.

Numberic NN



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SECTION 12: POST-OPERATIVE DATA


96.0 AICU_D ICU ADMISSION – DATE/TIME Record the date and time of admission to ICU from OR after surgery. Note: This does not include ICU admission prior to surgery i.e. indicate the date/time patient was admitted to ICU after surgery (regardless of other time/date of previous ICU admission). Enter 09/09/9999 00:00 for unknown date/time.


Level 1

97.0 EXTU_D EXTUBATION – DATE/TIME Record the date and time of extubation after surgery. Note: Ventilation time should be when the patient is attached to a ventilator including the weaning process but does not include spontaneous ventilation through a tracheostomy. Enter 09/09/9999 00:00 for unknown date/time.


Level 1

98.0 DICU_D ICU DISCHARGE – DATE/TIME Record the date and time of discharge from ICU. Note: This includes discharge to high dependency unit (HDU), general ward or death. Enter 09/09/999 00:00 for unknown date/time.


Level 1

99.0 REICU READMITTED TO ICU During the index operation, was the patient readmitted to ICU following the initial discharge from ICU to HDU or general ward? Note: This does not include patients initially in ICU and returned to theatre for complications.


Level 1

100.0 REINT RE-INTUBATION During the index admission, was the patient was re-intubated after the initial extubation? Note: This does not include patients who were intubated for a subsequent surgical procedure.


Level 1

100.1 REINT_D RE-INTUBATION – DATE/TIME Record the date and time when the patient was re-intubated. Enter 09/09/9999 00:00 for unknown date/time.


Level 2 Must not be null if REINT=1

100.2 REEXT_D RE-EXTUBATION – DATE/TIME Record the date and time when the patient was extubated following re-intubation. Enter 09/09/9999 00:00 for unknown date/time.


Level 2 Must not be null if REINT=1

101.0 DRAIN_4 ICC LOSS (FIRST 4 HOURS POST SURGERY) Record the fluid loss (in millilitres) from the pericardial/mediastinal (intercostal catheter) drains in the first 4 hours post-operation.

Numeric No. of mls NNNN -1=Unknown

Level 1



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COMPLICATIONS

COMPLICATIONS MUST NOT HAVE BEEN PRESENT PRE-OPERATIVELY


102.0 RTT RETURN TO THEATRE Did the patient return to the operating theatre? Note: This includes operative procedures done in the ICU that would normally be performed in the operating room.


Level 1

102.1 ROVD RETURN TO THEATRE – VALVE DYSFUNCTION Did the patient return to theatre for valve dysfunction?


Level 2 Must not be null if RTT=1

102.2 ROBL RETURN TO THEATRE – BLEEDING/TAMPONADE Did the patient return to theatre for bleeding/tamponade?



102.3 ROGO RETURN TO THEATRE – GRAFT OCCLUSION Did the patient return to theatre for:

a. Graft refashion OR b. Grafting of a previously ungrafted coronary.



102.4 ROSI RETURN TO THEATRE – DEEP STERNAL WOUND INFECTION Did the patient return to theatre for infection of sternal bone muscle and/or mediastinum?



102.5 RDTI RETURN TO THEATRE – DEEP THORACOTOMY WOUND INFECTION Did the patient return to theatre for infection involving a thoracotomy or parasternal site?



102.6 ROPA RETURN TO THEATRE – INSERTION OF PACEMAKER/AICD Did the patient return to theatre for insertion of pacemaker or AICD?



102.7 ROOC RETURN TO THEATRE – OTHER CARDIAC Did the patient return to theatre for other cardiac reasons (excluding insertion of pacemaker or AICD)?



102.8 RONC RETURN TO THEATRE – OTHER NON-CARDIAC Selection List Level 2



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Did the patient return to theatre for other non-cardiac reasons? 1=Yes 0=No

Must not be null if RTT=1

103.0 NRF NEW RENAL INSUFFICIENCY Was there acute post-operative renal insufficiency characterised by one of the following:

a. Increased serum creatinine to >0.2mmol/l (>200mol/l) AND a doubling or greater increase in creatinine over the baseline pre-operative value AND the patient did not require pre-operative dialysis/haemofiltration OR

b. A new post-operative requirement for dialysis/haemofiltration (when the patient did not require this pre-operatively).

Note: Renal insufficiency must not be present pre-operatively. Pre-operative renal transplant does not count as renal insufficiency if the patient did not have impaired kidney function and did not require dialysis/haemofiltration.


Level 1

103.1 HAEMOFIL HAEMOFILTRATION Did the patient undergo acute institution of haemofiltration (or dialysis) as treatment for new renal failure? Note: this excludes haemofiltration for removal of fluid with normal serum urea and creatinine.


Level 2 Must not be null if NRF=1

104.0 POSTCR HIGHEST POST-OP CREATININE LEVEL Record the highest serum creatinine level recorded after surgery.

20 mol/L to 2000 mol/L

Numeric NN-NNNN

20 mol/L to 2000

mol/L -1= Unknown

Level 1

105.0 POMI PERI-/POST- OPERATIVE MI Was a peri-/post- operative myocardial infarction (MI) diagnosed by finding at least two of the following criteria:

a. Enzyme level elevation either: CK-MB >30 units OR Troponin > 20.0 micrograms/L OR Troponin level equivalent documented at your instruction, provided operation does

not involve myocardial incision. b. New wall motion abnormalities c. Serial ECG (at least two) showing Q waves, duration ≥0.03ms in 2 contiguous leads.


Level 1



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106.0 POCS PERI-/POST- OPERATIVE CARDIOGENIC SHOCK Did the patient suffer peri-/ post- operative cardiogenic shock? Only code yes if all of the following criteria apply:

1. Sustained (>30 minutes) episode of systolic blood pressure <90mm Hg or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g. Intra-aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices to maintain BP > 90mm Hg); AND

2. Evidence of elevated filling pressures (e.g. pulmonary congestion on examination or chest radiograph); AND

3. Evidence of end organ hypoperfusion (e.g. urine output 30mL/hours, or cold/diaphoretic extremities, or obtunded mental status if previously normal, etc.).


Level 1

107.0 POSTHG POST-OPERATIVE HAEMOGLOBIN Record the lowest haemoglobin recorded post-operatively. 40g/L to 200g/L

Numeric NN-NNN 40g/L to 200g/L

Level 1

108.0 CIUSE CARDIAC INOTROPE USE – FOR LONGER THAN 4 HOURS POST-OPERATIVELY Was an inotrope used to maintain cardiac output or SVR for longer than 4 hours post-operatively? Note: Include Dopamine at > 300 µg/min. Do NOT include routinely administered Milrinone.


Level 1

109.0 IULOWOUT

CARDIAC INOTROPE USE – FOR LOW CARDIAC OUTPUT SYNDROME Were inotrope(s) used for low cardiac output syndrome longer than four hours post-operatively (i.e. when an inotrope is administered with the intent to improve cardiac output irrespective of the reason for that decision)? Note: Do NOT include routinely administered Milrinone.


Level 1

110.0 IULowSVR CARDIAC VASOPRESSOR USE – FOR LOW SVR SYNDROME Was a vasopressor used for low systemic vascular resistance syndrome for longer than 4 hours post-operatively (i.e. when a primarily alpha adrenergic agonist is given with the intent to increase SVR (where SVR < 800))? Note: This is usually in the presence of high cardiac output, however, does not include Noradrenaline given with Milrinone.


Level 1

111.0 NARRT NEW CARDIAC ARRHYTHMIA Did any new form of cardiac arrhythmia occur that required treatment? Note: Includes brady and tachy arrhythmias of atrial or ventricular origin and any A-V conduction disturbances or requirement for permanent pacemaker insertion.


Level 1



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111.1 HB NEW HEART BLOCK (REQUIRING PPM) Did the patient develop new heart block requiring the implantation of a permanent pacemaker prior to discharge?


Level 2 Must not be null if NARRT=1

111.2 BA NEW OTHER BRADYARRHYTHMIA (REQUIRING PPM) Did the patient develop a new bradyarrhythmia not otherwise specified requiring the implantation of permanent pacemaker prior to discharge?



111.3 CA CARDIAC ARREST Did the patient have a new cardiac arrest documented by one of the following:

a. Ventricular fibrillation OR b. Rapid ventricular tachycardia with haemodynamic instability OR c. Asystole OR d. Pulseless electrical activity (PEA)?



111.4 AFIB NEW ATRIAL ARRHYTHMIA (REQUIRING TREATMENT) ATRIAL FIBRILLATION OR FLUTTER Was there a new onset of atrial fibrillation/flutter (AF) requiring treatment? Note: Does not include recurrence of AF present pre-operatively.



111.5 NARRTV NEW VENTRICULAR TACHYCARDIA Did any new form of ventricular tachycardia (greater than 6 beat run) occur that required treatment?



112.0 CVA_P STROKE PERMANENT Did the patient experience a stroke or new central neurologic deficit (persisting for >72 hours) peri- or post-operatively? Note: Neurological deficit is characterised by persistent loss of neurological function caused by an ischaemic or haemorrhagic event.


Level 1

113.0 CVA_T STROKE TRANSIENT Did the patient experience a new transient central neurologic deficit that was resolved completely within 72 hours (TIA/RIND)?


Level 1

114.0 COMA NEW CONTINUOUS COMA ≥ 24 HOURS Did the patient have post-operative coma of neurologic aetiology lasting at least 24 hours? Note: This excludes metabolic and drug related coma.


Level 1



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115.0 VENT_P PROLONGED VENTILATION > 24 HOURS Was the patient on prolonged ventilation post-operatively for pulmonary insufficiency requiring ventilator support –includes (but not limited to) causes such as Adult Respiratory Distress Syndrome (ARDS) and pulmonary oedema –for a total period of longer than 24 hours? Use cumulative period if patient is re-intubated.


Level 1

116.0 PUEMB PULMONARY EMBOLISM Did the patient have a new pulmonary embolism diagnosed by study such as ventilation/perfusion (V/Q) scan or angiogram?


Level 1

117.0 PUPNU PNEUMONIA Was pneumonia diagnosed post-operatively by one of the following:

a. Positive cultures of sputum or trans-tracheal aspirate OR b. Clinical, including haematological findings consistent with the diagnosis of pneumonia and

radiographic evidence


Level 1

118.0 INFDS DEEP STERNAL WOUND INFECTION Did the patient develop infection of sternal bone, muscle and/or mediastinum? The patient must have wound debridement and one of the following:

a. Positive cultures b. Treatment with antibiotics


Level 1

119.0 SWI SUPERFICIAL ACCESS-WOUND INFECTION Did the patient develop an infection involving the skin and subcutaneous tissues of the incision occurring within 30-days post-operation? For this diagnosis to be made, ONE of the following must be present:

a. Purulent drainage from the superficial incision. b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial

incision. c. Superficial incision deliberately opened by surgeon whether or not it is culture positive. d. Diagnosis of superficial incisional surgical site infection by operating surgeon or other.

attending clinician


Level 1

120.0 DOWI DONOR SITE DEEP WOUND INFECTION Did the patient develop an infection involving deep soft tissues (e.g. fascial and muscle layers and/or organs/spaces opened or manipulated during surgery) occurring within 30 days after the operative procedure if implant not present?


Level 1



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For this diagnosis to be made, ONE of the following must be present: a. Purulent drainage from deep soft tissue but not from the organ/space component of the

surgical site. b. Spontaneous dehiscence at incision site or the wound is deliberately explored by a surgeon

with the patient showing evidence of one or more of the following signs or symptoms. Fever > 38˚C, localised pain or tenderness with culture-positive specimen. A culture-

negative finding does not meet this criterion unless the patient was on antibiotics immediately prior to the wound being explored and/or the culture being taken.

Organisms isolated from an aseptically obtained culture of fluid or tissue obtained from an organ/space.

An abscess or other evidence of infection involving a deep/organ space found on direct examination, during reoperation, or by histopathologic or radiologic examination.

Diagnosis of or antimicrobial treatment of a deep incisional or organ/space surgical site infection by operating surgeon or assisting physician.

121.0 INFTH DEEP ACCESS-WOUND INFECTION OF PARASTERNAL SITE (NOT OF STERNOTOMY) Did the patient develop an infection involving a thoracotomy or parasternal site? For this diagnosis to be made, ONE of the following must be present:

a. Wound opened with excision of tissue b. Positive culture c. Treatment with antibiotics


Level 1

122.0 INFSP SEPTICAEMIA Did the patient develop septicaemia defined by positive blood cultures supported by at least two of the following indices of clinical infection:

a. Fever b. Elevated granulocyte cell counts c. Elevated and increasing C-reactive protein (CRP) d. Elevated and increasing erythrocyte sedimentation rate (ESR) post-operatively.


Level 1

123.0 NAODS AORTIC DISSECTION Did dissection occur in any part of the aorta?


Level 1

124.0 LISCH ACUTE LIMB ISCHAEMIA Selection List Level 1



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Was there any evidence of limb ischaemia?

Code Time Point

0 None

2 Upper

3 Lower

0=None 2=Upper 3=Lower

125.0 ACOAG ANTICOAGULANT COMPLICATIONS Did the patient develop any bleeding, haemorrhage, and/or embolic events related to anticoagulant therapy?


Level 1

126.0 GIT GASTROINTESTINAL TRACT (GIT) COMPLICATIONS Did the patient develop any GIT complication post-operatively including any of the following:

a. GI bleeding requiring transfusion b. Pancreatitis with abnormal amylase/lipase requiring nasogastric suction therapy c. Cholecystitis requiring cholecystectomy or drainage d. Mesenteric ischaemia requiring exploration e. Hepatitis f. Other GI complication


Level 1

127.0 MSF MULTI-SYSTEM FAILURE Did the patient develop multi-system failure post-operatively? For this diagnosis to be made, TWO or more of the following major organ systems must fail concurrently for at least 48 hours:

a. Renal –new renal failure (previously defined) b. Respiratory –requires endotracheal intubation for respiratory dysfunction c. Cardiac –the use of inotropes and/or IABP to treat low cardiac output d. Hepatic failure on the basis of enzymes, and bilirubin estimation.


Level 1


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SECTION 13: MORTALITY/READMISSION


128.0 DISCHAR DISCHARGE Indicate from the list the location where the patient was discharged to (from the hospital following the admission during where the index operation was performed).

Code Discharge Location Location Definition

1 Home Discharged to home with no planned contact before routine review

2 Hospital in the home Discharged to home with planned visits to home by medical or paramedical staff.

3 Rehabilitation unit/hospital Discharged for inpatient rehabilitation

4 Local or referring hospital Discharged to hospital for continuing acute care

5 Hospital mortality

6 Other Cardiac Unit I.e. transferred to another hospital for further cardiac surgical intervention e.g. cardiac transplant or ECMO

Selection List 1=Home 2=Hospital in the home 3=Rehabilitation unit/hospital 4=Local or referring hospital 5=Hospital mortality 6=Other Cardiac Unit

Level 1

128.1 MORTPD MORTALITY POST-DISCHARGE Did the patient die after discharge from hospital but within 30 days of surgery?


Level 2 Must not be null if DISCHAR < 5

128.2 MORT_D MORTALITY – DATE Indicate the date of death if the patient:

a. Died within 30 days from date of surgery (whether discharged or not) b. Died in hospital (during the index admission at any time).

Date DD/MM/YYYY

Level 2 Must not be null if DISCHAR= 5 or MORTPD=1



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128.3 MORT_L MORTALITY – LOCATION Specify the location of patient mortality:

Code Mortality Location

1 Operating room

2 Hospital in which the operation was performed (other than the operating room e.g. ICU or general ward)

3 Home (including hospital in the home)

4 Other care facility

Selection List 1=Operating room 2=Hospital 3=Home 4=Other

Level 2 Must not be null if DISCHAR = 5 or MORTPD=1

128.4 MORT_R MORTALITY – PRIMARY CAUSE Indicate the PRIMARY cause of death, i.e. the first significant event which ultimately led to death. Select from ONE of the following:

Code Primary Cause Mortality

1 Cardiac cause

2 Neurologic event

3 Renal failure

4 Vascular event (peripheral vascular or aortic but not aortic dissection)

5 Infection

6 Respiratory failure

7 Valvular dysfunction

8 Multisystem failure (as defined in 127.0)

9 Other

10 Unknown

11 Pulmonary embolism

12 Aortic Dissection

Selection List 1=Cardiac 2=Neurologic 3=Renal 4=Vascular 5=Infection 6=Respiratory failure 7=Valvular 8=Multisystem failure 9=Other 10=Unknown 11=Pulmonary 12=Aortic

Level 2 Must not be null if DISCHAR = 5 or MORTPD=1

128.5 MORT_SR MORTALITY – SUBSEQUENT CAUSE Specific cause of death. This applies only when PRIMARY cause of death is cardiac or infection. If PRIMARY cause is cardiac, select from:

1. Ischaemic/Other

Selection List 1=Ischaemic 2=Other Cardiac 3=Septicaemia 4=Endocarditis

Level 2 Must not be null if MORT_R=1 or 5



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2. Other If PRIMARY cause if infection, selection from:

3. Septicaemia 4. Endocarditis 5. Other

5=Other Infection -1=Unknown

129.0 WITHDRAW COGNISANT PATIENT WITHDRAWS FROM TREATMENT Did the patient who was aware of the consequences of his/her actions, elect to withdraw treatment in circumstances where they would survive if treatment had continued. Note: Completing ‘YES’ to this field implies automatic review of patient’s hospital file and permission for ANZSCTS personnel to review their case.


Level 1

130.0 READ READMISSION ≤ 30 DAY FROM SURGERY Was the patient readmitted as an in-patient within 30 days from the date of surgery for ANY reason? Note: Readmission means admission to general hospital not emergency, short-stay wards or planned transfer to rehabilitation facility. Date of surgery counts as day zero.


Level 1

130.1 READAC READMISSION REASON – ANTICOAGULANT COMPLICATION Was the patient readmitted as an in-patient within 30 days from surgery due to an anticoagulant complication (i.e. haemorrhage associated with demonstrated over-anticoagulation or thrombosis or embolism associated with demonstrated under anticoagulation)?


Level 2 Must not be null if READ=1

130.2 READAR READMISSION REASON – ARRHYTHMIA Was the patient readmitted as an in-patient within 30 days from surgery for management of any arrhythmia?



130.3 READCHF READMIT REASON – CONGESTIVE HEART FAILURE (CHF) Was the patient readmitted as an in-patient within 30 days from surgery for treatment of congestive heart failure (CHF) as evidenced by one (or more) of the following:

a. Paroxysmal nocturnal dyspnoea (PND) b. Deteriorating dyspnoea on exertion (DOE) due to heart failure c. Chest x-ray (CXR) showing pulmonary congestion.





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130.4 READVD READMIT REASON – VALVE DYSFUNCTION Was the patient readmitted as an in-patient within 30 days from surgery for valve dysfunction?



130.5 READPE READMIT REASON – PERICARDIAL EFFUSION Was the patient readmitted as an in-patient within 30 days from surgery for treatment of pericardial effusion? Note: If the effusion (of whatever nature, i.e. serous, bloody, infective) has NOT required draining and/or caused tamponade then indicate other complications relating to cardiac surgery.



130.6 READCT READMIT REASON – CARDIAC TAMPONADE Was the patient readmitted as an in-patient within 30 days from surgery for cardiac tamponade? Note: If the pericardial effusion has caused cardiac tamponade which is a physiological diagnosis, then indicate cardiac tamponade only.



130.7 READPLE READMIT REASON – PLEURAL EFFUSION Was the patient readmitted as an in-patient within 30 days from surgery for symptomatic pleural effusion?



130.8 READOTHC READMISSION REASON – OTHER COMPLICATION RELATED TO CARDIAC SURGERY Was the patient readmitted as an in-patient within 30 days from surgery for treatment for an ‘other’ complication (not specified in 130.1-130.7) related to cardiac surgery (e.g. renal, hepatic, GI, etc.)?



130.9 READDSI READMIT REASON – DEEP STERNAL INFECTION Was the patient readmitted as an in-patient within 30 days from surgery for deep sternal wound infection? Note: Deep sternal wound infection involves muscle and bone, with or without mediastinal involvement and demonstrated by surgical exploration. Must have wound debridement and one of the following:

a. Positive culture b. Treatment with antibiotics



130.10 READIC READMIT REASON – INCISIONAL COMPLICATION Was the patient readmitted as an in-patient within 30 days from surgery for a complication involving the saphenous vein, radial artery harvest, thoracotomy or non-sternotomy cardiac access incision?





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130.11 READRC READMIT REASON – PNEUMONIA OR OTHER RESPIRATORY COMPLICATION Was the patient readmitted as an in-patient within 30 days from surgery for pneumonia or other respiratory complication? Pneumonia is diagnosed by the following:

a. Positive cultures of sputum or trans-tracheal aspirate OR b. Clinical, including haematological findings consistent with the diagnosis of pneumonia and

radiographic evidence



130.12 READMI READMIT REASON – MYOCARDIAL INFARCTION (MI) Was the patient readmitted as an in-patient within 30 days from surgery for myocardial infarction (MI), diagnosed according to the definition listed on pages (34-35) in this document?



130.13 READRA READMIT REASON – RECURRENT ANGINA Was the patient readmitted as an in-patient within 30 days from the date of surgery for recurrent angina? Objective confirmation that chest pain is due to ischaemia by exercise test (ECG, nuclear, echo, exercise test or angiography) is required to meet this diagnosis.



130.14 READOTHNC READMIT REASON – READMISSION UNRELATED TO CARDIAC SURGERY Was the patient readmitted as an in-patient within 30 days from surgery due to reasons not related to cardiac surgery?




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AUTOMATED DATA (not collected on data collection form)

Field Name Variable Name and Description Data Details Rules

PatID Patient ID This is an arbitrary number, (not a recognisable ID like SSN or Medical Record Number) that uniquely and permanently identifies each patient. Once assigned to a patient, this can never be changed or reused. Generated by the system this is a unique arbitrary permanent value for each patient.

Numeric Level 1

AdmitID Admission ID This is an arbitrary number, (not a recognisable ID like SSN or Medical Record Number) that uniquely and permanently identifies each admission. Once assigned to an admission, this can never be changed or reused. Generated by the system this is a unique arbitrary permanent value for each admission.

Numeric

Level 1

OpID Operation ID This is an arbitrary number, (not a recognisable ID like SSN or Medical Record Number) that uniquely and permanently identifies each operation. Once assigned to an operation, this can never be changed or reused. Generated by the system this is a unique arbitrary permanent value for each operation.

Numeric

Level 1

AGE Age Age of the patient calculated by: DOP - DOB Calculated where surgery date (DOP) and date of birth (DOB) are available. Age in years

Numeric NN

Level 1

BMI BMI Body Mass index calculated by: WKG / (HTM / 1002) Calculated where weight (WKG) and height (HTM) are available. Units in kg/m2

Numeric Haemodynamics NN.N

Level 1

BSA BSA Body Surface Area calculated by: 0.007184 x HTM^0.725 x WKG^0.42 Calculated where weight (WKG) and height (HTM) are available. Units in m2

Numeric Haemodynamics N.NN

Level 1



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eGFR Estimated Glomerular Filtration Rate eGFR calculated by: Males: (WKG*(140-AGE))/(72*(PRECR*1000*(1000/88.4))) Females: ((WKG*(140-AGE))/(72*(PRECR*1000*(1000/88.4)))*0.85) Calculated where age (AGE), last pre-operative creatinine level (PRECR) and weight (WKG) are available. Units in mL/min per 1.73m2

Numeric Haemodynamics NN.N

Level 1

ANG_T Angina - Type Indicated type of Angina present at time of surgery. If the patient’s Angina is controlled by transcutaneous or oral) medication, this is considered Stable Angina. The presence of ischemia that requires hospitalisation and use of intravenous nitrate, heparin therapy, s.c. clexane (include low Mol. Wt. Heparinoid) or intravenous Tirofiban (Aggrostat) for control is considered unstable. Calculated: If ANGRXG=0 and ANGRXH=0 and ANGRXC=0, 1=Stable If ANGRXG=1 OR ANGRXH=1 OR ANGRXC=1, 0=Unstable Calculated where ANGRXG, ANGRXH and ANGRXC are available.

Numeric Haemodynamics 1=Stable 2=Unstable

Level 2 Must not be null if CCS>0

DAN Number of Distal Anastomoses Indicates the total number of distal anastomoses Calculated by: DANITA+ RDAN+ DANV + DANGEP Calculated where DANITA, RDAN, DANV and DANGEP are available.

Numeric Coronary NN


PINT Prolonged Intubation Recorded as prolonged intubation if the intubation is greater than 24 hours. Calculated by: When REINT=1 If (EXTU_D - AICU_D) + (REEXT_D-REINT_D) ≥ 24 hours, 1=Yes If (EXTU_D - AICU_D) + (REEXT_D-REINT_D) < 24 hours, 0=No When REINT=0, If (EXTU_D - AICU_D) ≥ 24 hours, 1=Yes

Numeric Post-Operative (ICU) 1=Yes 0=No

Level 1



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If (EXTU_D - AICU_D) < 24 hours, 0=No Calculated where EXTU_D and AICU_D are available.

VENT Hours intubated (initial post-operative ventilation only) Indicate the number of hours post operation for which the patient was ventilated. Calculate from the date and time of intubation to that of extubation. Round to 2 decimal points. Use zero if the patient was extubated on the operating table. Do not count delayed re-intubation time. Calculated by: EXTU_D - AICU_D Calculated where EXTU_D and AICU_D are available. Units in Hours

Numeric Post-Operative (ICU) NNNN.NN

Level 1

ICU Hours in ICU (initial stay only) Number of hours spent by the patient in the ICU prior to transfer to the HDU or General Ward (does not include readmission to ICU). Round to 2 decimal points. Calculated by: DICU_D - AICU_D Calculated where DICU_D and AICU_D are available. Units in Hours

Numeric Post-Operative (ICU) NNNN.NN

Level 1

MORT30 Mortality within 30 Days of Surgery Mortality within 30 days of surgery calculated by: Mort_D - DOP If Mort_D - DOP≤30, 1=Yes If Mort_D - DOP>30, 0=No If Mort_D is blank (patient alive), Mort30=0 Calculated where DOP is available.

Numeric 1=Yes 0=No

Level 1

AOIM_T Aortic Valve Prosthesis – Implant Type Indicate the type of implant:

Code Type

1 Autograft

2 Bioprosthesis / Xenograft

3 Homograft / Allograft

4 Mechanical

5 Ring / Band

Text Valve 1=Autograft 2=Bioprosthesis/ Xenograft 3= Homograft/ Allograft 4=Mechanical

Level 3 Must not be null if AOPROC=3, 6, 15, 22, 23, or 24



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Derived value when Prosthesis is selected. 5=Ring/Band

AOEX_T Aortic Valve Prosthesis – Explant Type Indicate the type of explant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band

Derived value when Prosthesis is selected.

Text Valve 1=Autograft 2=Bioprosthesis/ Xenograft 3= Homograft/ Allograft 4=Mechanical 5=Ring/Band

Level 3 Optional

MIIM_T Mitral Valve Prosthesis – Implant Type Indicate the type of implant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band



Level 3 Must not be null if MIPROC = 2,3,4, 10 or 27

MIEX_T Mitral Valve Prosthesis – Explant Type Indicate the type of explant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band



Level 3 Optional



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TRIM_T Tricuspid Valve Prosthesis – Implant Type Indicate the type of implant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band



Level 3 Must not be null if TRPROC = 2,3,4 or 10

TREX_T Tricuspid Valve Prosthesis – Explant Type Indicate the type of explant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band



Level 3 Optional

PUIM_T Pulmonary Valve Prosthesis – Implant Type Indicate the type of implant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band



Level 3 Must not be null if PUPROC = 3



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PUEX_T Pulmonary Valve Prosthesis – Explant Type Indicate the type of explant:

Code Type

1 Autograft



4 Mechanical

5 Ring / Band



Level 3 Optional

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